Ellen Keizer

No identifiable Hb1Ac or lifestyle change after a comprehensive diabetes programme including motivational interviewing: A cluster randomised trial

Abstract Objective. To study the effectiveness of a comprehensive diabetes programme in general practice that integrates patient-centred lifestyle counselling into structured diabetes care. Design and setting. Cluster randomised trial in general practices. Intervention. Nurse-led structured diabetes care with a protocol, record keeping, reminders, and feedback, plus training in motivational interviewing and agenda setting. Subjects. Primary care nurses in 58 general practices and their 940 type 2 diabetes patients with an HbA1c concentration above 7%, and a body mass index (BMI) above 25 kg/m2. Main outcome measures. HbA1c, diet, and physical activity (medical records and patient questionnaires). Results. Multilevel linear and logistic regression analyses adjusted for baseline outcomes showed that despite active nurse participation in the intervention, the comprehensive programme was no more effective than usual care after 14 months, as shown by HbA1c levels (difference between groups = 0.13; CI 20.8–0.35) and diet (fat (difference between groups = 0.19; CI 20.82–1.21); vegetables (difference between groups = 0.10; CI-0.21–0.41); fruit (difference between groups = 20.02; CI 20.26–0.22)), and physical activity (difference between groups = 21.15; CI 212.26–9.97), or any of the other measures of clinical parameters, patients readiness to change, or quality of life. Conclusion. A comprehensive programme that integrated lifestyle counselling based on motivational interviewing principles integrated into structured diabetes care did not alter HbA1c or the lifestyle related to diet and physical activity. We thus question the impact of motivational interviewing in terms of its ability to improve routine diabetes care in general practice.

Minimal improvement of nurses’ motivational interviewing skills in routine diabetes care one year after training: a cluster randomized trial

BackgroundThe effectiveness of nurse-led motivational interviewing (MI) in routine diabetes care in general practice is inconclusive. Knowledge about the extent to which nurses apply MI skills and the factors that affect the usage can help to understand the black box of this intervention. The current study compared MI skills of trained versus non-trained general practice nurses in diabetes consultations. The nurses participated in a cluster randomized trial in which a comprehensive program (including MI training) was tested on improving clinical parameters, lifestyle, patients’ readiness to change lifestyle, and quality of life.MethodsFifty-eight general practices were randomly assigned to usual care (35 nurses) or the intervention (30 nurses). The ratings of applying 24 MI skills (primary outcome) were based on five consultation recordings per nurse at baseline and 14 months later. Two judges evaluated independently the MI skills and the consultation characteristics time, amount of nurse communication, amount of lifestyle discussion and patients’ readiness to change. The effect of the training on the MI skills was analysed with a multilevel linear regression by comparing baseline and the one-year follow-up between the interventions with usual care group. The overall effect of the consultation characteristics on the MI skills was studied in a multilevel regression analyses.ResultsAt one year follow up, it was demonstrated that the nurses improved on 2 of the 24 MI skills, namely, “inviting the patient to talk about behaviour change” (mean difference=0.39, p=0.009), and “assessing patient’s confidence in changing their lifestyle” (mean difference=0.28, p=0.037). Consultation time and the amount of lifestyle discussion as well as the patients’ readiness to change health behaviour was associated positively with applying MI skills.ConclusionsThe maintenance of the MI skills one year after the training program was minimal. The question is whether the success of MI to change unhealthy behaviour must be doubted, whether the technique is less suitable for patients with a complex chronic disease, such as diabetes mellitus, or that nurses have problems with the acquisition and maintenance of MI skills in daily practice. Overall, performing MI skills during consultation increases, if there is more time, more lifestyle discussion, and the patients show more readiness to change.Trial registrationCurrent Controlled Trials ISRCTN68707773

Reducing the use of out-of-hours primary care services: A survey among Dutch general practitioners.

