Ben van Steenkiste

Barriers to implementing cardiovascular risk tables in routine general practice.

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.

Involving patients in cardiovascular risk management with nurse-led clinics: a cluster randomized controlled trial

Background: Preventive guidelines on cardiovascular risk management recommend lifestyle changes. Support for lifestyle changes may be a useful task for practice nurses, but the effect of such interventions in primary prevention is not clear. We examined the effect of involving patients in nurse-led cardiovascular risk management on lifestyle adherence and cardiovascular risk. Methods: We performed a cluster randomized controlled trial in 25 practices that included 615 patients. The intervention consisted of nurse-led cardiovascular risk management, including risk assessment, risk communication, a decision aid and adapted motivational interviewing. The control group received a minimal nurse-led intervention. The self-reported outcome measures at one year were smoking, alcohol use, diet and physical activity. Nurses assessed 10-year cardiovascular mortality risk after one year. Results: There were no significant differences between the intervention groups. The effect of the intervention on the consumption of vegetables and physical activity was small, and some differences were only significant for subgroups. The effects of the intervention on the intake of fat, fruit and alcohol and smoking were not significant. We found no effect between the groups for cardiovascular 10-year risk. Interpretation: Nurse-led risk communication, use of a decision aid and adapted motivational interviewing did not lead to relevant differences between the groups in terms of lifestyle changes or cardiovascular risk, despite significant within-group differences.

Implementing training and support, financial reimbursement, and referral to an internet-based brief advice program to improve the early identification of hazardous and harmful alcohol consumption in primary care (ODHIN) : study protocol for a cluster randomized factorial trial

BackgroundThe European level of alcohol consumption, and the subsequent burden of disease, is high compared to the rest of the world. While screening and brief interventions in primary healthcare are cost-effective, in most countries they have hardly been implemented in routine primary healthcare. In this study, we aim to examine the effectiveness and efficiency of three implementation interventions that have been chosen to address key barriers for improvement: training and support to address lack of knowledge and motivation in healthcare providers; financial reimbursement to compensate the time investment; and internet-based counselling to reduce workload for primary care providers.Methods/designIn a cluster randomized factorial trial, data from Catalan, English, Netherlands, Polish, and Swedish primary healthcare units will be collected on screening and brief advice rates for hazardous and harmful alcohol consumption. The three implementation strategies will be provided separately and in combination in a total of seven intervention groups and compared with a treatment as usual control group. Screening and brief intervention activities will be measured at baseline, during 12 weeks and after six months. Process measures include health professionals’ role security and therapeutic commitment of the participating providers (SAAPPQ questionnaire). A total of 120 primary healthcare units will be included, equally distributed over the five countries. Both intention to treat and per protocol analyses are planned to determine intervention effectiveness, using random coefficient regression modelling.DiscussionEffective interventions to implement screening and brief interventions for hazardous alcohol use are urgently required. This international multi-centre trial will provide evidence to guide decision makers.Trial registrationClinicalTrials.gov. Trial identifier: NCT01501552

The SMILE study: a study of medical information and lifestyles in Eindhoven, the rationale and contents of a large prospective dynamic cohort study

BackgroundHealth problems, health behavior, and the consequences of bad health are often intertwined. There is a growing need among physicians, researchers and policy makers to obtain a comprehensive insight into the mutual influences of different health related, institutional and environmental concepts and their collective developmental processes over time.Methods/DesignSMILE is a large prospective cohort study, focusing on a broad range of aspects of disease, health and lifestyles of people living in Eindhoven, the Netherlands. This study is unique in its kind, because two data collection strategies are combined: first data on morbidity, mortality, medication prescriptions, and use of care facilities are continuously registered using electronic medical records in nine primary health care centers. Data are extracted regularly on an anonymous basis. Secondly, information about lifestyles and the determinants of (ill) health, sociodemographic, psychological and sociological characteristics and consequences of chronic disease are gathered on a regular basis by means of extensive patient questionnaires. The target population consisted of over 30,000 patients aged 12 years and older enrolled in the participating primary health care centers.DiscussionDespite our relatively low response rates, we trust that, because of the longitudinal character of the study and the high absolute number of participants, our database contains a valuable set of information.SMILE is a longitudinal cohort with a long follow-up period (15 years). The long follow-up and the unique combination of the two data collection strategies will enable us to disentangle causal relationships. Furthermore, patient-reported characteristics can be related to self-reported health, as well as to more validated physician registered morbidity. Finally, this population can be used as a sampling frame for intervention studies. Sampling can either be based on the presence of certain diseases, or on specific lifestyles or other patient characteristics.

