J. van Lieshout

Medication management strategy for older people with polypharmacy in general practice: a qualitative study on prescribing behaviour in primary care.

BACKGROUNDnFor older patients with polypharmacy, medication management is a process of careful deliberation that needs periodic adjustment based on treatment effects and changing conditions. Because of the heterogeneity of the patient group, and limited applicability of current guidelines, it is difficult for GPs to build up a routine.nnnAIMnTo gain insight into GPs medication management strategies for patients with polypharmacy, and to explore the GPs perspectives and needs on decision-making support to facilitate this medication management.nnnDESIGN AND SETTINGnTwo focus group meetings with Dutch GPs, discussing four clinical vignettes of patients with multimorbidity and polypharmacy.nnnMETHODnQuestions about medication management of the vignettes were answered individually; the strategy chosen in each case was discussed in plenary. Analysis followed a Framework approach.nnnRESULTSnIn total, 12 GPs described a similar strategy regarding the patients medication management: defining treatment goals; determining primary goals; and adjusting medications based on the treatment effect, GPs and patients preferences, and patient characteristics. There was variation in the execution of this strategy between the GPs. The GPs would like to discuss their choices with other professionals and they valued structured medication reviews with the patient, as well as quick and practical support tools that work on demand.nnnCONCLUSIONnTo facilitate decision making, a more extensive and structured collaboration between healthcare professionals is desired, as well as support to execute structured medication reviews with eligible patients, and some on-demand tools for individual consultations.

Effectiveness of personalised support for self-management in primary care: a cluster randomised controlled trial

BACKGROUNDnSelf-management support is an important component of the clinical management of many chronic conditions. The validated Self-Management Screening questionnaire (SeMaS) assesses individual characteristics that influence a patients ability to self-manage.nnnAIMnTo assess the effect of providing personalised self-management support in clinical practice on patients activation and health-related behaviours.nnnDESIGN AND SETTINGnA cluster randomised controlled trial was conducted in 15 primary care group practices in the south of the Netherlands.nnnMETHODnAfter attending a dedicated self-management support training session, practice nurses in the intervention arm discussed the results of SeMaS with the patient at baseline, and tailored the self-management support. Participants completed a 13-item Patient Activation Measure (PAM-13) and validated lifestyle questionnaires at baseline and after 6 months. Data, including individual care plans, referrals to self-management interventions, self-monitoring, and healthcare use, were extracted from patients medical records. Multilevel multiple regression was used to assess the effect on outcomes.nnnRESULTSnThe PAM-13 score did not differ significantly between the control (n = 348) and intervention (n = 296) arms at 6 months. In the intervention arm, 29.4% of the patients performed self-monitoring, versus 15.2% in the control arm (effect size r = 0.9, P = 0.01). In the per protocol analysis (control n = 348; intervention n = 136), the effect of the intervention was significant on the number of individual care plans (effect size r = 1.3, P = 0.04) and on self-monitoring (effect size r = 1.0, P = 0.01).nnnCONCLUSIONnThis study showed that discussing SeMaS and offering tailored support did not affect patient activation or lifestyle, but did stimulate patients to self-monitor and use individual care plans.

Process evaluation of five tailored programs to improve the implementation of evidence-based recommendations for chronic conditions in primary care

BackgroundAlthough there is evidence that tailored implementation strategies can be effective, there is little evidence on which methods of tailoring improve the effect. We designed and evaluated five tailored programs (TPs) each consisting of various strategies. The aim of this study was to examine (a) how determinants of practice prioritized in the design phase of the TPs were perceived by health care professionals who had been exposed to the TPs and whether they suggested other important determinants of practice and (b) how professionals used the offered strategies and whether they suggested other strategies that might have been more effective.MethodsWe conducted a mixed-method process evaluation linked to five cluster-randomized trials carried out in five European countries to implement recommendations for five chronic conditions in primary care settings. The five TPs used a total of 28 strategies which aimed to address 38 determinants of practice. Interviews of professionals in the intervention groups and a survey of professionals in the intervention and control groups were performed. Data collection was conducted by each research team in the respective national language. The interview data were first analyzed inductively by each research team, and subsequently, a meta-synthesis was conducted. The survey was analyzed descriptively.ResultsWe conducted 71 interviews; 125 professionals completed the survey. The survey showed that 76xa0% (nu2009=u200929) of targeted determinants of practice were perceived as relevant and 95xa0% (nu2009=u200936) as being modified by the implementation interventions by 66 to 100xa0% of professionals. On average, 47xa0% of professionals reported using the strategies and 51xa0% considered them helpful, albeit with substantial variance between countries and strategies. In the interviews, 89 determinants of practice were identified, of which 70xa0% (nu2009=u200962) had been identified and 45xa0% (nu2009=u200940) had been prioritized in the design phase. The interviewees suggested 65 additional strategies, of which 54xa0% (nu2009=u200935) had been identified and 20xa0% (nu2009=u200913) had been prioritized, but not selected in the final programs.ConclusionsThis study largely confirmed the perceived relevance of the targeted determinants of practice. This contrasts with the fact that no impact of the trials on the implementation of the recommendations could be observed. The findings suggest that better methods for prioritization of determinants and strategies are needed.Trial registrationEach of the five trials was registered separately in recognized trial registries. Details are given in the respective trial outcome papers.

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.