Dirk Wijkel

Psychiatric consultation for somatizing patients in the family practice setting : A feasibility study

Objective: The purpose of the study was to assess the feasibility of a psychiatric consultation intervention for somatizing patients in the family practice setting in terms of 1) patient compliance, 2) patient satisfaction, and 3) compliance and satisfaction of general practitioners (GPs). Method: In a period of nine months, forty-six patients were selected for psychiatric consultation in six solo family practices in a semi-urban area in the Netherlands. The consultation included an interview with the consulting psychiatrist, the patient, and the GP. A written summary of the consultation was provided to the GP and the patient. A booster session with a GP and psychiatrist was included to evaluate and reinforce the recommendations. Results: The majority of the selected patients agreed to participate after informed consent. An intervention was implemented containing interpersonal techniques, reattribution, clarification, and structuring. GP compliance with recommendations was 100 percent, patient compliance 75 percent. Conclusion: A standardized psychiatric consultation for somatizing patients in a family practice setting can be implemented. Several levels of implementation can be distinguished.

Implementation of a shared care guideline for back pain: Effect on unnecessary referrals

Objective To determine the effect of the implementation of a shared care guideline for the lumbosacral radicular syndrome (LRS) on unnecessary early referrals and the duration of the total diagnostic procedure. Design Introduction of shared care guideline in November 2005. Pre-test in 2005 (April to October), a first post-test in 2006 (April to October) and a second post-test in 2007 (April to October). Setting and Intervention The introduction of a shared care guideline derived from national guidelines for GPs and several medical/paramedical specialists in two Dutch regions. Three hundred and sixty GPs, 550 physiotherapists and two hospitals (9 neurologists and 18 radiologists) were involved. The essential component of the guideline was a trade-off: if the GP complied with the conservative management approach in the first 6 weeks, the hospital guaranteed a priority appointment with the neurologist after 6 weeks, if still required. Main Outcome Measures The neurologists in both hospitals registered whether a patient had been unnecessarily referred during the first 6 weeks. The duration of the total diagnostic procedure was defined as the number of days between referral by the GP and the consultation when the neurologist made the final diagnosis. Results The percentage of patients being unnecessarily referred within 6 weeks fell significantly from 15% in 2005 to 9% in 2006 and 8% in 2007. The duration of the total diagnostic procedure also fell significantly in both the long and short terms. Conclusions The introduction of a shared care guideline for all care providers in a region reduces the number of unnecessary early referrals for patients with LRS.

Do patients matter? Contribution of patient and care provider characteristics to the adherence of general practitioners and midwives to the Dutch national guidelines on imminent miscarriage

Objective—To assess the relative contribution of patient and care provider characteristics to the adherence of general practitioners (GPs) and midwives to two specific recommendations in the Dutch national guidelines on imminent miscarriage. The study focused on performing physical examinations at the first contact and making a follow up appointment after 10 days because these are essential recommendations and there was much variation in adherence between different groups of providers. Design—Prospective recording by GPs and midwives of care provided for patients with symptoms of imminent miscarriage. Setting—General practices and midwifery practices in the Netherlands. Subjects—73 GPs and 38 midwives who agreed to adhere to the guidelines; 391 patients were recorded during a period of 12 months. Main measures—Adherence to physical examinations and making a follow up appointment were measured as part of a larger prospective recording study on adherence to the guidelines on imminent miscarriage. Patient and care provider characteristics were obtained from case recordings and interviews, respectively. Multilevel analysis was performed to assess the contribution of several care provider and patient characteristics to adherence to two selected recommendations: the number of recommended physical examinations at the first contact and the number of days before a follow up appointment took place. Results—In the multilevel model explaining variance in adherence to physical examinations, the care providers acceptance of the recommendations was the most important factor. Severity of symptoms and referral to an obstetrician were significant factors at the patient level. In the model for follow up appointments the characteristics of the care provider were less important. Referral to an obstetrician and probability diagnosis were significant factors at the patient level. Conclusions—The study showed that characteristics of both the patient and care provider contribute to the variability in adherence. Furthermore, the contribution of the characteristics differed per recommendation. It is therefore advised that the contribution of both patient and care provider characteristics per recommendation should be carefully examined. If implementation is to be successful, strategies should be developed to address these specific contributions. (Quality in Health Care 2000;9:106–110)

Feasibility of guidelines for the management of threatened miscarriage in general practice/family medicine

Objective: to determine the feasiblity in daily practice of guidelines on threatened miscarriage for general practice. The guidelines on threatened miscarriage were issued in 1989 by the Dutch College of General Practitioners. Methods: prospective recording of appointments by 86 general practitioners (GPs) in the Netherlands, who agreed to adhere to the threatened miscarriage guidelines. Interviews with the GPs after the recording period of 12 months. Adherence to each recommendation and reasons for non-adherence were measured. Results: 75 GPs actually recorded 251 patients. The GPs adhered to most recommendations in the guidelines except as regards carrying out physical examinations at both first appointment and follow-ups. Reasons for non-adherence with the physical examinations were mainly based on the GPs criticism of these recommendations. Scarcely anyone adhered to the recommmendation on follow-up appointments after ten days and a counselling consultation after six weeks. The GPs criticism of these recommendations, and the patients wishes were mentioned as reasons for non-adherence. In 9% of the cases, the GPs policy was overridden either by the patient arranging an ultra-sound scan via a locum or a midwife, or by the obstetrician taking control after the GP had requested an ultrasound scan. Conclusions: in daily practice, care providers may encounter obstacles in adherence to guidelines. As for the threatened miscarriage guidelines, the GPs criticism of the guidelines was an important reason for non-adherence, followed by the situation of the specific patient (such as medical history) and the patients wishes. Furthermore, poor collaboration between GPs, midwives and obstetricians was another obstacle in adherence. Those recommendations that are most often not adhered to should be reviewed. Furthermore, to reduce conflicts about ultrasound scans and referals, agreement on policy on threatened miscarriage should be established between GPs, midwives and obstetricians. (aut.ref.)