Professional's Attitudes Do Not Influence Screening and Brief Interventions Rates for Hazardous and Harmful Drinkers: Results from ODHIN Study

AIMS To determine the relation between existing levels of alcohol screening and brief intervention rates in five European jurisdictions and role security and therapeutic commitment by the participating primary healthcare professionals. METHODS Health care professionals consisting of, 409 GPs, 282 nurses and 55 other staff including psychologists, social workers and nurse aids from 120 primary health care centres participated in a cross-sectional 4-week survey. The participants registered all screening and brief intervention activities as part of their normal routine. The participants also completed the Shortened Alcohol and Alcohol Problems Perception Questionnaire (SAAPPQ), which measure role security and therapeutic commitment. RESULTS The only significant but small relationship was found between role security and screening rate in a multilevel logistic regression analysis adjusted for occupation of the provider, number of eligible patients and the random effects of jurisdictions and primary health care units (PHCU). No significant relationship was found between role security and brief intervention rate nor between therapeutic commitment and screening rate/brief intervention rate. The proportion of patients screened varied across jurisdictions between 2 and 10%. CONCLUSION The findings show that the studied factors (role security and therapeutic commitment) are not of great importance for alcohol screening and BI rates. Given the fact that screening and brief intervention implementation rate has not changed much in the last decade in spite of increased policy emphasis, training initiatives and more research being published, this raises a question about what else is needed to enhance implementation.

Systematic review of implementation strategies for risk tables in the prevention of cardiovascular diseases.

Background Cardiovascular disease prevention is guided by so-called risk tables for calculating individual’s risk numbers. However, they are not widely used in routine practice and it is important to understand the conditions for their use. Objectives Systematic review of the literature on professionals’ performance regarding cardiovascular risk tables, in order to develop effective implementation strategies. Selection criteria Studies were eligible for inclusion if they reported quantitative empirical data on the effect of professional, financial, organizational or regulatory strategies on the implementation of cardiovascular risk tables. Participants were physicians or nurses. Outcome measure Primary: professionals’ self-reported performance related to actual use of cardiovascular risk tables. Secondary: patients’ cardiovascular risk reduction. Data collection and analysis An extensive strategy was used to search MEDLINE, EMBASE, CINAHL, and PSYCHINFO from database inception to February 2007. Main results The review included 9 studies, covering 3 types of implementation strategies (or combinations). Reported effects were moderate, sometimes conflicting and contradictory. Although no clear relation was observed between a particular type of strategy and success or failure of the implementation, promising strategies for patient selection and risk assessment seem to be teamwork, nurse led-clinics and integrated IT support. Conclusions Implementation strategies for cardiovascular risk tables have been sparsely studied. Future research on implementation of cardiovascular risk tables needs better embedding in the systematic and problem-based approaches developed in implementation science.

Disease or no disease? Disagreement on diagnoses between self-reports and medical records of adult patients.

Abstract Background: Previous studies reported moderate to good agreement between patients’ self-reported diseases and physicians’ registered diseases. Disagreement might hamper a good doctor–patient relationship and hamper good quality of care. Disagreement can be associated with demographic and psychosocial patient characteristics. Objectives: To evaluate the level of agreement on reported chronic diseases between patients and their general practitioners (GPs); to assess whether disagreement relates to patient characteristics. Methods: This study is embedded in a large GP based prospective cohort. Questionnaires of 2893 patients reporting on 14 chronic diseases are used. The agreement (percentage) between self-reported chronic diseases and the medical records was assessed first by descriptive statistics. To control for agreement by chance alone Cohens kappa value was calculated. Type of (dis) agreement was further evaluated and associated with patient characteristics. Results: Despite high agreement on diseases between patients and GPs, kappas varied from 0.17 (inflammatory joint diseases and rheumatoid arthritis) to 0.86 (diabetes mellitus). Most often under-reporting and over-reporting was related to a decreased physical and mental quality of life and higher age. Conclusion: kappa values between patients and GPs appeared to be low in this study.

Increased attendance rate: BMI matters, lifestyles don't. Results from the Dutch SMILE study.

