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Müskens JLJM, van Dulmen SA, Hek K, Westert GP, Kool RB. Low-value chronic prescription of acid reducing medication among Dutch general practitioners: impact of a patient education intervention. BMC Prim Care 2024; 25:106. [PMID: 38575887 PMCID: PMC10996147 DOI: 10.1186/s12875-024-02351-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 03/27/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Dyspepsia is a commonly encountered clinical condition in Dutch general practice, which is often treated through the prescription of acid-reducing medication (ARM). However, recent studies indicate that the majority of chronic ARM users lack an indication for their use and that their long-term use is associated with adverse outcomes. We developed a patient-focussed educational intervention aiming to reduce low-value (chronic) use of ARM. METHODS We conducted a randomized controlled study, and evaluated its effect on the low-value chronic prescription of ARM using data from a subset (n = 26) of practices from the Nivel Primary Care Database. The intervention involved distributing an educational waiting room posters and flyers informing both patients and general practitioners (GPs) regarding the appropriate indications for prescription of an ARM for dyspepsia, which also referred to an online decision aid. The interventions' effect was evaluated through calculation of the odds ratio of a patient receiving a low-value chronic ARM prescription over the second half of 2021 and 2022 (i.e. pre-intervention vs. post-intervention). RESULTS In both the control and intervention groups, the proportion of patients receiving chronic low-value ARM prescriptions slightly increased. In the control group, it decreased from 50.3% in 2021 to 49.7% in 2022, and in the intervention group it increased from 51.3% in 2021 to 53.1% in 2022. Subsequent statistical analysis revealed no significant difference in low-value chronic prescriptions between the control and intervention groups (Odds ratio: 1.11 [0.84-1.47], p > 0.05). CONCLUSION Our educational intervention did not result in a change in the low-value chronic prescription of ARM; approximately half of the patients of the intervention and control still received low-value chronic ARM prescriptions. The absence of effect might be explained by selection bias of participating practices, awareness on the topic of chronic AMR prescriptions and the relative low proportion of low-value chronic ARM prescribing in the intervention as well as the control group compared to an assessment conducted two years prior. TRIAL REGISTRATION 10/31/2023 NCT06108817.
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Affiliation(s)
- Joris L J M Müskens
- IQ Health Science Department, Radboud University Medical Center, Research Institute for Medical Innovation, Nijmegen, The Netherlands.
| | - Simone A van Dulmen
- IQ Health Science Department, Radboud University Medical Center, Research Institute for Medical Innovation, Nijmegen, The Netherlands
| | - Karin Hek
- Nivel, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Gert P Westert
- IQ Health Science Department, Radboud University Medical Center, Research Institute for Medical Innovation, Nijmegen, The Netherlands
| | - Rudolf B Kool
- IQ Health Science Department, Radboud University Medical Center, Research Institute for Medical Innovation, Nijmegen, The Netherlands
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Müskens JLJM, Olde Hartman TC, Schers HJ, Akkermans RP, Westert GP, Kool RB, van Dulmen SA. Trends in low-value GP care during the COVID-19 pandemic: a retrospective cohort study. BMC Prim Care 2024; 25:73. [PMID: 38418951 PMCID: PMC10900726 DOI: 10.1186/s12875-024-02306-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 02/12/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Several studies showed that during the pandemic patients have refrained from visiting their general practitioner (GP). This resulted in medical care being delayed, postponed or completely forgone. The provision of low-value care, i.e. care which offers no net benefit for the patient, also could have been affected. We therefore assessed the impact of the COVID-19 restrictions on three types of low-value GP care: 1) imaging for back or knee problems, 2) antibiotics for otitis media acuta (OMA), and 3) repeated opioid prescriptions, without a prior GP visit. METHODS We performed a retrospective cohort study using registration data from GPs part of an academic GP network over the period 2017-2022. The COVID-19 period was defined as the period between April 2020 to December 2021. The periods before (January 2017 to April 2020) and after the COVID-19 period (January 2022 to December 2022) are the pre- and post-restrictions periods. The three clinical practices examined were selected by two practicing GPs from a top 30 of recommendations originating from the Dutch GP guidelines, based on their perceived prevalence and relevance in practice (van Dulmen et al., BMC Primary Care 23:141, 2022). Multilevel Poisson regression models were built to examine changes in the incidence rates (IR) of both registered episodes and episodes receiving low-value treatment. RESULTS During the COVID-19 restrictions period, the IRs of episodes of all three types of GP care decreased significantly. The IR of episodes of back or knee pain decreased by 12%, OMA episodes by 54% and opioid prescription rate by 13%. Only the IR of OMA episodes remained significantly lower (22%) during the post-restrictions period. The provision of low-value care also changed. The IR of imaging for back or knee pain and low-value prescription of antibiotics for OMA both decreased significantly during the COVID-restrictions period (by 21% and 78%), but only the low-value prescription rate of antibiotics for OMA remained significantly lower (by 63%) during the post-restrictions period. The IR of inappropriately repeated opioid prescriptions remained unchanged over all three periods. CONCLUSIONS This study shows that both the rate of episodes as well as the rate at which low-value care was provided have generally been affected by the COVID-19 restrictions. Furthermore, it shows that the magnitude of the impact of the restrictions varies depending on the type of low-value care. This indicates that deimplementation of low-value care requires tailored (multiple) interventions and may not be achieved through a single disruption or intervention alone.
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Affiliation(s)
- Joris L J M Müskens
- Radboud University Medical Center, IQ Health Science Department, Nijmegen, The Netherlands.
| | - Tim C Olde Hartman
- Radboud University Medical Center, Department of Primary and Community Care at Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Henk J Schers
- Radboud University Medical Center, Department of Primary and Community Care at Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Reinier P Akkermans
- Radboud University Medical Center, IQ Health Science Department, Nijmegen, The Netherlands
| | - Gert P Westert
- Radboud University Medical Center, IQ Health Science Department, Nijmegen, The Netherlands
| | - Rudolf B Kool
- Radboud University Medical Center, IQ Health Science Department, Nijmegen, The Netherlands
| | - Simone A van Dulmen
- Radboud University Medical Center, IQ Health Science Department, Nijmegen, The Netherlands
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Verkerk EW, Waal GHD, Overtoom LC, Westert GP, Vermeulen H, Kool RB, van Dulmen SA. Low-value wound care: Are nurses and physicians choosing wisely? A mixed methods study. Int J Nurs Pract 2023; 29:e13170. [PMID: 37272259 DOI: 10.1111/ijn.13170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 05/02/2023] [Accepted: 05/22/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND Choosing Wisely is an international movement that stimulates conversations about unnecessary care. The campaign created five recommendations including a statement that less wound care is sometimes better. AIMS The study aims to evaluate nurses' and physicians' adherence to the Choosing Wisely recommendations for acute wound care in the Netherlands and the barriers and facilitators to improve this. DESIGN This is a mixed methods study using a survey and interviews. METHODS The survey was completed by 171 nurses and 71 physicians from November 2017 to February 2018. A total of 17 nurses and 6 physicians were interviewed. RESULTS Awareness of the five recommendations ranged from 62% to 89% for nurses and 46% to 85% for physicians. However, up to 15% of the nurses and 28% of physicians were aware but did not adhere to the recommendations. Barriers to adhering were a lack of knowledge, the work environment and perceptions of patients' preferences. Repeated attention, cost-consciousness and an open culture facilitated the implementation. CONCLUSION Although most nurses and physicians were aware of the recommendations, not all adhered to them. Increasing awareness is not enough for successful implementation. A tailored approach that removes the barriers is necessary, such as increasing knowledge about wounds and changing the work environment.
