Mariëlle Kroese

A METHOD FOR RESEARCH PROGRAMMING IN THE FIELD OF EVIDENCE-BASED MEDICINE

OBJECTIVE This paper presents the method we used in programming research on the efficacy of therapeutic interventions for nine chronic benign pain disorders. METHODS We started with an inventory to identify commonly applied interventions. For these interventions we searched the literature to identify gaps in evidence. First, we searched for recent reviews, of which we assessed the methodologic quality. If only reviews of poor or moderate quality were found, a new systematic review was recommended. When we found no recent reviews, we searched for randomized controlled trials (RCTs). If there was insufficient or inconsistent evidence, the performance of a new RCT was advised. This structured procedure resulted in a list with topics for which new systematic reviews were recommended and topics for which new RCTs were needed. These lists were the starting points for priority setting by four Centers for Pain Management and Research. All members of the centers were asked to state the priority of each topic. The resulting hierarchy of topics for their own center was discussed in a meeting in each center, giving participants the opportunity to elucidate their views and considerations. RESULTS The final result was a robust priority list for the need of research (systematic reviews and RCTs) on chronic benign pain syndromes. DISCUSSION The strength and weaknesses of this approach are discussed. This method of priority setting is by no means restricted to treatments for chronic pain; it is also a useful approach for programming research to enable evidence-based medicine in other fields of interest.

Specialized rheumatology nurse substitutes for rheumatologists in the diagnostic process of fibromyalgia: A cost-consequence analysis and a randomized controlled trial

Objective. To perform a cost-consequence analysis of the substitution of specialized rheumatology nurses (SRN) for rheumatologists (RMT) in the diagnostic process of fibromyalgia (FM), using both a healthcare and societal perspective and a 9-month period. Methods. Alongside a randomized controlled trial, we measured costs and consequences of a nurse-led diagnostic consult (SRN group, n = 97) versus a rheumatologist-led diagnostic consult [usual care (UC) group, n = 96]. Patients were followed for 9 months. Every second month a questionnaire on medical consumption and social participation was filled out. Satisfaction was measured 1 week after the first consultation. During followup, health status was measured by health-related quality of life (EQ-5D), functional status (Fibromyalgia Impact Questionnaire), fatigue (Checklist Individual Strength), and self-efficacy (Generalized Self-Efficacy Scale). Results. Patients in the SRN group were significantly more satisfied. Improvements in health status were similar in both groups after 9 months of followup. Total costs for healthcare consumption and patient and family costs were significantly lower in the SRN group (€1298 vs €1644; difference €346; 95% CI –€746 to –€2). Total societal costs were €3853 per patient for the SRN group and €5293 for the UC group after 9 months of followup (difference €1440; 95% CI –€3721 to €577). Conclusion. From both a healthcare and societal perspective, the nurse-led diagnostic process can be recommended. Patients in the SRN group were significantly more satisfied, improvements in health status were similar in both groups, and total societal costs were lower for the SRN group compared to the RMT group after 9 months’ followup. Registered with Current Controlled Trials, no. ISRCTN77212411.

Therapeutic approaches to fibromyalgia in the Netherlands: a comparison between 1998 and 2005

RATIONALE In this study, information was gathered from five disciplines on their usual management methods for fibromyalgia (FM) in order to asses whether treatment regimens have changed in the Netherlands during a period of 6 years. In addition, insight was gained into the therapeutic motives of the professionals. METHOD A questionnaire was sent to a sample of 150 persons per discipline: general practitioners (GPs), rheumatologists (RMTs), rehabilitation specialists (RS), physical therapists and psychologists. RESULTS The overall response rate was 40.4%. The referral behaviour changed (significantly), especially between GPs and RMTs. An increased choice for aerobic exercise (RS: P = 0.023) and multidisciplinary therapy (RMT: P = 0.046) was found. RMTs and RS showed decreased medication prescribing (RMT: P = 0.024). Preferences of treatment for FM differ per discipline. The choice is principally made on the basis of subjective, professional group-bound factors. Particularly for GPs, dynamic patient factors are an important motive in the management of FM. CONCLUSIONS Despite the fact that most changes found are in conformity with the literature, the absolute application percentages of recommended therapies are still very low. The differences in practice between the several disciplines seem explicable on the basis of the factors that have a prominent role in the choice of a therapy for FM. This study underlines the need for further research into methods and processes of the management of FM, and their clinical effectiveness. An effective way of dissemination, especially of guidelines, is essential.

Interprofessional communication failures in acute care chains: How can we identify the causes?

Abstract Although communication failures between professionals in acute care delivery occur, explanations for these failures remain unclear. We aim to gain a deeper understanding of interprofessional communication failures by assessing two different explanations for them. A multiple case study containing six cases (i.e. acute care chains) was carried out in which semi-structured interviews, physical artifacts and archival records were used for data collection. Data were entered into matrices and the pattern-matching technique was used to examine the two complementary propositions. Based on the level of standardization and integration present in the acute care chains, the six acute care chains could be divided into two categories of care processes, with the care chains equally distributed among the categories. Failures in communication occurred in both groups. Communication routines were embedded within organizations and descriptions of communication routines in the entire acute care chain could not be found. Based on the results, failures in communication could not exclusively be explained by literature on process typology. Literature on organizational routines was useful to explain the occurrence of communication failures in the acute care chains. Organizational routines can be seen as repetitive action patterns and play an important role in organizations, as most processes are carried out by means of routines. The results of this study imply that it is useful to further explore the role of organizational routines on interprofessional communication in acute care chains to develop a solution for failures in handover practices.

Barriers to implementation of a redesign of information transfer and feedback in acute care: results from a multiple case study

BackgroundAccurate information transfer is an important element of continuity of care and patient safety. Despite the demonstrated urge for improvement of communication in acute care, there is a lack of data on improvements of communication. This study aims to describe the barriers to implementation of a redesign of the existing model for information transfer and feedback.MethodsA case study with six cases (i.e. acute care chains), using mixed methods was carried out in the Netherlands. The redesign was implemented in one acute care chain while the five other acute care chains served as control groups. Focus group interviews were held with members of the acute care chains and questionnaires were sent to care providers working in the acute care chains.ResultsRespondents reported three sets of barriers for implementation of the model: (a) existing routines for information transfer and feedback in organizations within the acute care chain; (b) barriers related to the implementation method and time period; and (c) the absence of a high ‘sense of urgency’ amongst providers in the acute care chain which would aid in improving the communication process.ConclusionsThis study shows that organizational factors play an important role in the success or failure of redesigning a communication process. Organizational routines can hamper implementation of a redesign if it differs too much from the routines of care providers involved. Besides focussing on provider characteristics in the implementation of a redesigned process, specific attention should be paid to unlearning existing organizational routines.