Wim Verstappen

Improving Test Ordering in Primary Care: The Added Value of a Small-Group Quality Improvement Strategy Compared With Classic Feedback Only

PURPOSE We wanted to evaluate the added value of small peer-group quality improvement meetings compared with simple feedback as a strategy to improve test-ordering behavior. Numbers of tests ordered by primary care physicians are increasing, and many of these tests seem to be unnecessary according to established, evidence-based guidelines. METHODS We enrolled 194 primary care physicians from 27 local primary care practice groups in 5 health care regions (5 diagnostic centers). The study was a cluster randomized trial with randomization at the local physician group level. We evaluated an innovative, multifaceted strategy, combining written comparative feedback, group education on national guidelines, and social influence by peers in quality improvement sessions in small groups. The strategy was aimed at 3 specific clinical topics: cardiovascular issues, upper abdominal complaints, and lower abdominal complaints. The mean number of tests per physician per 6 months at baseline and the physicians’ region were used as independent variables, and the mean number of tests per physician per 6 months was the dependent variable. RESULTS The new strategy was executed in 13 primary care groups, whereas 14 groups received feedback only. For all 3 clinical topics, the decrease in mean total number of tests ordered by physicians in the intervention arm was far more substantial (on average 51 fewer tests per physician per half-year) than the decrease in mean number of tests ordered by physicians in the feedback arm (P = .005). Five tests considered to be inappropriate for the clinical problem of upper abdominal complaints decreased in the intervention arm, with physicians in the feedback arm ordering 13 more tests per 6 months (P = .002). Interdoctor variation in test ordering decreased more in the intervention arm. CONCLUSION Compared with only disseminating comparative feedback reports to primary care physicians, the new strategy of involving peer interaction and social influence improved the physicians’ test-ordering behavior. To be effective, feedback needs to be integrated in an interactive, educational environment.

What do primary care physicians and researchers consider the most important patient safety improvement strategies

BackgroundAlthough it has been increasingly recognised that patient safety in primary care is important, little is known about the feasibility and effectiveness of different strategies to improve patient safety in primary care. In this study, we aimed to identify the most important strategies by consulting an international panel of primary care physicians and researchers.MethodsA web-based survey was undertaken in an international panel of 58 individuals from eight countries with a strong primary care system. The questionnaire consisted of 38 strategies to improve patient safety. We asked the respondents whether these strategies were currently used in their own country, and whether they felt them to be important.ResultsMost of the 38 presented strategies were seen as important by a majority of the participants, but the use of strategies in daily practice varied widely. Strategies that yielded the highest scores (>70%) regarding importance included a good medical record system (82% felt this was very important, while 83% said it was implemented in more than half of the practices), good telephone access (71% importance, 83% implementation), standards for record keeping (75% importance, 62% implementation), learning culture (74% importance, 10% implementation), vocational training on patient safety for GPs (81% importance, 24% implementation) and the presence of a patient safety guideline (81% importance, 15% implementation).ConclusionAn international panel of primary care physicians and researchers felt that many different strategies to improve patient safety were important. Highly important strategies with poor implementation included a culture that is positive for patient safety, education on patient safety for physicians, and the presence of a patient safety guideline.

Patient safety features are more present in larger primary care practices

OBJECTIVES This study aimed to explore whether specific characteristics of a general practice organization were associated with aspects of patient safety management. METHODS Secondary analysis of data from 271 primary care practices, collected in 10 European countries. These data were collected by a practice visitor and physician questionnaires. For this study we constructed 10 measures of patient safety, covering 45 items as outcomes, and 6 measures of practice characteristics as possible predictors for patient safety. RESULTS Eight of the 10 patient safety measures yielded higher scores in larger practices (practices with more than 2 general practitioners). Medication safety (B 0.64), practice building safety (B 0.49) and incident reporting items (B 0.47) showed the strongest associations with practice size. Also measures on hygiene (B 0.37), medical record keeping (B 0.30), quality improvement (B 0.28), professional competence (B 0.24) and organized patient feedback items (B 0.24) had higher scores in larger practices. CONCLUSION Larger general practice practices may have better safety management, although through our measurements no causal relationship could be established in this study.

