Elke Huntink

Identifying determinants of care for tailoring implementation in chronic diseases: an evaluation of different methods.

BackgroundThe tailoring of implementation interventions includes the identification of the determinants of, or barriers to, healthcare practice. Different methods for identifying determinants have been used in implementation projects, but which methods are most appropriate to use is unknown.MethodsThe study was undertaken in five European countries, recommendations for a different chronic condition being addressed in each country: Germany (polypharmacy in multimorbid patients); the Netherlands (cardiovascular risk management); Norway (depression in the elderly); Poland (chronic obstructive pulmonary disease—COPD); and the United Kingdom (UK) (obesity). Using samples of professionals and patients in each country, three methods were compared directly: brainstorming amongst health professionals, interviews of health professionals, and interviews of patients. The additional value of discussion structured through reference to a checklist of determinants in addition to brainstorming, and determinants identified by open questions in a questionnaire survey, were investigated separately. The questionnaire, which included closed questions derived from a checklist of determinants, was administered to samples of health professionals in each country. Determinants were classified according to whether it was likely that they would inform the design of an implementation intervention (defined as plausibly important determinants).ResultsA total of 601 determinants judged to be plausibly important were identified. An additional 609 determinants were judged to be unlikely to inform an implementation intervention, and were classified as not plausibly important. Brainstorming identified 194 of the plausibly important determinants, health professional interviews 152, patient interviews 63, and open questions 48. Structured group discussion identified 144 plausibly important determinants in addition to those already identified by brainstorming.ConclusionsSystematic methods can lead to the identification of large numbers of determinants. Tailoring will usually include a process to decide, from all the determinants that are identified, those to be addressed by implementation interventions. There is no best buy of methods to identify determinants, and a combination should be used, depending on the topic and setting. Brainstorming is a simple, low cost method that could be relevant to many tailored implementation projects.

Tailored Implementation of Evidence-Based Practice for Patients with Chronic Diseases

Background When designing interventions and policies to implement evidence based healthcare, tailoring strategies to the targeted individuals and organizations has been recommended. We aimed to gather insights into the ideas of a variety of people for implementing evidence-based practice for patients with chronic diseases, which were generated in five European countries. Methods A qualitative study in five countries (Germany, Netherlands, Norway, Poland, United Kingdom) was done, involving overall 115 individuals. A purposeful sample of four categories of stakeholders (healthcare professionals, quality improvement officers, healthcare purchasers and authorities, and health researchers) was involved in group interviews in each of the countries to generate items for improving healthcare in different chronic conditions per country: chronic obstructive pulmonary disease, cardiovascular disease, depression in elderly people, multi-morbidity, obesity. A disease-specific standardized list of determinants of practice in these conditions provided the starting point for these groups. The content of the suggested items was categorized in a pre-defined framework of 7 domains and specific themes in the items were identified within each domain. Results The 115 individuals involved in the study generated 812 items, of which 586 addressed determinants of practice. These largely mapped onto three domains: individual health professional factors, patient factors, and professional interactions. Few items addressed guideline factors, incentives and resources, capacity of organizational change, or social, political and legal factors. The relative numbers of items in the different domains were largely similar across stakeholder categories within each of the countries. The analysis identified 29 specific themes in the suggested items across countries. Conclusion The type of suggestions for improving healthcare practice was largely similar across different stakeholder groups, mainly addressing healthcare professionals, patient factors and professional interactions. As this study is one of the first of its kind, it is important that more research is done on tailored implementation strategies.

Effectiveness of a tailored intervention to improve cardiovascular risk management in primary care: study protocol for a randomised controlled trial

AbstractBackgroundCardiovascular disease (CVD) is an important worldwide cause of mortality. In The Netherlands, CVD is the leading cause of death for women and the second cause of death for men. Recommendations for diagnosis and treatment of CVD are not well implemented in primary care. In this study, we aim to examine the effectiveness of a tailored implementation program targeted at practice nurses to improve healthcare for patients with (high risk for) CVD.Methods/designA two-arm cluster randomized trial is planned. We offer practice nurses a tailored program to improve adherence to six specific recommendations related to blood pressure and cholesterol target values, risk profiling and lifestyle advice. Practice nurses are offered training and feedback on their motivational interviewing technique and an e-learning program on cardiovascular risk management (CVRM). They are also advised to screen for the presence and severity of depressive symptoms in patients. We also advise practice nurses to use selected E-health options (selected websites and Twitter-consult) in patients without symptoms of depression. Patients with mild depressive symptoms are referred to a physical exercise group. We recommend referring patients with major depressive symptoms for assessment and treatment of depressive symptoms if appropriate before starting CVRM. Data from 900 patients at high risk of CVD or with established CVD will be collected in 30 general practices in several geographical areas in The Netherlands. The primary outcome measure is performance of practice nurses in CVRM and reflects application of recommendations for personalized counselling and education of CVRM patients. Patients’ health-related lifestyles (physical exercise, diet and smoking status) will be measured with validated questionnaires and medical record audit will be performed to document estimated CVD risk. Additionally, we will survey and interview participating healthcare professionals for exploration of processes of change. The control practices will provide usual care.DiscussionTailored interventions can improve healthcare. An understanding of the methods to reach the improved healthcare can be improved. This research contributes a share of it. Identification of the determinants of practice and developing implementation interventions were two steps which were completed. The subsequent step was implementation of the tailored intervention program.Trial registrationName trial register: Nederlands trial registerWeb address of trial register: http://www.trialregister.nl Data of registration: 11 July 2013Number of registration:NTR4069