Abstract Background: Out-of-hours primary care services have a high general practitioner (GP) workload with increasing costs, while half of all contacts are non-urgent. Objectives: To identify views of GPs to influence the use of the out-of-hours GP cooperatives. Methods: Cross-sectional survey study among a random sample of 800 GPs in the Netherlands. Results: Of the 428 respondents (53.5% response rate), 86.5% confirmed an increase in their workload and 91.8% felt that the number of patient contacts could be reduced. A total of 75.4% GP respondents reported that the 24-h service society was a ‘very important’ reason why patients with non-urgent problems attended the GP cooperative; the equivalent for worry or anxiety was 65.8%, and for easy accessibility, 60.1%. Many GPs (83.9%) believed that the way telephone triage is currently performed contributes to the high use of GP cooperatives. Measures that GPs believed were both desirable and effective in reducing the use of GP cooperatives included co-payment for patients, stricter triage, and a larger role for the telephone consultation doctor. GPs considered patient education, improved telephone accessibility of daytime general practices, more possibilities for same-day appointments, as well as feedback concerning the use of GP cooperatives to practices and triage nurses also desirable, but less effective. Conclusion: This study provides several clues for influencing the use of GP cooperatives. Further research is needed to examine the impact and safety of these strategies. Key Messages GPs believe that the number of patient contacts with the GP cooperative could be reduced. Strategies to reduce the use of GP cooperatives perceived as both effective and advisable by GPs are introducing co-payment for patients, stricter triage and a larger role for the telephone consultation doctor.

GPs’ experiences with out-of-hours GP cooperatives: A survey study from the Netherlands

Abstract Background: Out-of-hours primary care has been provided by general practitioner (GP) cooperatives since the year 2000 in the Netherlands. Early studies in countries with similar organizational structures showed positive GP experiences. However, nowadays it is said that GPs experience a high workload at the cooperative and that they outsource a considerable part of their shifts. Objectives: To examine positive and negative experiences of GPs providing out-of-hours primary care, and the frequency and reasons for outsourcing shifts. Methods: A cross-sectional observational survey among 688 GPs connected to six GP cooperatives in the Netherlands, using a web-based questionnaire. Results: The response was 55% (n = 378). The main reasons for working in GP cooperatives were to retain registration as GP (79%) and remain experienced in acute care (74%). GPs considered the peak hours (81%) and the high number of patients (73%) as the most negative aspects. Most GPs chose to provide the out-of-hours shifts themselves: 85% outsourced maximally 25% of their shifts. The percentage of outsourced shifts increased with age. Main reasons for outsourcing were the desire to have more private time (76%); the high workload in daytime practice (71%); and less the workload during out-of-hours (46%). Conclusion: GPs are motivated to work in out-of-hours GP cooperatives, and they outsource few shifts. GPs consider the peak load and the large number of (non-urgent) help requests as the most negative aspects. To motivate and involve GPs for 7 × 24-h primary care, it is important to set limits on their workload.

Misperception of patients with type 2 diabetes about diet and physical activity, and its effects on readiness to change

Background:  The aim of the present study was to assess misperceptions about lifestyle among patients with type 2 diabetes and their effects on readiness to change.

The psychometric properties of the 'safety attitudes questionnaire' in out-of-hours primary care services in the Netherlands

Background The Safety Attitudes Questionnaire (SAQ) is one of the most widely used instruments to assess safety culture among healthcare providers. The ambulatory version of the SAQ (SAQ-AV) can be used in the primary care setting. Our study objective was to examine the underlying factors and psychometric properties of the Dutch translation of the SAQ-AV in out-of-hours primary care services. Design Cross-sectional observational study using a web-survey. Setting Sixteen out-of-hours general practitioner cooperatives and two call centers in the Netherlands. Participants Primary healthcare providers in out-of-hours services. Main outcome measures Item-descriptive statistics, factor loadings, Cronbach’s alpha scores, corrected item-total correlations, scale correlations. Results The questionnaire was answered by 853 (43.2%) healthcare professionals. In the factor analyses, 784 respondents were included; mainly general practitioners (N = 470) and triage nurses (N = 189). Items were included in the analyses based on question type and results from previous studies. Five factors were drawn with reliability scores between .49 and .86 and a good construct validity. The five factors covered 27 of the 62 questionnaire items, with three to five items per factor. Conclusions The Dutch translation of the SAQ-AV, with five factors, seems to be a reliable tool for measuring patient safety culture and guide quality improvement interventions in out-of-hours primary care services. The Dutch factor structure differed from the original SAQ-AV and other translated versions. In future studies, the questionnaire should be validated further by examining if there is a relationship between the responses on the SAQ-AV, patient experiences, and the occurrence of adverse events.