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Affiliation(s)
- Eva W Verkerk
- Radboud Institute for Health Sciences, Department of IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Getty Huisman-de Waal
- Radboud Institute for Health Sciences, Department of IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lydia C Overtoom
- Radboud Institute for Health Sciences, Department of IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gert P Westert
- Radboud Institute for Health Sciences, Department of IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hester Vermeulen
- Radboud Institute for Health Sciences, Department of IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rudolf B Kool
- Radboud Institute for Health Sciences, Department of IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Simone A van Dulmen
- Radboud Institute for Health Sciences, Department of IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
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Remers TEP, Kruse FM, van Dulmen SA, Oostra DL, Maessen MFM, Jeurissen PPT, Rikkert MGMO. Effects of DementiaNet's Community Care Network Approach on Admission Rates and Healthcare Costs: A Longitudinal Cohort Analysis. Int J Health Policy Manag 2023; 12:7700. [PMID: 38618787 PMCID: PMC10699814 DOI: 10.34172/ijhpm.2023.7700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 10/07/2023] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND People with dementia are increasingly living at home, relying on primary care providers for most healthcare needs. Suboptimal collaboration and communication between providers could cause inefficiencies and worse patient outcomes. Innovative strategies are needed to address this growing disease burden and rising healthcare costs. The DementiaNet programme, a community care network approach targeted at patients with dementia in the Netherlands, has been shown to improve patient's quality of care. However, very little is known about the impact of DementiaNet on admission risks and healthcare costs. This study addresses this knowledge gap. METHODS A longitudinal cohort analysis was performed, using medical and long-term care claims data from 38 525 patients between 2015-2019. The primary outcomes were risk of hospital admission and annual total healthcare costs. Mixed-model regression analyses were used to identify changes in outcomes. RESULTS Patients who received care from a DementiaNet community care network showed a general trend in lower risk of admission for all types of admissions studied (ie, hospital, emergency ward, intensive care, crisis, and nursing home). Also, the intervention group showed a significant reduction of 12% in nursing days (relative risk [RR] 0.88; 95% CI: 0.77- 0.96). No significant differences were found for total healthcare costs. However, we found effects in two sub-elements of total healthcare costs, being a decrease of 19.7% (95% CI: 7.7%-30.2%) in annual hospital costs and an increase of 10.2% (95% CI: 2.3%-18.6%) in annual primary care costs. CONCLUSION Our study indicates that DementiaNet's community care network approach may reduce admission risks for patients with dementia over a long-term period of five years. This is accompanied by a decrease in nursing days and savings in hospital care that exceed increased primary care costs. This improvement in integrated dementia care supports wider scale implementation and evaluation of these networks.
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Affiliation(s)
- Toine EP Remers
- Radboud university medical center, Scientific center for quality of healthcare (IQ healthcare), Nijmegen, The Netherlands
| | - Florien M. Kruse
- Radboud university medical center, Scientific center for quality of healthcare (IQ healthcare), Nijmegen, The Netherlands
| | - Simone A. van Dulmen
- Radboud university medical center, Scientific center for quality of healthcare (IQ healthcare), Nijmegen, The Netherlands
| | - Dorien L. Oostra
- Radboud university medical center, Department of Geriatric Medicine, Nijmegen, The Netherlands
| | - Martijn FM Maessen
- Coöperatie Volksgezondheidszorg, Business intelligence services, Arnhem, The Netherlands
| | - Patrick PT Jeurissen
- Radboud university medical center, Scientific center for quality of healthcare (IQ healthcare), Nijmegen, The Netherlands
| | - Marcel GM Olde Rikkert
- Radboud university medical center, Department of Geriatric Medicine, Nijmegen, The Netherlands
- Radboud university medical center, Donders Institute for Brain, Cognition and Behaviour, Department of Geriatric Medicine, Radboud Alzheimer Centre, Nijmegen, The Netherlands
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Auener SL, van Dulmen SA, Atsma F, van der Galiën O, Bellersen L, van Kimmenade R, Westert GP, Jeurissen PPT. Characteristics Associated With Telemonitoring Use Among Patients With Chronic Heart Failure: Retrospective Cohort Study. J Med Internet Res 2023; 25:e43038. [PMID: 37851505 PMCID: PMC10620630 DOI: 10.2196/43038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 02/28/2023] [Accepted: 08/28/2023] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND Chronic heart failure (HF) is a chronic disease affecting more than 64 million people worldwide, with an increasing prevalence and a high burden on individual patients and society. Telemonitoring may be able to mitigate some of this burden by increasing self-management and preventing use of the health care system. However, it is unknown to what degree telemonitoring has been adopted by hospitals and if the use of telemonitoring is associated with certain patient characteristics. Insight into the dissemination of this technology among hospitals and patients may inform strategies for further adoption. OBJECTIVE We aimed to explore the use of telemonitoring among hospitals in the Netherlands and to identify patient characteristics associated with the use of telemonitoring for HF. METHODS We performed a retrospective cohort study based on routinely collected health care claim data in the Netherlands. Descriptive analyses were used to gain insight in the adoption of telemonitoring for HF among hospitals in 2019. We used logistic multiple regression analyses to explore the associations between patient characteristics and telemonitoring use. RESULTS Less than half (31/84, 37%) of all included hospitals had claims for telemonitoring, and 20% (17/84) of hospitals had more than 10 patients with telemonitoring claims. Within these 17 hospitals, a total of 7040 patients were treated for HF in 2019, of whom 5.8% (409/7040) incurred a telemonitoring claim. Odds ratios (ORs) for using telemonitoring were higher for male patients (adjusted OR 1.90, 95% CI 1.50-2.41) and patients with previous hospital treatment for HF (adjusted OR 1.76, 95% CI 1.39-2.24). ORs were lower for higher age categories and were lowest for the highest age category, that is, patients older than 80 years (OR 0.30, 95% CI 0.21-0.44) compared to the reference age category (18-59 years). Socioeconomic status, degree of multimorbidity, and excessive polypharmacy were not associated with the use of telemonitoring. CONCLUSIONS The use of reimbursed telemonitoring for HF was limited up to 2019, and our results suggest that large variation exists among hospitals. A lack of adoption is therefore not only due to a lack of diffusion among hospitals but also due to a lack of scaling up within hospitals that already deploy telemonitoring. Future studies should therefore focus on both kinds of adoption and how to facilitate these processes. Older patients, female patients, and patients with no previous hospital treatment for HF were less likely to use telemonitoring for HF. This shows that some patient groups are not served as much by telemonitoring as other patient groups. The underlying mechanism of the reported associations should be identified in order to gain a deeper understanding of telemonitoring use among different patient groups.