Stakeholders’ contributions to tailored implementation programs: an observational study of group interview methods

BackgroundTailored strategies to implement evidence-based practice can be generated in several ways. In this study, we explored the usefulness of group interviews for generating these strategies, focused on improving healthcare for patients with chronic diseases.MethodsParticipants included at least four categories of stakeholders (researchers, quality officers, health professionals, and external stakeholders) in five countries. Interviews comprised brainstorming followed by a structured interview and focused on different chronic conditions in each country. We compared the numbers and types of strategies between stakeholder categories and between interview phases. We also determined which strategies were actually used in tailored intervention programs.ResultsIn total, 127 individuals participated in 25 group interviews across five countries. Brainstorming generated 8 to 120 strategies per group; structured interviews added 0 to 55 strategies. Healthcare professionals and researchers provided the largest numbers of strategies. The type of strategies for improving healthcare practice did not differ systematically between stakeholder groups in four of the five countries. In three out of five countries, all components of the chosen intervention programs were mentioned by the group of researchers.ConclusionsGroup interviews with different stakeholder categories produced many strategies for tailored implementation of evidence-based practice, of which the content was largely similar across stakeholder categories.

Perceived determinants of cardiovascular risk management in primary care: disconnections between patient behaviours, practice organisation and healthcare system.

BackgroundAlthough conditions for high quality cardiovascular risk management in primary care in the Netherlands are favourable, there still remains a gap between practice guideline recommendations and practice. The aim of the current study was to identify determinants of cardiovascular primary care in the Netherlands.MethodsWe performed a qualitative study, using semi-structured interviews with healthcare professionals and patients with established cardiovascular diseases or at high cardiovascular risk. A framework analysis was used to cluster the determinants into seven domains: 1) guideline factors, 2) individual healthcare professional factors, 3) patient factors, 4) professional interaction, 5) incentives and recourses, 6) mandate, authority and accountability, and 7) social, political and legal factors.ResultsTwelve healthcare professionals and 16 patients were interviewed. Healthcare professionals and patients mentioned a variety of factors concerning all seven domains. Determinants of practice according to the health care professionals were related to communication between healthcare professionals, patients’ lack of knowledge and self-management, time management, market mechanisms in the Dutch healthcare system and motivational interviewing skills of healthcare professionals. Patients mentioned determinants related to their knowledge of risk factors for cardiovascular diseases, medication adherence and self-management as key determinants. A key finding is the mismatch between healthcare professionals’ and patients’ views on patient’s knowledge and self-management.ConclusionsPerceived determinants of cardiovascular risk management were mainly related to patient behaviors and (but only for health professionals) to the healthcare system. Though health care professionals and patients agree upon the importance of patients’ knowledge and self-management, their judgment of the current state of knowledge and self-management is entirely different.

Process evaluation of a tailored intervention programme of cardiovascular risk management in general practices

BackgroundA tailored implementation programme to improve cardiovascular risk management (CVRM) in general practice had little impact on outcomes. The questions in this process evaluation concerned (1) impact on counselling skills and CVRM knowledge of practice nurses, (2) their use of the various components of the intervention programme and adoption of recommended practices and (3) patients’ perceptions of counselling for CVRM.MethodsA mixed-methods process evaluation was conducted. We assessed practice nurses’ motivational interviewing skills on audio-taped consultations using Motivational Interviewing Treatment Integrity (MITI). They also completed a clinical knowledge test. Both practice nurses and patients reported on their experiences in a written questionnaire and interviews. A multilevel regression analysis and an independent sample t test were used to examine motivational interviewing skills and CVRM knowledge. Framework analysis was applied to analyse qualitative data.ResultsData from 34 general practices were available, 19 intervention practices and 14 control practices. No improvements were measured on motivational interviewing skills in both groups. There appeared to be better knowledge of CVRM in the control group. On average half of the practice nurses indicated that they adopted the recommended interventions, but stated that they did not necessarily record this in patients’ medical files. The tailored programme was perceived as too large. Time, follow-up support and reminders were felt to be lacking. About 20% of patients in the intervention group visited the general practice during the intervention period, yet only a small number of these patients were referred to recommended options.ConclusionsThe tailored programme was only partly used by practice nurses and had little impact on either their clinical knowledge and communication skills or on patient reported healthcare. If the assumed logical model of change is valid, a more intensive programme is needed to have an impact on CVRM in general practice at all.