INTRODUCTION a small group of frequent attenders is responsible for a disproportional large percentage of all daytime consultations in general practice. High attendance rates are related to demographic and psychological characteristics. Differences in attendance rates are only partly explained by chronic diseases. Furthermore, lifestyles might be relevant too. The aim of this study was to examine the effect of lifestyle on attendance rates. METHOD this study is part of the Study of Medical Information and Lifestyles in Eindhoven, the Netherlands (SMILE). Generalized estimated equations were used to determine the relation between attendance rate and the different lifestyle factors (N = 4444). RESULTS a higher body mass index was related to increased attendance rate in both male [relative risk (RR) 1.02; 95% confidence interval (CI) 1.01-1.03] and female patients (RR 1.01; 95% CI 1.01-1.02). Lifestyles were not related to the attendance rate, except for a sedentary lifestyle in women (RR 1.08; 95% CI 1.04-1.12). DISCUSSION since half of the Dutch population suffers from overweight or obesity and this number is still increasing, attendance rates will rise further. In order to relieve the GPs, nurse practitioners could play a more prominent role in lifestyle interventions concerning overweight and obesity and its related diseases.

The challenge of transferring an implementation strategy from academia to the field. A process evaluation of local quality improvement collaboratives in Dutch primary care using the normalization process theory

RATIONALE, AIMS AND OBJECTIVES A quality improvement strategy consisting of comparative feedback and peer review embedded in available local quality improvement collaboratives proved to be effective in changing the test-ordering behaviour of general practitioners. However, implementing this strategy was problematic. We aimed for large-scale implementation of an adapted strategy covering both test ordering and prescribing performance. Because we failed to achieve large-scale implementation, the aim of this study was to describe and analyse the challenges of the transferring process. METHODS In a qualitative study 19 regional health officers, pharmacists, laboratory specialists and general practitioners were interviewed within 6 months after the transfer period. The interviews were audiotaped, transcribed and independently coded by two of the authors. The codes were matched to the dimensions of the normalization process theory. RESULTS The general idea of the strategy was widely supported, but generating the feedback was more complex than expected and the need for external support after transfer of the strategy remained high because participants did not assume responsibility for the work and the distribution of resources that came with it. CONCLUSION Evidence on effectiveness, a national infrastructure for these collaboratives and a general positive attitude were not sufficient for normalization. Thinking about managing large databases, responsibility for tasks and distribution of resources should start as early as possible when planning complex quality improvement strategies. Merely exploring the barriers and facilitators experienced in a preceding trial is not sufficient. Although multifaceted implementation strategies to change professional behaviour are attractive, their inherent complexity is also a pitfall for large-scale implementation.

Predictability of Persistent Frequent Attendance in Primary Care: A Temporal and Geographical Validation Study

Background Frequent attenders are patients who visit their general practitioner exceptionally frequently. Frequent attendance is usually transitory, but some frequent attenders become persistent. Clinically, prediction of persistent frequent attendance is useful to target treatment at underlying diseases or problems. Scientifically it is useful for the selection of high-risk populations for trials. We previously developed a model to predict which frequent attenders become persistent. Aim To validate an existing prediction model for persistent frequent attendance that uses information solely from General Practitioners’ electronic medical records. Methods We applied the existing model (N = 3,045, 2003–2005) to a later time frame (2009–2011) in the original derivation network (N = 4,032, temporal validation) and to patients of another network (SMILE; 2007–2009, N = 5,462, temporal and geographical validation). Model improvement was studied by adding three new predictors (presence of medically unexplained problems, prescriptions of psychoactive drugs and antibiotics). Finally, we derived a model on the three data sets combined (N = 12,539). We expressed discrimination using histograms of the predicted values and the concordance-statistic (c-statistic) and calibration using the calibration slope (1 = ideal) and Hosmer-Lemeshow tests. Results The existing model (c-statistic 0.67) discriminated moderately with predicted values between 7.5 and 50 percent and c-statistics of 0.62 and 0.63, for validation in the original network and SMILE network, respectively. Calibration (0.99 originally) was better in SMILE than in the original network (slopes 0.84 and 0.65, respectively). Adding information on the three new predictors did not importantly improve the model (c-statistics 0.64 and 0.63, respectively). Performance of the model based on the combined data was similar (c-statistic 0.65). Conclusion This external validation study showed that persistent frequent attenders can be prospectively identified moderately well using data solely from patients’ electronic medical records.