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Affiliation(s)
- Stefan L Auener
- IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Simone A van Dulmen
- IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Femke Atsma
- IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Louise Bellersen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Roland van Kimmenade
- Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Gert P Westert
- IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Patrick P T Jeurissen
- IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
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Heus P, van Dulmen SA, Weenink JW, Naaktgeboren CA, Takada T, Verkerk EW, Kamm I, van der Laan MJ, Hooft L, Kool RB. What are Effective Strategies to Reduce Low-Value Care? An Analysis of 121 Randomized Deimplementation Studies. J Healthc Qual 2023; 45:261-271. [PMID: 37428942 PMCID: PMC10461725 DOI: 10.1097/jhq.0000000000000392] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
BACKGROUND Low-value care is healthcare leading to no or little clinical benefit for the patient. The best (combinations of) interventions to reduce low-value care are unclear. PURPOSE To provide an overview of randomized controlled trials (RCTs) evaluating deimplementation strategies, to quantify the effectiveness and describe different combinations of strategies. METHODS Analysis of 121 RCTs (1990-2019) evaluating a strategy to reduce low-value care, identified by a systematic review. Deimplementation strategies were described and associations between strategy characteristics and effectiveness explored. RESULTS Of 109 trials comparing deimplementation to usual care, 75 (69%) reported a significant reduction of low-value healthcare practices. Seventy-three trials included in a quantitative analysis showed a median relative reduction of 17% (IQR 7%-42%). The effectiveness of deimplementation strategies was not associated with the number and types of interventions applied. CONCLUSIONS AND IMPLICATIONS Most deimplementation strategies achieved a considerable reduction of low-value care. We found no signs that a particular type or number of interventions works best for deimplementation. Future deimplementation studies should map relevant contextual factors, such as the workplace culture or economic factors. Interventions should be tailored to these factors and provide details regarding sustainability of the effect.
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Kroon D, Stadhouders NW, van Dulmen SA, Kool RB, Jeurissen PP. Why Reducing Low-Value Care Fails to Bend the Cost Curve, and Why We Should Do it Anyway. Int J Health Policy Manag 2023; 12:7803. [PMID: 37579380 PMCID: PMC10461860 DOI: 10.34172/ijhpm.2023.7803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 04/16/2023] [Indexed: 08/16/2023] Open
Affiliation(s)
- Daniëlle Kroon
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands
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Auener SL, Jeurissen PPT, Lok DJA, van Duijn HJ, van Pol PEJ, Westert GP, van Dulmen SA. Use of regional transmural agreements to support the right care in the right place for patients with chronic heart failure-a qualitative study. Neth Heart J 2023; 31:109-116. [PMID: 36507945 PMCID: PMC9742644 DOI: 10.1007/s12471-022-01740-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Chronic heart failure (CHF) poses a major challenge for healthcare systems. As these patients' needs vary over time in intensity and complexity, the coordination of care between primary and secondary care is critical for them to receive the right care in the right place. To support the continuum of care needed, Dutch regional transmural agreements (RTAs) between healthcare providers have been developed. However, little is known about how the stakeholders have experienced the development and use of these RTAs. The aim of this study was to gain insight into how stakeholders have experienced the development and use of RTAs for CHF and explore which factors affected this. METHODS We interviewed 25 stakeholders from 9 Dutch regions based on the Measurement Instrument for Determinants of Innovations framework. Interview recordings were transcribed verbatim and analysed through open thematic coding. RESULTS In most cases, the RTA development was considered relatively easy. However, the participants noted that sustainable use of the RTAs faced different complexities and influencing factors. These barriers concerned the following themes: education of primary care providers, referral process, patients' willingness, relationships between healthcare providers, reimbursement by health insurance companies, electronic health record (EHR) systems and outcomes. CONCLUSION Some complexities, such as reimbursement and EHR systems, are likely to benefit from specialised support or a national approach. On a regional level, interregional learning can improve stakeholders' experiences. Future research should focus on quantitative effects of RTAs on outcomes and potential financing models for projects that aim to transition care from one setting to another.
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Affiliation(s)
- Stefan L. Auener
- grid.10417.330000 0004 0444 9382Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ Healthcare), Nijmegen, The Netherlands
| | - Patrick P. T. Jeurissen
- grid.10417.330000 0004 0444 9382Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ Healthcare), Nijmegen, The Netherlands
| | - Dirk J. A. Lok
- grid.413649.d0000 0004 0396 5908Department of Cardiology, Deventer Hospital, Deventer, The Netherlands
| | | | - Petra E. J. van Pol
- grid.440209.b0000 0004 0501 8269Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Gert P. Westert
- grid.10417.330000 0004 0444 9382Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ Healthcare), Nijmegen, The Netherlands
| | - Simone A. van Dulmen
- grid.10417.330000 0004 0444 9382Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ Healthcare), Nijmegen, The Netherlands
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Auener SL, van Dulmen SA, van Kimmenade R, Westert GP, Jeurissen PPJ. Sustainable adoption of noninvasive telemonitoring for chronic heart failure: A qualitative study in the Netherlands. Digit Health 2023; 9:20552076231196998. [PMID: 37654710 PMCID: PMC10467184 DOI: 10.1177/20552076231196998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 08/08/2023] [Indexed: 09/02/2023] Open
Abstract
Objective Noninvasive telemonitoring aims to improve healthcare for patients with chronic heart failure (HF) by reducing hospitalizations and improving patient experiences. Yet, sustainable adoption seems to be limited. Therefore, the goal of our study is to gain insight in the processes that support sustainable adoption of telemonitoring for patients with HF. Methods We conducted semi-structured interviews with 25 stakeholders that were involved with the adoption of telemonitoring, such as healthcare professionals, policymakers and healthcare insurers. We analyzed the interviews by using a combination of open-coding and the themes of the Non-adoption or Abandonment of technology by individuals and difficulties achieving Scale-up, Spread and Sustainability framework. Results We found that telemonitoring projects have moved beyond initial pilot phases despite a high level of complexity on multiple topics. The patient selection, the business case, the evidence, the aims of telemonitoring, integration of telemonitoring in the care pathway, reimbursement, and future centralization were items that yielded different and sometimes contradictory opinions. Conclusions This study showed that the sustainable adoption of telemonitoring for HF is a complex endeavor. Different aims and perspectives play an important role in the patient selection, design, evaluations and envisioned futures of telemonitoring. High conviction among participants of the added value that telemonitoring may support further adoption of telemonitoring. Structural evaluations will be needed to guide cyclical improvement and adapt programs to employ telemonitoring in such a manner that it contributes to collectively supported aims.
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Affiliation(s)
- Stefan L. Auener
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Simone A. van Dulmen
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - R van Kimmenade
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gert P Westert
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Patrick PJ Jeurissen
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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Verburg AC, Zincken J, Kiers H, van Dulmen SA, van der Wees PJ. Experiences of physiotherapists regarding a standard set of measurement instruments to improve quality of care for patients with chronic obstructive pulmonary disease: a mixed methods study. J Patient Rep Outcomes 2022; 6:79. [PMID: 35852671 PMCID: PMC9296726 DOI: 10.1186/s41687-022-00487-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 07/05/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Rationale
The quality of physiotherapy care for patients with chronic obstructive pulmonary disease (COPD) can be improved by comparing outcomes of care in practice.
