Mirjam Harmsen

The Impact of Nonphysician Clinicians Do They Improve the Quality and Cost-Effectiveness of Health Care Services?

Health care is changing rapidly. Unacceptable variations in service access and quality of health care and pressures to contain costs have led to the redefinition of professional roles. The roles of nonphysician clinicians (nurses, physician assistants, and pharmacists) have been extended to the medical domain. It is expected that such revision of roles will improve health care effectiveness and efficiency. The evidence suggests that nonphysician clinicians working as substitutes or supplements for physicians in defined areas of care can maintain and often improve the quality of care and outcomes for patients. The effect on health care costs is mixed, with savings dependent on the context of care and specific nature of role revision. The evidence base underpinning these conclusions is strongest for nurses with a marked paucity of research into pharmacists and physician assistants. More robust evaluative studies into role revision are needed, particularly with regard to economic impacts, before definitive conclusions can be drawn.

Incidence rates and management of urinary tract infections among children in Dutch general practice: results from a nation-wide registration study

BackgroundWe aimed to investigate incidence rates of urinary tract infections in Dutch general practice and their association with gender, season and urbanisation level, and to analyse prescription and referral in case of urinary tract infections.MethodDuring one calendar year, 195 general practitioners in 104 practices in the Netherlands registered all their patient contacts. This study was performed by the Netherlands Institute for Health Services Research (NIVEL) in 2001. Of 82,053 children aged 0 to 18 years, the following variables were collected: number of episodes per patient, number of contacts per episode, month of the year in which the diagnosis of urinary tract infection was made, age, gender, urbanisation level, drug prescription and referral.ResultsThe overall incidence rate was 19 episodes per 1000 person years. The incidence rate in girls was 8 times as high as in boys. The incidence rate in smaller cities and rural areas was 2 times as high as in the three largest cities. Throughout the year, incidence rates varied with a decrease in summertime for children at the age of 0 to 12 years. Of the prescriptions, 66% were in accordance with current guidelines, but only 18% of the children who had an indication were actually referred.ConclusionThis study shows that incidence rates of urinary tract infections are not only related to gender and season, but also to urbanisation. General practitioners in the Netherlands frequently do not follow the clinical guidelines for urinary tract infections, especially with respect to referral.

Management of children's urinary tract infections in Dutch family practice: a cohort study

BackgroundOptimal clinical management of childhood urinary tract infections (UTI) potentiates long-term positive health effects. Insight into the quality of care in Dutch family practices for UTIs was limited, particularly regarding observation periods of more than a year. Our aim was to describe the clinical management of young childrens UTIs in Dutch primary care and to compare this to the national guideline recommendations.MethodsIn this cohort study, all 0 to 6-year-old children with a diagnosed UTI in 2001 were identified within the Netherlands Information Network of General Practitioners (LINH), which comprises 120 practices. From the Dutch guideline on urinary tract infections, seven indicators were derived, on prescription, follow-up, and referral.ResultsOf the 284 children with UTI who could be followed for three years, 183 (64%) were registered to have had one cystitis episode, 52 (18%) had two episodes, and 43 (15%) had three or more episodes. Another six children were registered to have had one or two episodes of acute pyelonephritis. Overall, antibiotics were prescribed for 66% of the children having had ≤ 3 cystitis episodes, two-thirds of whom received the antibiotics of first choice. About 30% of all episodes were followed up in general practice. Thirty-eight children were referred (14%), mostly to a paediatrician (76%). Less than one-third of the children who should have been referred was actually referred.ConclusionTreatment of childhood UTIs in Dutch family practice should be improved with respect to prescription, follow-up, and referral. Quality improvement should address the low incidence of urinary tract infections in children in family practice.

Management of Childhood Urinary Tract Infections: An Economic Modeling Study

UNLABELLED Childhood urinary tract infections (UTIs) can lead to renal scarring and ultimately to terminal renal failure, which has a high impact on quality of life, survival, and health-care costs. Variation in the treatment of UTIs between practices is high. OBJECTIVE To assess the cost-effectiveness of a maximum care model for UTIs in children, implying more testing and antibiotic treatment, compared with current practice in primary care in The Netherlands. METHODS We performed a probabilistic modeling study using Markov models. Figures used in the model were derived from a systematic review of the research literature. Multidimensional Monte Carlo simulation was used for the probabilistic analyses. RESULTS Maximum care gained 0.00102 (males) and 0.00219 (girls) QALYs (quality-adjusted life-years) and saved 42.70 euro (boys) and 77.81 euro (girls) in 30 years compared with current care, and was thus dominant. Net monetary benefit of maximum care ranged from 20 euro to 200 euro for a willingness to pay for a QALY ranging from 0 euro to 80,000 euro, respectively. Maximum care was also dominant over improved current care, although less dominant than to current care. CONCLUSIONS This study suggested that maximum care for childhood UTI was dominant in the long run to current care, meaning that it delivered more quality of life at lower costs. Nevertheless, making firm conclusions is not possible, given the limitations of the input data.