Complaints Against Family Physicians Submitted to Disciplinary Tribunals in the Netherlands: Lessons for Patient Safety

PURPOSE We analyzed the disciplinary law verdicts concerning family physicians, submitted to the Dutch disciplinary law system, to identify domains of high risk of harm for patients in family practice. METHODS The Dutch disciplinary law system offers patients the opportunity to file complaints against physicians outside a legal malpractice system, without possibility of financial compensation in case of verdicts in which the physician was found to be at fault. We performed an analysis of 250 random disciplinary law verdicts on Dutch family physicians submitted to disciplinary tribunals and published between 2008 and 2010. Our analysis focused on clinical domains represented in the verdicts with serious permanent damage or death. RESULTS Of the 74 complaints with a serious health outcome, 44.6% (n = 33) were related to a wrong diagnosis, 23.0% (n = 17) to insufficient care, 8.1% (n = 6) to a wrong treatment, 8.1% (n = 6) to a late arrival at a house visit, 5.4% (n = 4) to a late referral to the hospital, and 1.4% (n = 1) to insufficient information given; 9.5% (n = 7) consisted of other complaints. The wrong or late diagnosis-related cases mostly consisted of myocardial infarction and stroke (35.1%) and malignancies (33.7%). The family physician was disciplined as a result of 37 of these 74 complaints (50%). Logistic regression analysis showed that a serious outcome was associated with a higher probability of disciplinary measures (B=0.703; P =.02) CONCLUSIONS The disciplinary law system in the Netherlands differs fundamentally from a legal malpractice system. It can be used to learn from patients’ complaints with a view on improving patient safety.

A research agenda on patient safety in primary care. Recommendations by the LINNEAUS collaboration on patient safety in primary care.

ABSTRACT Background: Healthcare can cause avoidable serious harm to patients. Primary care is not an exception, and the relative lack of research in this area lends urgency to a better understanding of patient safety, the future research agenda and the development of primary care oriented safety programmes. Objective: To outline a research agenda for patient safety improvement in primary care in Europe and beyond. Methods: The LINNEAUS collaboration partners analysed existing research on epidemiology and classification of errors, diagnostic and medication errors, safety culture, and learning for and improving patient safety. We discussed ideas for future research in several meetings, workshops and congresses with LINNEAUS collaboration partners, practising GPs, researchers in this field, and policy makers. Results: This paper summarizes and integrates the outcomes of the LINNEAUS collaboration on patient safety in primary care. It proposes a research agenda on improvement strategies for patient safety in primary care. In addition, it provides background information to help to connect research in this field with practicing GPs and other healthcare workers in primary care. Conclusion: Future research studies should target specific primary care domains, using prospective methods and innovative methods such as patient involvement.

Variation in requests for imaging investigations by general practitioners: a multilevel analysis

Objectives To describe the variation in the numbers of imaging investigations requested by general practitioners (GPs) and to find likely explanations for this variation. Methods Cross-sectional survey of the use of eight imaging investigations by 229 GPs collaborating in 40 local GP groups from five regions in the Netherlands during 1997. A multivariable, multilevel regression analysis was used to link these data with survey data on professional characteristics such as knowledge about and attitude towards test ordering, and with data on contextual factors such as practice type or experience with feedback on test-ordering data. Results Data for 221 GPs (97%) were available. After adjustment for practice size and working time, the median number of imaging investigations ordered per GP was 148 (interquartile range 71 to 300), with large differences (up to twofold) between the regions (P<0.001). Overall, chest X-rays were the largest single category (median =48; interquartile range 17 to 100). GPs working in a group practice requested, on average, 34% fewer investigations than their colleagues working in single-person practices (95% confidence interval 17 to 48%). Conclusions Only practice type was found to be associated with the number of imaging investigations requested, adjusted for practice size and working time factor. No further explanations were found for the inter-regional differences. Future studies on the ordering of imaging investigations by GPs should attempt to delineate contextual from regional factors.

Patient safety improvement programmes for primary care. Review of a Delphi procedure and pilot studies by the LINNEAUS collaboration on patient safety in primary care

ABSTRACT Background: To improve patient safety it is necessary to identify the causes of patient safety incidents, devise solutions and measure the (cost-) effectiveness of improvement efforts. Objective: This paper provides a broad overview with practical guidance on how to improve patient safety. Methods: We used modified online Delphi procedures to reach consensus on methods to improve patient safety and to identify important features of patient safety management in primary care. Two pilot studies were carried out to assess the value of prospective risk analysis (PRA), as a means of identifying the causes of a patient safety incident. Results: A range of different methods can be used to improve patient safety but they have to be contextually specific. Practice organization, culture, diagnostic errors and medication safety were found to be important domains for further improvement. Improvement strategies for patient safety could benefit from insights gained from research on implementation of evidence-based practice. Patient involvement and prospective risk analysis are two promising and innovative strategies for improving patient safety in primary care. Conclusion: A range of methods is available to improve patient safety, but there is no ‘magic bullet.’ Besides better use of the available methods, it is important to use new and potentially more effective strategies, such as prospective risk analysis.