Aim
To evaluate the experiences of physiotherapists implementing a standard set of measurement instruments to measure outcomes and improve the quality of care for patients with COPD.
Methods
This sequential explanatory mixed methods study was performed in two parts. In the quantitative part, a survey of 199 physiotherapists was conducted to evaluate their attitudes and knowledge, as well as the influence of contextual factors (i.e., practice policy and support from colleagues), in the implementation of the standard measurement set. In the qualitative part, 11 physiotherapists participated in individual interviews to elucidate their experiences using a thematical framework.
Results
The survey showed that, on average, 68.4% of the physiotherapists reported having a positive attitude about using the standard set, 85.0% felt they had sufficient knowledge of the measurement instruments, and 84.7% felt supported by practice policy and colleagues. In total, 80.3% of physiotherapists thought the standard set had added value in clinical practice, and 90.3% indicated that the measurement instruments can be valuable for evaluating treatment outcomes. The physiotherapists mentioned several barriers, such as lack of time and the unavailability of the entire standard set of measurement instruments in their practice. Moreover, the physiotherapists indicated that the measurement instruments have added value in providing transparency to policymakers through the anonymized publication of outcomes.
Conclusion
Physiotherapists support the use of the standard set of measurement instruments to improve the quality of physiotherapy treatment for patients with COPD.
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Kroon D, van Dulmen SA, Westert GP, Jeurissen PPT, Kool RB. Development of the SPREAD framework to support the scaling of de-implementation strategies: a mixed-methods study. BMJ Open 2022; 12:e062902. [PMID: 36343997 PMCID: PMC9644331 DOI: 10.1136/bmjopen-2022-062902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE We aimed to increase the understanding of the scaling of de-implementation strategies by identifying the determinants of the process and developing a determinant framework. DESIGN AND METHODS This study has a mixed-methods design. First, we performed an integrative review to build a literature-based framework describing the determinants of the scaling of healthcare innovations and interventions. PubMed and EMBASE were searched for relevant studies from 1995 to December 2020. We systematically extracted the determinants of the scaling of interventions and developed a literature-based framework. Subsequently, this framework was discussed in four focus groups with national and international de-implementation experts. The literature-based framework was complemented by the findings of the focus group meetings and adapted for the scaling of de-implementation strategies. RESULTS The literature search resulted in 42 articles that discussed the determinants of the scaling of innovations and interventions. No articles described determinants specifically for de-implementation strategies. During the focus groups, all participants agreed on the relevance of the extracted determinants for the scaling of de-implementation strategies. The experts emphasised that while the determinants are relevant for various countries, the implications differ due to different contexts, cultures and histories. The analyses of the focus groups resulted in additional topics and determinants, namely, medical training, professional networks, interests of stakeholders, clinical guidelines and patients' perspectives. The results of the focus group meetings were combined with the literature framework, which together formed the supporting the scaling of de-implementation strategies (SPREAD) framework. The SPREAD framework includes determinants from four domains: (1) scaling plan, (2) external context, (3) de-implementation strategy and (4) adopters. CONCLUSIONS The SPREAD framework describes the determinants of the scaling of de-implementation strategies. These determinants are potential targets for various parties to facilitate the scaling of de-implementation strategies. Future research should validate these determinants of the scaling of de-implementation strategies.
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Affiliation(s)
| | | | | | | | - Rudolf B Kool
- IQ Healthcare, Radboudumc, Nijmegen, The Netherlands
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12
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Verkerk EW, van Dulmen SA, Westert GP, Hooft L, Heus P, Kool RB. Reducing low-value care: what can we learn from eight de-implementation studies in the Netherlands? BMJ Open Qual 2022. [PMCID: PMC9454034 DOI: 10.1136/bmjoq-2021-001710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Reducing the overuse of care that is proven to be of low value increases the quality and safety of care. We aimed to identify lessons for reducing low-value care by looking at: (1) The effects of eight de-implementation projects. (2) The barriers and facilitators that emerged. (3) The experiences with the different components of the projects. Methods We performed a process evaluation of eight multicentre projects aimed at reducing low-value care. We reported the quantitative outcomes of the eight projects on the volume of low-value care and performed a qualitative analysis of the project teams’ experiences and evaluations. A total of 40 hospitals and 198 general practitioners participated. Results Five out of eight projects resulted in a reduction of low-value care, ranging from 11.4% to 61.3%. The remaining three projects showed no effect. Six projects monitored balancing measures and observed no negative consequences of their strategy. The most important barriers were a lack of time, an inability to reassure the patient, a desire to meet the patient’s wishes, financial considerations and a discomfort with uncertainty. The most important facilitators were support among clinicians, knowledge of the harms of low-value care and a growing consciousness that more is not always better. Repeated education and feedback for clinicians, patient information material and organisational changes were valued components of the strategy. Conclusions Successfully reducing low-value care is possible in spite of the powerful barriers that oppose it. The projects managed to recruit many hospitals and general practices, with five of them achieving significant results without measuring negative consequences. Based on our findings, we offer practical recommendations for successfully reducing low-value care.