Verminderen van zorgconsumptie op huisartsenposten

SamenvattingKeizer E, Maassen I, Smits M, Giesen P. Verminderen van zorgconsumptie op huisartsenposten. Huisarts Wet 2014;57(10):510-4.DoelOp huisartsenposten (HAP’s) is de werkdruk hoog en stijgen de kosten sterk, terwijl de helft van de hulpvragen uiteindelijk weinig urgent blijkt. Het is dus belangrijk aanknopingspunten te zoeken om de zorgconsumptie op HAP’s – en daarmee de werkdruk en de kosten – in de hand te houden.MethodeWij voerden een crosssectioneel vragenlijstonderzoek uit onder een aselecte steekproef van 800 huisartsen.ResultatenVan de 428 respondenten (53,5%) bevestigde 86,5% dat de werkdruk op de HAP is toegenomen en was 91,8% van mening dat de zorgconsumptie kan worden teruggedrongen. Volgens de huisartsen zijn de belangrijkste redenen om bij een laagurgente klacht niet op de eigen huisarts te wachten de 24-uurs maatschappij (75,4%), ongerustheid of angst (65,8%) en de laagdrempelige toegang tot de HAP (60,1%). Een grote meerderheid van de respondenten (83,9%) vond dat de telefonische triage strenger kan: te veel patiënten met laagurgente hulpvragen krijgen een consult of visite. De meest effectieve maatregelen om de zorgconsumptie te verminderen zijn volgens de respondenten: een eigen bijdrage van de patiënt, strengere triage en een grotere rol voor de telefoonarts. Minder effectief, maar even wenselijk, zijn patiëntenvoorlichting, betere telefonische bereikbaarheid van de huisartsenpraktijk, spreekuurtijd reserveren om patiënten dezelfde dag te zien en terugkoppeling van gegevens over de zorgconsumptie op HAP’s naar praktijken en triagisten.ConclusieHet overgrote deel van de ondervraagde huisartsen acht maatregelen noodzakelijk om de zorgconsumptie op HAP’s te verminderen. Het invoeren van een eigen bijdrage, strengere triage en een grotere rol voor de telefoonarts verdienen nader onderzoek, met aandacht voor het effect op de zorgconsumptie en de patiëntveiligheid.AbstractKeizer E, Maassen I, Smits M, Giesen P. How to control the use of primary care out-of-hours services? Huisarts Wet 2014;57(10):510-4.AimPrimary care out-of-hours services have a high workload and costs are increasing, but half of all contacts are of low urgency. It is important to look for ways to control the use of these services, and thereby the workload and costs.MethodCross-sectional survey study among a random sample of 800 general practitioners.ResultsOf the 428 respondents (53.5%), 86.5% confirmed that their workload had increased and 91.8% thought that the number of patient contacts could be reduced. They considered the main reasons why people with low urgency symptoms attended these services rather than wait to see their own GP to be the 24-hour society (75.4%), worry or anxiety 65.8%), and a low barrier to contact the service (60.1%). Many GPs (83.9%) believed that telephone triage (triage nurse and system) in part contributes to the high use of out-of hours services: too many patients with non-urgent problems are given a consultation. Measures that were believed both desirable and effective to reduce the number of patient contacts were a financial contribution from the patient, stricter triage, and a greater role for the telephone doctor in handling low-urgency cases. Patient education, improved telephone accessibility of daytime general practices, more possibilities for same-day appointments, and feedback of health consumption to practices and triage nurses were also considered desirable, but less effective.ConclusionMost GPs believe that steps should be taken to reduce the use of out-of-hours services, such as introducing a financial contribution from the patient, stricter triage, and a greater role for the telephone doctor. Further research is needed to examine the impact and safety of these strategies.

Migrants’ motives and expectations for contacting out-of-hours primary care: a survey study

BackgroundMigrants are more likely to use out-of-hours primary care, especially for nonurgent problems. Their motives and expectations for help-seeking are as yet unknown. The objective of this study is to examine the motives and expectations of migrants for contacting out-of-hours primary care.MethodsWe used data from a survey study of 11,483 patients who contacted a General Practitioner (GP) cooperative in the Netherlands between 2009 and 2014 (response rate 45.6%). Logistic regression analysis was used to test differences in motives and expectations between non-western and western migrants and native Dutch patients.ResultsThe main motives for contacting a GP cooperative for non-western and western migrants were an urgent need for contact with a GP (54.9%–52.4%), worry (49.3%–43.0%), and a need for medical information (21.3%–26.2%). These were also the most important motives for native Dutch patients. Compared to native Dutch patients, non-western migrants more often perceived an urgent need for a GP (OR 1.65; 99% CI 1.27–2.16), less often needed information (OR 0.59; 99% CI 0.43–0.81), and more often experienced problems contacting their own GP during office hours (OR 1.71; 99% CI 1.21–2.43). Western migrants also reported experiencing problems more often in contacting their own GP (OR 1.38; 99% CI 1.04–1.84).As well as for natives, most non-western and western migrants expected to see a doctor (46.2%–46.6%) or get advice (39.6%–41.5%). Non-western migrants expected more often to get physical examination (OR 1.53; 99% CI 1.14–2.04), and prescription (OR 1.37; 99% CI 1.00–1.88). We found no differences in expectations between western migrants and native Dutch patients.ConclusionThe main motives and expectations of migrants are similar to native Dutch patients, yet non-western migrants more often wanted action from the GP, e.g. examination or prescription, and less often passive forms of assistance such as giving information. At the same time they experience problems accessing their own GP. We recommend stimulation of self-care, education about the purpose of a GP cooperative, and examination and improvement of accessibility of daytime primary care.