Implementatie van een protocol gericht op de zorgketen voor patienten met een Lumbosacraal Radiculair Syndroom

SamenvattingVolgens de NHG-standaard Lumbosacraal Radiculair Syndroom (vaak hernia genoemd) dient de huisarts de eerste zes weken een conservatief beleid te voeren. In de praktijk accepteren patiënten dit soms moeizaam. Onder andere omdat meer patiënten dan wenselijk volgens de NHG-standaard worden doorverwezen, ontstaan lange toegangs- en doorlooptijd in het ziekenhuis: gemiddeld acht en veertien weken in 1998 in het St. Annaziekenhuis in Geldrop. Daarnaast is er geen goede afstemming tussen disciplines in de behandellijn. Daardoor worden enerzijds patiënten ‘voortijdig’ verwezen; anderzijds maken patiënten met een indicatie voor verwijzing een lange wachttijd door. De voorgestelde interventie betrof een wijziging van de logistiek in het ziekenhuis en begeleiding bij de invoering van een protocol: indien de huisarts de NHG-standaard volgde, garandeerde het ziekenhuis daarna versnelde toegang tot de neuroloog en een MRI. Naast uitgebreide voorlichting werden werkafspraken en een gezamenlijke patiëntenfolder gemaakt. Bij het project waren 98 huisartsen, 150 fysiotherapeuten, vier neurologen en zes radiologen betrokken. In het artikel beschrijven we de stappen die systematisch zijn doorlopen bij de invoering en de uitkomsten van het implementatieproces. De belangrijkste conclusie is dat systematische invoering van de NHG-standaard, dat wil zeggen ondersteuning van de eerste lijn in combinatie met een logistieke reorganisatie in het ziekenhuis, mogelijk is. Het aantal voortijdige verwijzingen was laag en de gemiddelde toegangs- en doorlooptijden in het ziekenhuis namen af.AbstractImplementation of a Lumbosacral Radicular Syndrom guidelineWe carried out a feasibility study on the implementation of a LRS-guideline (Lumbosacral Radicular Syndrom) in the Geldrop region, including one hospital and all 98 GPs and 150 physiotherapists referring to this hospital. We redesigned the care process in primary care and hospital for LRS-patients. A trade off was made between the medical specialists (neurologists, radiologists) and the GPs and physiotherapists. If the GP/physiotherapist adhered to the LRS-guideline (conservative management first six weeks), after six weeks, in turn, the hospital guaranteed a priority consultation with the neurologist and priority for MRI. A determinant analysis was carried out among GPs and physiotherapists and a multifaceted implementation strategy was developed that was tailored to the critical determinants. The results showed that the number of patients being referred within six weeks, with no indication, decreased. The waiting time for first consultation with the neurologist and the duration of the total diagnostic procedure also decreased.

S99– Implementation of a shared care guideline for back pain: Effects on unnecessary referrals and diagnostic procedure

PRIMARY TRACK: Guideline implementation SECONDARY TRACK: Guideline implementation methods BACKGROUND (INTRODUCTION): Facilitative intermediaries (FIs) can promote the uptake of knowledge but with variable impact across studies. The means by which FIs exert influence has been poorly conceptualized, operationalized, and reported. To guide future research, this study described how FI attributes and role influenced guideline use. LEARNING OBJECTIVES (TRAINING GOALS): 1. Review the evidence on roles that influence health professional knowledge and behavior. 2. Learn about limitations in the way these roles are conceptualized and operationalized. 3. Understand how such roles could be modified to enhance their impact. 4. Assess the need for ongoing research to evaluate the attributes, roles, and impact of facilitative intermediaries. METHODS: Multiple databases were searched from 1992 to June 2009 for English-language studies where FIs promoted guideline use. Two individuals independently selected eligible studies and extracted data. RESULTS: Ninety-seven studies (32 observational, 65 randomized) were eligible for review (138 retrieved from 451 search results). The FI was frequently external to the target setting (56) and part of a multifaceted intervention (61). Fiftyone studies provided details about FI training, which ranged from single workshops of varying length to 30-week programs. No studies described how the FI was meant to exert influence. FI role was evaluated in 23 studies according to number or duration of, or satisfaction with, FI interactions. FI activities included phone calls, single presentations, and a range of 1 to 15 visits varying in length from 10 minutes to 1 hour. Impact on professional behavior was assessed in 86 studies with significant improvement on at least 1 measure in 58 (21 observational, 37 randomized). Impact on clinical outcomes was assessed in 22 studies with significant improvement on at least 1 measure in 2 randomized studies. DISCUSSION (CONCLUSION): Future research should evaluate FI role alone rather than as part of multifaceted interventions, recruit and train internal candidates, plan and evaluate FI activities based on explicit intended role, and assess roles that actively assist with adoption over time rather than single efforts to inform or persuade. TARGET AUDIENCE(S): 1. Evidence synthesizer, developer of systematic reviews or meta-analyses 2. Guideline developer 3. Guideline implementer 4. Developer of guideline-based products 5. Quality improvement manager/facilitator 6. Medical educator