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Affiliation(s)
- Eva W Verkerk
- Department of IQ healthcare, Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Simone A van Dulmen
- Department of IQ healthcare, Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Gert P Westert
- Department of IQ healthcare, Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Lotty Hooft
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Pauline Heus
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Rudolf B Kool
- Department of IQ healthcare, Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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Remers TE, Wackers EM, van Dulmen SA, Jeurissen PP. Towards population-based payment models in a multiple-payer system: the case of the Netherlands. Health Policy 2022; 126:1151-1156. [DOI: 10.1016/j.healthpol.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 05/10/2022] [Accepted: 09/21/2022] [Indexed: 11/04/2022]
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Verburg AC, van Dulmen SA, Kiers H, Nijhuis-van der Sanden MWG, van der Wees PJ. A practice test and selection of a core set of outcome-based quality indicators in Dutch primary care physical therapy for patients with COPD: a cohort study. ERJ Open Res 2022; 8:00008-2022. [PMID: 35983539 PMCID: PMC9379355 DOI: 10.1183/23120541.00008-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 06/06/2022] [Indexed: 12/02/2022] Open
Abstract
Aim To estimate the comparability and discriminability of outcome-based quality indicators by performing a practice test in Dutch physical therapy primary care, and to select a core set of outcome-based quality indicators that are well accepted by physical therapists based on their perceived added value as a quality improvement tool. Methods First, a list of potential quality indicators was defined, followed by determination of the comparability (case-mix adjusted multilevel analysis) and discriminability (intraclass correlation coefficient (ICC)). Second, focus group meetings were conducted with stakeholders (physical therapists and senior researchers) to select a core set of quality indicators. Results Overall, 229 physical therapists from 137 practices provided 2651 treatment episodes. Comparability: in 10 of the 11 case-mix adjusted models, the ICC increased compared with the intercept-only model. Discriminability: the ICC ranged between 0.01 and 0.34, with five of the 11 ICCs being >0.10. The majority of physical therapists in each focus group preferred the inclusion of seven quality indicators in the core set, including three process and four outcome indicators based upon the 6-min walk test (6MWT), the Clinical COPD Questionnaire (CCQ), and the determination of quadriceps strength using a hand-held dynamometer. Conclusion This is the first study to describe the comparability and discriminability of the outcome-based quality indicators selected for patients with COPD treated in primary care physical therapy practices. Future research should focus on increasing data collection in daily practice and on the development of tangible methods to use as the core set of a quality improvement tool. The major finding of this study is that all participants in the focus groups accepted the quality indicators as a quality improvement tool based on their perceived added value and selected a core set of seven outcome-based quality indicators for COPD.https://bit.ly/3NJuQtq
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van Dulmen SA, Tran NH, Wiersma T, Verkerk EW, Messaoudi JC, Burgers JS, Kool RB. Identifying and prioritizing do-not-do recommendations in Dutch primary care. BMC Prim Care 2022; 23:141. [PMID: 35658832 PMCID: PMC9164383 DOI: 10.1186/s12875-022-01713-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 04/18/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Low-value care provides minimal or no benefit for the patient, wastes resources, and can cause harm. Explicit do-not-do recommendations in clinical guidelines are a first step in reducing low-value care. The aim of this study was to identify and prioritize do-not-do recommendations in general practice guidelines with priority for implementation. METHODS We used a mixed method design in Dutch primary care. First, we identified do-not-do recommendations through a systematic assessment of 92 Dutch guidelines for general practitioners (GPs), resulting in 385 do-not-do recommendations. Second, we selected 146 recommendations addressing high prevalent conditions. Third, a random sample of 5000 Dutch GPs was invited for an online survey to prioritize recommendations based on the prevalence of the condition and low-value care practice, potential harm, and potential cost reduction on a scale from 1 to 5/6. Total scores could range from 4 to 22. Recommendations with a median score > 12 were included. In total, 440 GPs completed the survey. RESULTS The selection process led to 30 prioritised recommendations. These covered drug treatments (n = 12), diagnostics (n = 10), referral to other healthcare professions (n = 5), and non-drug treatment (n = 3). CONCLUSION Dutch clinical guidelines include many do-not-do recommendations that are perceived as highly relevant by the GPs. The list of 30 high-priority do-not-do recommendations can be used to raise awareness of low-value care among GPs. As the recommendations are supported with the latest evidence from international studies, primary healthcare professionals and policy makers worldwide can use the list for further validating the list in their local context and designing strategies to reduce low-value care.
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Affiliation(s)
- Simone A van Dulmen
- Radboud university medical center, Radboud Institute for Health Science, IQ healthcare, PO Box 9101 (160), 6500 HB, Nijmegen, the Netherlands.
| | - Ngoc Hue Tran
- Radboud university medical center, Radboud Institute for Health Science, IQ healthcare, PO Box 9101 (160), 6500 HB, Nijmegen, the Netherlands
| | - Tjerk Wiersma
- Dutch College of General Practitioners, Mercatorlaan 1200, 3528 BL, Utrecht, the Netherlands
| | - Eva W Verkerk
- Radboud university medical center, Radboud Institute for Health Science, IQ healthcare, PO Box 9101 (160), 6500 HB, Nijmegen, the Netherlands
| | - Jasmine Cl Messaoudi
- Radboud university medical center, Radboud Institute for Health Science, IQ healthcare, PO Box 9101 (160), 6500 HB, Nijmegen, the Netherlands
| | - Jako S Burgers
- Dutch College of General Practitioners, Mercatorlaan 1200, 3528 BL, Utrecht, the Netherlands
- Department Family Medicine, Care and Public Health Research Institute, Peter Debyeplein 1, 6229 HA, Maastricht, the Netherlands
| | - Rudolf B Kool
- Radboud university medical center, Radboud Institute for Health Science, IQ healthcare, PO Box 9101 (160), 6500 HB, Nijmegen, the Netherlands
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16
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Müskens JL, van Dulmen SA, Wiersma T, Burgers JS, Hek K, Westert GP, Kool RB. Low-value pharmaceutical care among Dutch GPs: a retrospective cohort study. Br J Gen Pract 2022; 72:e369-e377. [PMID: 35314429 PMCID: PMC8966784 DOI: 10.3399/bjgp.2021.0625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 01/31/2022] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Low-value pharmaceutical care exists in general practice. However, the extent among Dutch GPs remains unknown. AIM To assess the prevalence of low-value pharmaceutical care among Dutch GPs. DESIGN AND SETTING Retrospective cohort study using data from patient records. METHOD The prevalence of three types of pharmaceutical care prescribed by GPs between 2016 and 2019 were examined: topical antibiotics for conjunctivitis, benzodiazepines for non-specific lower back pain, and chronic acid-reducing medication (ARM) prescriptions. Multilevel logistic regression analysis was performed to assess prescribing variation and the influence of patient characteristics on receiving a low-value prescription. RESULTS Large variation in prevalence as well as practice variation was observed among the types of low-value pharmaceutical GP care examined. Between 53% and 61% of patients received an inappropriate antibiotics prescription for conjunctivitis, around 3% of patients with lower back pain received an inappropriate benzodiazepine prescription, and 88% received an inappropriate chronic ARM prescription during the years examined. The odds of receiving an inappropriate antibiotic or benzodiazepine prescription increased with age (P<0.001), but decreased for chronic inappropriate ARM prescriptions (P<0.001). Sex affected only the odds of receiving a non-indicated chronic ARM, with males being at higher risk (P<0.001). The odds of receiving an inappropriate ARM increased with increasing neighbourhood socioeconomic status (P<0.05). Increasing practice size decreased the odds of inappropriate antibiotic and benzodiazepine prescriptions (P<0.001). CONCLUSION The results show that the prevalence of low-value pharmaceutical GP care varies among these three clinical problems. Significant variation in inappropriate prescribing exists between different types of pharmaceutical care - and GP practices.