Good practice statements on safe laboratory testing: A mixed methods study by the LINNEAUS collaboration on patient safety in primary care

ABSTRACT Background: The systems-based management of laboratory test ordering and results handling is a known source of error in primary care settings worldwide. The consequences are wide-ranging for patients (e.g. avoidable harm or poor care experience), general practitioners (e.g. delayed clinical decision making and potential medico-legal implications) and the primary care organization (e.g. increased allocation of resources to problem-solve and dealing with complaints). Guidance is required to assist care teams to minimize associated risks and improve patient safety. Objective: To identify, develop and build expert consensus on ‘good practice’ guidance statements to inform the implementation of safe systems for ordering laboratory tests and managing results in European primary care settings. Methods: Mixed methods studies were undertaken in the UK and Ireland, and the findings were triangulated to develop ‘good practice’ statements. Expert consensus was then sought on the findings at the wider European level via a Delphi group meeting during 2013. Results: We based consensus on 10 safety domains and developed 77 related ‘good practice’ statements (≥ 80% agreement levels) judged to be essential to creating safety and minimizing risks in laboratory test ordering and subsequent results handling systems in international primary care. Conclusion: Guidance was developed for improving patient safety in this important area of primary care practice. We need to consider how this guidance can be made accessible to frontline care teams, utilized by clinical educators and improvement advisers, implemented by decision makers and evaluated to determine acceptability, feasibility and impacts on patient safety.

Organisational targets of patient safety improvement programs in primary care; an international web-based survey.

BackgroundOrganisational problems contribute to many errors in healthcare delivery. Our objective was to identify the most important organisational items in primary care which could be targeted by programs to improve patient safety.MethodsA web-based survey was undertaken in an international panel of 65 experts on patient safety from 20 countries. They were asked to rate 52 patient safety items on a five-point Likert scale which regards importance of each item for use for educational interventions to improve patient safety.ResultsThe following 7 organizational items were regarded ‘extremely important’ by more than 50% of the experts: the use of sterile equipment with small surgical procedures (63%), the availability of adequate emergency drugs in stock (60%), regular cleaning of facilities (59%), the use of sterile surgical gloves when recommended (57%), the availability of at least one adequately trained staff member to deal with collapse and need for resuscitation (56%), adequate information handover when a patient is discharged from the hospital (56%) and periodically training of GPs in basic life support and other medical emergencies (53%).ConclusionSeven organisational items were consistently prioritized; other items may be relevant in specific countries only. The logical next step is to develop and evaluate interventions targeted at these items.

A safety incident reporting system for primary care. A systematic literature review and consensus procedure by the LINNEAUS collaboration on patient safety in primary care

Background: Incident reporting is widely used in both patient safety improvement programmes, and in research on patient safety. Objective: To identify the key requirements for incident reporting systems in primary care; to develop an Internet-based incident reporting and learning system for primary care. Methods: A literature review looking at the purpose, design and requirements of an incident reporting system (IRS) was used to update an existing incident reporting system, widely used in Germany. Then, an international expert panel with knowledge on IRS developed the criteria for the design of a new web-based incident reporting system for European primary care. A small demonstration project was used to create a web-based reporting system, to be made freely available for practitioners and researchers. The expert group compiled recommendations regarding the desirable features of an incident reporting system for European primary care. These features covered the purpose of reporting, who should be involved in reporting, the mode of reporting, design considerations, feedback mechanisms and preconditions necessary for the implementation of an IRS. Results: A freely available web-based reporting form was developed, based on these criteria. It can be modified for local contexts. Practitioners and researchers can use this system as a means of recording patient safety incidents in their locality and use it as a basis for learning from errors. Conclusion: The LINNEAUS collaboration has provided a freely available incident reporting system that can be modified for a local context and used throughout Europe.