Development of quality indicators based on a multidisciplinary, evidence-based guideline on pediatric constipation.

Several clinical guidelines for childhood functional constipation have been developed, but none of them is accompanied by a set of quality indicators. It is important to gain insight into the quality of care in daily practice in order to improve the implementation of clinical guidelines. This can be done by developing and measuring quality indicators. We identified a set of quality indicators for diagnosis and treatment of children with functional constipation, based on the existing Dutch evidence-based multidisciplinary guideline ‘Functional constipation in children between 0 and 18 years’ and expert opinions of professionals and patients. Assessment of the initial 84 potential quality indicators was done by using a RAND-modified Delphi method. The final set consisted of seven representative quality indicators (one structure and six process quality indicators) for children with functional constipation, covering the dimensions of diagnosis, medical treatment, non-medical treatment and referral. This study describes a systematic method to develop a set of seven process and structure quality indicators that can be used to monitor quality of health care for children with functional constipation.

Patient safety in midwifery care for low-risk women: instrument development.

INTRODUCTION Few studies have examined the safety of midwife-led care for low-risk childbearing women. While most women have a low-risk profile at the start of pregnancy, validated measures to detect patient safety risks for this population are needed. The increased interest of midwife-led care for childbearing women to substitute for other models of care requires careful evaluation of safety aspects. In this study, we developed and tested an instrument for safety assessment of midwifery care. METHODS A structured approach was followed for instrument development. First, we reviewed the literature on patient safety in general and obstetric and midwifery care in particular. We identified 5 domains of patient risk: organization, communication, patient-related risk factors, clinical management, and outcomes. We then developed a prototype to assess patient records and, in an iterative process, reviewed the prototype with the help of a review team of midwives and safety experts. The instrument was pilot tested for content validity, reliability, and feasibility. RESULTS Trained reviewers with clinical midwifery expertise applied the instrument. We were able to reduce the original 100-item screening instrument to 32 items and applied the instrument to patient records in a reliable manner. With regard to the validity of the instrument, review of the literature and the validation procedure produced good content validity. DISCUSSION A valid and feasible instrument to assess patient safety in low-risk childbearing women is now available and can be used for quantitative analyses of patient records and to identify unsafe situations. Identification and analysis of patient safety incidents required clinical judgment and consultation with the panel of safety experts. The instrument allows us to draw conclusions about safety and to recommend steps for specific, domain-based improvements. Studies on the use of the instrument for improving patient safety are recommended.

How do Dutch general practitioners diagnose children's urinary tract infections?

OBJECTIVE To study which tests general practitioners used to diagnose a urinary tract infection (UTI) in children and which patient characteristics were associated with test choice. DESIGN Retrospective chart review on the diagnosis of UTIs in children in Dutch general practices who were diagnosed as having a UTI. A total of 49 general practices participated in the study, and provided information on 148 children aged 0-12 years old. RESULTS The nitrite test, which is recommended as first step, was performed in 87% of the children during the first contact. Less than 30% of the children had a dipslide and 37% a cultured urine. About half of all children with a UTI diagnosis had a follow-up contact in general practice, and an average of 83% of these children had their urine tested. The recommended test, a dipslide, was performed in 26% of the children with a follow-up contact. Patient age and UTI history were associated with choice of test. CONCLUSIONS The diagnostic procedures for UTIs in children in general practices could be improved, with focus on the importance of an accurate UTI diagnosis in all children, and explaining which tests should be performed and what the test results mean.

Verbetering mogelijk in de behandeling van kinderen met urineweginfecties

Een tijdige opsporing en behandeling van urineweginfecties bij (jonge) kinderen kan helpen om eventuele littekenvorming in de nieren te voorkomen. Op latere leeftijd kan littekenvorming leiden tot bijvoorbeeld hypertensie, problemen tijdens de zwangerschap of zelfs nierfalen. De richtlijnen uit de NHG-Standaard Urineweginfecties zijn duidelijk over het beleid in de huisartsenpraktijk wat betreft antibiotica, follow-up en verwijzen. Maar hoe handelt de Nederlandse huisarts bij kinderen met een urineweginfectie? En is verbetering mogelijk?