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Affiliation(s)
- Joris Ljm Müskens
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Centre, Nijmegen
| | - Simone A van Dulmen
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Centre, Nijmegen
| | | | - Jako S Burgers
- Department of General Practice, School CAPHRI, Maastricht University, Maastricht; senior consultant, Dutch College of General Practitioners, Utrecht
| | - Karin Hek
- Nivel, Netherlands Institute for Health Services Research, Utrecht
| | - Gert P Westert
- 'Doen of laten?', IQ Healthcare, Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Centre, Nijmegen
| | - Rudolf B Kool
- 'Doen of laten?', IQ Healthcare, Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Centre, Nijmegen
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Auener SL, Remers TEP, van Dulmen SA, Westert GP, Kool RB, Jeurissen PPT. The Effect of Noninvasive Telemonitoring for Chronic Heart Failure on Health Care Utilization: Systematic Review. J Med Internet Res 2021; 23:e26744. [PMID: 34586072 PMCID: PMC8515232 DOI: 10.2196/26744] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 03/18/2021] [Accepted: 06/30/2021] [Indexed: 12/20/2022] Open
Abstract
Background Chronic heart failure accounts for approximately 1%-2% of health care expenditures in most developed countries. These costs are primarily driven by hospitalizations and comorbidities. Telemonitoring has been proposed to reduce the number of hospitalizations and decrease the cost of treatment for patients with heart failure. However, the effects of telemonitoring on health care utilization remain unclear. Objective This systematic review aims to study the effect of telemonitoring programs on health care utilization and costs in patients with chronic heart failure. We assess the effect of telemonitoring on hospitalizations, emergency department visits, length of stay, hospital days, nonemergency department visits, and health care costs. Methods We searched PubMed, Embase, and Web of Science for randomized controlled trials and nonrandomized studies on noninvasive telemonitoring and health care utilization. We included studies published between January 2010 and August 2020. For each study, we extracted the reported data on the effect of telemonitoring on health care utilization. We used P<.05 and CIs not including 1.00 to determine whether the effect was statistically significant. Results We included 16 randomized controlled trials and 13 nonrandomized studies. Inclusion criteria, population characteristics, and outcome measures differed among the included studies. Most studies showed no effect of telemonitoring on health care utilization. The number of hospitalizations was significantly reduced in 38% (9/24) of studies, whereas emergency department visits were reduced in 13% (1/8) of studies. An increase in nonemergency department visits (6/9, 67% of studies) was reported. Health care costs showed ambiguous results, with 3 studies reporting an increase in health care costs, 3 studies reporting a reduction, and 4 studies reporting no significant differences. Health care cost reductions were realized through a reduction in hospitalizations, whereas increases were caused by the high costs of the telemonitoring program or increased health care utilization. Conclusions Most telemonitoring programs do not show clear effects on health care utilization measures, except for an increase in nonemergency outpatient department visits. This may be an unwarranted side effect rather than a prerequisite for effective telemonitoring. The consequences of telemonitoring on nonemergency outpatient visits should receive more attention from regulators, payers, and providers. This review further demonstrates the high clinical and methodological heterogeneity of telemonitoring programs. This should be taken into account in future meta-analyses aimed at identifying the effective components of telemonitoring programs.
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Affiliation(s)
- Stefan L Auener
- IQ healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Toine E P Remers
- IQ healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Simone A van Dulmen
- IQ healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Gert P Westert
- IQ healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Rudolf B Kool
- IQ healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Patrick P T Jeurissen
- IQ healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
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Kroon D, Steutel NF, Vermeulen H, Tabbers MM, Benninga MA, Langendam MW, van Dulmen SA. Effectiveness of interventions aiming to reduce inappropriate drug prescribing: an overview of interventions. Journal of Pharmaceutical Health Services Research 2021. [DOI: 10.1093/jphsr/rmab038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Abstract
Objective
Inappropriate prescribing of drugs is associated with unnecessary harms for patients and healthcare costs. Interventions to reduce these prescriptions are widely studied, yet the effectiveness of different types of interventions remains unclear. Therefore, we provide an overview regarding the effectiveness of intervention types that aim to reduce inappropriate drug prescriptions, unrestricted by target drugs, population or setting.
Methods
For this overview, systematic reviews (SRs) were used as the source for original studies. EMBASE and MEDLINE were searched from inception to August 2018. All SRs aiming to evaluate the effectiveness of interventions to reduce inappropriate prescribing of drugs were eligible for inclusion. The SRs and their original studies were screened for eligibility. Interventions of the original studies were categorized by type of intervention. The percentage of interventions showing a significant reduction of inappropriate prescribing were reported per intervention category.
Key findings
Thirty-two SRs were included, which provided 319 unique interventions. Overall, 61.4% of these interventions showed a significant reduction in inappropriate prescribing of drugs. Strategies that were most frequently effective in reducing inappropriate prescribing were multifaceted interventions (73.2%), followed by interventions containing additional diagnostic tests (antibiotics) (70.4%), computer interventions (69.2%), audit and feedback (66.7%), patient-mediated interventions (62.5%) and multidisciplinary (team) approach (57.1%). The least frequently effective intervention was an education for healthcare professionals (50.0%).
Conclusion
The majority of the interventions were effective in reducing inappropriate prescribing of drugs. Multifaceted interventions most frequently showed a significant reduction of inappropriate prescribing. Education for healthcare professionals is the most frequently included intervention in this overview, yet this category is least frequently effective.
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Affiliation(s)
- Daniëlle Kroon
- Radboud University Medical Center, Radboud Institute of Health Sciences, IQ healthcare, Nijmegen, The Netherlands
| | - Nina F Steutel
- Department of Clinical Epidemiology, Bioinformatics and Biostatistics, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health institute, The Netherlands
- Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands
| | - Hester Vermeulen
- Radboud University Medical Center, Radboud Institute of Health Sciences, IQ healthcare, Nijmegen, The Netherlands
- Faculty of Health and Social Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Merit M Tabbers
- Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands
| | - Marc A Benninga
- Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands
| | - Miranda W Langendam
- Department of Clinical Epidemiology, Bioinformatics and Biostatistics, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health institute, The Netherlands
| | - Simone A van Dulmen
- Radboud University Medical Center, Radboud Institute of Health Sciences, IQ healthcare, Nijmegen, The Netherlands
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Meerhoff GA, Verburg AC, Schapendonk RM, Cruijsberg J, Nijhuis-van der Sanden MWG, van Dulmen SA, Van der Wees PJ. Reliability, validity and discriminability of patient reported outcomes for non-specific low back pain in a nationwide physical therapy registry: A retrospective observational cohort study. PLoS One 2021; 16:e0251892. [PMID: 34081704 PMCID: PMC8174721 DOI: 10.1371/journal.pone.0251892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 05/04/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND A national clinical registry was established in the Netherlands containing data directly sampled from electronic health record systems of physical therapists (PTs). This registry aims to evaluate the potential of patient reported outcome measures (PROMs) to develop quality indicators (QIs) in physical therapy care. PURPOSE To test to what extent the collected PROM data are reliable, valid and discriminatory between practices in measuring outcomes of patients with non-specific low back pain (NSLBP). METHODS In this retrospective cohort study 865 PT practices with 6,560 PTs voluntarily collected PROM data of patients with NSLBP, using the Quebec Back Pain Disability Scale (QBPDS), the Numeric Pain Rating Scale (NPRS) and the Patient Specific Functioning Scale (PSFS). Reliability was determined by analysing the completeness of the dataset, the comparability by using national reference data, and through checking selection bias in the included patients. Validity was tested using the known-groups contrast between patients with (sub)acute vs. chronic NSLBP. To determine discriminative ability of outcomes between PT practices, case-mix corrected hierarchical multilevel analyses were performed. RESULTS Reliability was sufficient by confirming fifteen of the sixteen hypotheses: 59% of all patients opted in for data analysis, 42% of these included patients showed repeated measurement, comparing with reference data and potential selection bias showed < 5% between group differences, while differences between (sub)acute and chronic NSLB-groups were significantly larger than 5% (less treatment sessions, lager differences in outcomes in (sub)acute NSLB patients). In addition, all nine adjusted hierarchical multilevel models confirm that the collected dataset on outcomes in PT care is able to discriminate between practices using PROM results of patients with NSLBP (ICC-scores range 0.11-0.21). LIMITATIONS Although we have shown the reliability, validity and discriminative ability of the dataset in the quest to develop QIs, we are aware that reducing missing values in patient records and the selective participation of PTs that belong to the innovators needs attention in the next stages of implementation to avoid bias in the results. CONCLUSION PROMs of patients with NSLBP collected in the national clinical registry of KNGF are reliable, valid and able to discriminate between primary care PT practices.