Patient safety culture in out-of-hours primary care services in the Netherlands: a cross-sectional survey

Abstract Objective: To examine patient safety culture in Dutch out-of-hours primary care using the safety attitudes questionnaire (SAQ) which includes five factors: teamwork climate, safety climate, job satisfaction, perceptions of management and communication openness. Design: Cross-sectional observational study using an anonymous web-survey. Setting Sixteen out-of-hours general practitioner (GP) cooperatives and two call centers in the Netherlands. Subjects Primary healthcare providers in out-of-hours services. Main outcome measures Mean scores on patient safety culture factors; association between patient safety culture and profession, gender, age, and working experience. Results: Overall response rate was 43%. A total of 784 respondents were included; mainly GPs (N = 470) and triage nurses (N = 189). The healthcare providers were most positive about teamwork climate and job satisfaction, and less about communication openness and safety climate. The largest variation between clinics was found on safety climate; the lowest on teamwork climate. Triage nurses scored significantly higher than GPs on each of the five patient safety factors. Older healthcare providers scored significantly higher than younger on safety climate and perceptions of management. More working experience was positively related to higher teamwork climate and communication openness. Gender was not associated with any of the patient safety factors. Conclusions: Our study showed that healthcare providers perceive patient safety culture in Dutch GP cooperatives positively, but there are differences related to the respondents’ profession, age and working experience. Recommendations for future studies are to examine reasons for these differences, to examine the effects of interventions to improve safety culture and to make international comparisons of safety culture. Key Points Creating a positive patient safety culture is assumed to be a prerequisite for quality and safety. We found that: • healthcare providers in Dutch GP cooperatives perceive patient safety culture positively; • triage nurses scored higher than GPs, and older and more experienced healthcare professionals scored higher than younger and less experienced professionals – on several patient safety culture factors; and • within the GP cooperatives, safety climate and openness of communication had the largest potential for improvement.

Drukte op de HAP door ouders met jonge kinderen

SamenvattingInleiding Ouders met kinderen tussen 0 en 4 jaar doen relatief vaak een beroep op de huisartsenpost (HAP), en niet altijd met medisch noodzakelijke klachten. Wij onderzochten een aantal strategieën om hun zorgkeuze zo te beïnvloeden dat de werkdruk en de kosten op de HAP niet te hoog worden.Methode In de periode 2013-2015 stuurden we in vier Oost-Nederlandse huisartsenpraktijken vragenlijsten naar alle daar ingeschreven gezinnen met kinderen tussen 0 en 4 jaar (n = 797). We beschreven vier schriftelijke casussen – twee urgente en twee niet-urgente – in willekeurige combinatie met vier ‘vraagbeheersingsstrategieën’: een afspraak met de eigen huisarts de volgende ochtend, een eigen bijdrage, online advies, en inzicht in de kosten. Elk gezin ontving een vragenlijst met drie casussen die een strategie bevatten en één referentiecasus zonder strategie. Met logistische regressieanalyse testten we in hoeverre de toegevoegde strategieën de keuzes van de respondenten beïnvloedden.Resultaten We ontvingen 377 vragenlijsten retour (respons 47,3%). ‘Online advies’ leidde zowel bij de niet-urgente (OR 0,26; 95%-BI 0,11 tot 0,58) als bij de urgente casussen (OR 0,16; 95%-BI 0,08 tot 0,32) tot een adequatere zorgkeuze. Ook ‘inzicht in de kosten’ (OR 0,59; 95%-BI 0,38 tot 0,92) en ‘afspraak de volgende ochtend’ (OR 0,57; 95%-BI 0,34 tot 0,97) verbeterden de zorgkeuze, maar alleen bij urgente casussen. ‘Eigen bijdrage’ had geen invloed op de zorgkeuze.Conclusie Online advies kan in potentie het onnodig gebruik van huisartsenzorg buiten kantoortijd verminderen en een adequate zorgkeuze in urgente situaties juist bevorderen. Het gebruik van gevalideerde online tools zou gestimuleerd moeten worden.