Maatwerk bij CVRM

SamenvattingPraktijkondersteuners zijn niet altijd op de hoogte van de relatie tussen hart- en vaatziekten en mogelijk depressieve symptomen. Dat blijkt uit onderzoek naar het effect van een groot internationaal project. Tijdens dit project hebben de onderzoekers het implementatieprogramma ‘Maatwerk bij CVRM’ ontwikkeld voor de zorg van patiënten met (verhoogd risico) op hart- en vaatziekten. Zij lichten het programma in dit artikel toe.

Patient cardiovascular risk self-management: results from a randomized trial of motivational interviewing delivered by practice nurses

Abstract Background To enhance cardiovascular risk management and patients’ self-management, a tailored programme to improve cardiovascular risk management was tested in a randomized trial. The presented study concerned secondary analysis. Objectives To explore the correlations of practice nurses’ counselling skills at baseline on chronic illness care (measured with Patient Assessment of Chronic Illness Care questionnaire) and patients’ self-management (assessed with Patient Activation Measure) at follow-up and to examine the effect of the tailored implementation programme on chronic illness care and patients’ self-management. Methods A two-arm cluster randomized trial was conducted in 34 general practices in the Netherlands. Counselling skills of practice nurses at baseline were abstracted from audio-taped consultations, which were assessed by Motivational Interviewing Treatment Integrity. Data of 2184 patients with established cardiovascular disease or at high cardiovascular risk were gathered at inclusion and at 6 months follow-up by a composite questionnaire. Multilevel regression analysis was applied, controlling for patient characteristics. Results Counselling skills of practice nurses were not associated with chronic illness care and patients’ self-management scores. At follow-up, patients in the intervention group experienced less chronic illness care and were less activated in disease management than patients in the control group. The most important predictors were patients’ age, gender and education level. Conclusions The logic model underlying the implementation programme needs to be reconsidered, because patient perceptions were neither influenced by nurses’ counselling skills nor by other components of the implementation programme.

Een implementatieprogramma CVRM voor praktijkondersteuners

SamenvattingHuntink E, Wensing M, van Lieshout J. Een implementatieprogramma CVRM voor praktijkondersteuners. Huisarts Wet 2017;60(12):623-5.Achtergrond Cardiovasculair risicomanagement (CVRM) is in Nederland vooral een taak van de huisarts en de praktijkondersteuner (poh). Die taak is voor verbetering vatbaar. In het kader van een Europees project ontwikkelden wij een implementatieprogramma ‘Maatwerk bij CVRM’ dat gericht is op poh’s. Methode Clustergerandomiseerd interventieonderzoek in 34 Nederlandse huisartsenpraktijken, door loting toegewezen aan een interventiearm en een controlearm. We analyseerden patiëntendossiers en schriftelijke vragenlijsten voor patiënten, en interviewden poh’s uit de interventiearm. Primaire uitkomstmaat was een in het patiëntendossier vastgelegd leefstijladvies, secundaire uitkomstmaten waren bloeddruk, cholesterol, BMI, roken, voeding en beweging. Resultaten De interventiearm telde 20 poh’s verdeeld over 19 huisartsenpraktijken, de controlearm 14 poh’s verdeeld over 15 huisartsenpraktijken. In totaal 2229 patiënten vulden de vragenlijst in. We vonden zes maanden na inclusie geen significante verschillen in de primaire uitkomstmaat en evenmin in bloeddruk, cholesterol, BMI, roken en voeding. Patiënten in de interventiearm scoorden significant beter op het gebied van lichaamsbeweging. De poh’s pasten de overige behandeladviezen nauwelijks toe, met name de adviezen betreffende depressieve symptomen bij de patiënt. Ze misten regelmatige reminders en ondersteuning vanuit de onderzoeksteam. Conclusie De poh’s waren enthousiast over het implementatieprogramma, maar voerden de aanbevelingen matig uit. Er is in de praktijk nog te weinig aandacht voor mogelijke depressieve symptomen bij patiënten met (risico op) hart- en vaatziekten. Implementatieprogramma’s gericht op poh’s kunnen effectiever worden als men poh’s en patiënten nadrukkelijker betrekt bij de ontwikkeling en ze meer op maat maakt voor de individuele huisartsenpraktijk.

Maatwerk bij hart- en vaatziekten

SamenvattingDe auteurs, wetenschappelijk onderzoekers aan Radboudumc, ontwikkelden een interventieprogramma voor praktijkondersteuners die zich bezighouden met cardiovasculair risicomanagement. Het doel is maatwerk leveren voor patiënten met hart- en vaatziekten. Zo houdt het programma er rekening mee dat mensen met depressieve klachten andere zorg behoeven dan mensen zonder die klachten. Het programma kent drie soorten benaderingen: voor respectievelijk patiënten zonder symptomen van depressie, met beperkte symptomen, en met uitgebreide symptomen.Het programma bestaat uit nascholing op de werkplek voor praktijkondersteuners, en interventies op maat voor patiënten. Een webprogramma over cardiovasculair risicomanagement frist de kennis van praktijkondersteuners op, een training in motiverende gespreksvoering zorgt voor patiëntencommunicatie op maat.