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Affiliation(s)
- Guus A Meerhoff
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
- Royal Dutch Society for Physical Therapy (KNGF), Amersfoort, The Netherlands
| | - Arie C Verburg
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Renske M Schapendonk
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
- Dutch Health Authority (NZA), Utrecht, The Netherlands
| | - Juliette Cruijsberg
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | | | - Simone A van Dulmen
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Philip J Van der Wees
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
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Müskens JLJM, Kool RB, van Dulmen SA, Westert GP. Overuse of diagnostic testing in healthcare: a systematic review. BMJ Qual Saf 2021; 31:54-63. [PMID: 33972387 PMCID: PMC8685650 DOI: 10.1136/bmjqs-2020-012576] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 04/08/2021] [Accepted: 04/19/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Overuse of diagnostic testing substantially contributes to healthcare expenses and potentially exposes patients to unnecessary harm. Our objective was to systematically identify and examine studies that assessed the prevalence of diagnostic testing overuse across healthcare settings to estimate the overall prevalence of low-value diagnostic overtesting. METHODS PubMed, Web of Science and Embase were searched from inception until 18 February 2020 to identify articles published in the English language that examined the prevalence of diagnostic testing overuse using database data. Each of the assessments was categorised as using a patient-indication lens, a patient-population lens or a service lens. RESULTS 118 assessments of diagnostic testing overuse, extracted from 35 studies, were included in this study. Most included assessments used a patient-indication lens (n=67, 57%), followed by the service lens (n=27, 23%) and patient-population lens (n=24, 20%). Prevalence estimates of diagnostic testing overuse ranged from 0.09% to 97.5% (median prevalence of assessments using a patient-indication lens: 11.0%, patient-population lens: 2.0% and service lens: 30.7%). The majority of assessments (n=85) reported overuse of diagnostic testing to be below 25%. Overuse of diagnostic imaging tests was most often assessed (n=96). Among the 33 assessments reporting high levels of overuse (≥25%), preoperative testing (n=7) and imaging for uncomplicated low back pain (n=6) were most frequently examined. For assessments of similar diagnostic tests, major variation in the prevalence of overuse was observed. Differences in the definitions of low-value tests used, their operationalisation and assessment methods likely contributed to this observed variation. CONCLUSION Our findings suggest that substantial overuse of diagnostic testing is present with wide variation in overuse. Preoperative testing and imaging for non-specific low back pain are the most frequently identified low-value diagnostic tests. Uniform definitions and assessments are required in order to obtain a more comprehensive understanding of the magnitude of diagnostic testing overuse.
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Affiliation(s)
- Joris L J M Müskens
- IQ healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Rudolf Bertijn Kool
- IQ healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Simone A van Dulmen
- IQ healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Gert P Westert
- IQ healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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Verburg AC, van Dulmen SA, Kiers H, Nijhuis-van der Sanden MWG, van der Wees PJ. Patient-Reported Outcome-Based Quality Indicators in Dutch Primary Care Physical Therapy for Patients With Nonspecific Low Back Pain: A Cohort Study. Phys Ther 2021; 101:6258995. [PMID: 33929546 PMCID: PMC8336590 DOI: 10.1093/ptj/pzab118] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 02/13/2021] [Accepted: 04/07/2021] [Indexed: 11/14/2022]
Abstract
OBJECTIVE The purpose of this study was to define and select a core set of outcome-based quality indicators, accepted by stakeholders on usability and perceived added value as a quality improvement tool, and to formulate recommendations for the next implementation step. METHODS In phase 1, 15 potential quality indicators were defined for patient-reported outcome measures and associated domains, namely the Numeric Pain Rating Scale (NPRS) for pain intensity, the Patient Specific Functioning Scale (PSFS) for physical activity, the Quebec Back Pain Disability Scale for physical functioning, and the Global Perceived Effect-Dutch Version for perceived effect. Their comparability and discriminatory characteristics were described using cohort data. In phase 2, a core set of quality indicators was selected based on consensus among stakeholders in focus group meetings. RESULTS In total, 65,815 completed treatment episodes for patients with nonspecific low back pain were provided by 1009 physical therapists from 219 physical therapist practices. The discriminability between physical therapists of all potential 15 quality indicators was adequate, with intraclass correlation coefficients between 0.08 and 0.30. Stakeholders selected a final core set of 6 quality indicators: 2 process indicators (the routine measurement of NPRS and the PSFS) and 4 outcome indicators (pretreatment and posttreatment change scores for the NPRS, PSFS, Quebec Back Pain Disability Scale, and the minimal clinically important difference of the Global Perceived Effect-Dutch Version). CONCLUSION This study described and selected a core set of outcome-based quality indicators for physical therapy in patients with nonspecific low back pain. The set was accepted by stakeholders for having added value for daily practice in physical therapy primary care and was found useful for quality improvement initiatives. Further studies need to focus on improvement of using the core set of outcome-based quality indicators as a quality monitoring and evaluation instrument. IMPACT Patient-reported outcome-based quality indicators developed from routinely collected clinical data are promising for use in quality improvement in daily practice.
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Affiliation(s)
- Arie C Verburg
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, PO Box 9101, 6500 HB, Nijmegen, The Netherlands,Address all correspondence to Dr Verburg at:
| | - Simone A van Dulmen
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Henri Kiers
- Institute of Human Movement Studies, Utrecht University of Applied Sciences, Utrecht, The Netherlands,Association for Quality in Physical Therapy (SKF), Zwolle, The Netherlands
| | - Maria W G Nijhuis-van der Sanden
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Philip J van der Wees
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
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22
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van Dulmen SA, Kruse FM, Burgers JS. [Primary health care through the eyes of the general practitioner; an international study]. Ned Tijdschr Geneeskd 2021; 165:D5419. [PMID: 33914426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
This study is based on a large international survey, which collected the views of general practitioners (GPs) in 11 different countries on their respective healthcare systems in 2019. Findings show that Dutch GPs are positive about the quality of GP care and that they are satisfied with their profession. However, findings also show that there is room for improvement. (i) Work pressure and work-related stress among GPs is high in the Netherlands, which may be due to moves to substitute primary care for some hospital care. (ii) Dutch GPs are behind other high-income countries in their uptake of some digital applications (e.g. video consultations). (iii) According to Dutch GPs, pressure from patients, lack of time, and fear of complaints contributes to provision of low-value care. The COVID-19 epidemic has created opportunities to improve Dutch GP care further, for example through wider uptake of digital health applications.
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Affiliation(s)
- Simone A van Dulmen
- Radboudumc, afd. Scientific Center for Quality of Healthcare, Nijmegen
- Contact: Simone A. van Dulmen
| | - Florien M Kruse
- Radboudumc, afd. Scientific Center for Quality of Healthcare, Nijmegen
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23
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Kool RB, Verkerk EW, Winnemuller LJ, Wiersma T, Westert GP, Burgers JS, van Dulmen SA. Identifying and de-implementing low-value care in primary care: the GP's perspective-a cross-sectional survey. BMJ Open 2020; 10:e037019. [PMID: 32499273 PMCID: PMC7279641 DOI: 10.1136/bmjopen-2020-037019] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE General practitioners have an important role in reducing low-value care as gatekeepers of the health system. The aim of this study was to assess the experiences of Dutch general practitioners regarding low-value care and to identify their needs to decrease low-value primary care. DESIGN We performed a cross-sectional study. PARTICIPANTS We sent a survey to 500 general practitioners. SETTING Primary care in the Netherlands. PRIMARY AND SECONDARY OUTCOMES The survey contained questions about the provision of low-value care and on clinical cases about lumbosacral spine X-rays in patients with low back pain and vitamin B12 laboratory tests without an evidence-based indication. We also asked general practitioners what they needed to reduce low-value care. RESULTS A total of 182 general practitioners (37%) responded. 67% indicated that low-value care practices are regularly provided in general practice. 57% of the general practitioners have seen negative consequences of low-value care, in particular side effects of medication. The most provided low-value care practices are medication prescriptions such as antibiotics and laboratory tests such as vitamin B12 tests. The most reported drivers are patient-related. General practitioners want to maintain a good relationship with their patients by offering their patients an intervention instead of watchful waiting. Lack of time also plays a major role. In order to reduce low-value care, general practitioners suggested that educating patients on the value of tests and treatments might help. Supporting general practitioners and other healthcare professionals with clear guidelines as well as having more time for consultation were also mentioned by general practitioners. CONCLUSION General practitioners are aware of providing unnecessary care despite their role as gatekeepers and have reasons for this. They need support in order to change their practice. This support might consist of better education of healthcare professionals and providing more time for consultation. Local and national media, such as websites and television, could be used to educate patients while guidelines could support professionals in reducing low-value care.
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Affiliation(s)
- Rudolf Bertijn Kool
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Eva W Verkerk
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Lieke Ja Winnemuller
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Tjerk Wiersma
- Dutch College of General Practitioners, Utrecht, The Netherlands
| | - Gert P Westert
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Jaco S Burgers
- Dutch College of General Practitioners, Utrecht, The Netherlands
- Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Simone A van Dulmen
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Centre, Nijmegen, The Netherlands
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24
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Grimshaw JM, Patey AM, Kirkham KR, Hall A, Dowling SK, Rodondi N, Ellen M, Kool T, van Dulmen SA, Kerr EA, Linklater S, Levinson W, Bhatia RS. De-implementing wisely: developing the evidence base to reduce low-value care. BMJ Qual Saf 2020; 29:409-417. [PMID: 32029572 PMCID: PMC7229903 DOI: 10.1136/bmjqs-2019-010060] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 12/11/2019] [Accepted: 01/13/2020] [Indexed: 01/30/2023]
Abstract
Choosing Wisely (CW) campaigns globally have focused attention on the need to reduce low-value care, which can represent up to 30% of the costs of healthcare. Despite early enthusiasm for the CW initiative, few large-scale changes in rates of low-value care have been reported since the launch of these campaigns. Recent commentaries suggest that the focus of the campaign should be on implementation of evidence-based strategies to effectively reduce low-value care. This paper describes the Choosing Wisely De-Implementation Framework (CWDIF), a novel framework that builds on previous work in the field of implementation science and proposes a comprehensive approach to systematically reduce low-value care in both hospital and community settings and advance the science of de-implementation.The CWDIF consists of five phases: Phase 0, identification of potential areas of low-value healthcare; Phase 1, identification of local priorities for implementation of CW recommendations; Phase 2, identification of barriers to implementing CW recommendations and potential interventions to overcome these; Phase 3, rigorous evaluations of CW implementation programmes; Phase 4, spread of effective CW implementation programmes. We provide a worked example of applying the CWDIF to develop and evaluate an implementation programme to reduce unnecessary preoperative testing in healthy patients undergoing low-risk surgeries and to further develop the evidence base to reduce low-value care.
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Affiliation(s)
- Jeremy M Grimshaw
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Andrea M Patey
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kyle R Kirkham
- Department of Anesthesia and Pain Management-Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, Women's College Hospital, Toronto, Ontario, Canada
| | - Amanda Hall
- Primary Healthcare Research Institute, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
| | - Shawn K Dowling
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital University Hospital Bern, Bern, Switzerland
| | - Moriah Ellen
- Department of Health Systems Management, Guilford Glazer Faculty of Business and Management and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- McMaster Health Forum, McMaster University, Hamilton, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Tijn Kool
- Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Center, Nijmegen, Gelderland, The Netherlands
| | - Simone A van Dulmen
- Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Center, Nijmegen, Gelderland, The Netherlands
| | - Eve A Kerr
- Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Stefanie Linklater
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Wendy Levinson
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- St. Michael's Hospital, Toronto, Ontario, Canada
| | - R Sacha Bhatia
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
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25
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Meerhoff GA, van Dulmen SA, Cruijsberg JK, Nijhuis-van der Sanden MWG, Van der Wees PJ. Which Factors Influence the Use of Patient-Reported Outcome Measures in Dutch Physiotherapy Practice? A Cross-Sectional Study. Physiother Can 2020; 72:63-70. [PMID: 34385750 DOI: 10.3138/ptc-2018-0028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Purpose: Patient-reported outcome measures (PROMs) have the potential to enhance the quality of health care but, as a result of suboptimal implementation, it is unclear whether they fulfil this role in physiotherapy practice. This cross-sectional study aimed to identify the factors influencing PROM use in Dutch private physiotherapy practices. Method: A total of 444 physiotherapists completed a self-assessment questionnaire and uploaded the data from their electronic health record (EHR) systems to the national registry of outcome data. Univariate and multivariate ordinal logistic and linear regression analysis were used to identify the factors associated with self-reported PROM use and PROM use registered in the EHR systems, which were derived from the self-assessment questionnaire and from the data in the national registry, respectively. Five categories with nine independent variables were selected as potential factors for regression analysis. The similarity between self-reported and registered PROM use was verified. Results: On the basis of self-report and EHR report, we found that 21.6% and 29.8% of participants, respectively, used PROMs with more than 80% of their patients, and we identified the factors associated with PROM use. Conclusions: The factors associated with PROM use are EHR systems that support PROM use and more knowledge about PROM use. These findings can guide future strategies to enhance the use of PROMs in physiotherapy practice.
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Affiliation(s)
- Guus A Meerhoff
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen.,Royal Dutch Society for Physiotherapy, Amersfoort, the Netherlands
| | - Simone A van Dulmen
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen
| | - Juliette K Cruijsberg
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen
| | | | - Philip J Van der Wees
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen
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26
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van der Wees PJ, Verkerk EW, Verbiest MEA, Zuidgeest M, Bakker C, Braspenning J, de Boer D, Terwee CB, Vajda I, Beurskens A, van Dulmen SA. Development of a framework with tools to support the selection and implementation of patient-reported outcome measures. J Patient Rep Outcomes 2019; 3:75. [PMID: 31889232 PMCID: PMC6937349 DOI: 10.1186/s41687-019-0171-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 12/18/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Patient reported outcomes (PROs) provide information on a patient's health status coming directly from the patient. Measuring PROs with patient reported outcome measures (PROMs) has gained wide interest in clinical practice for individual patient care, as well as in quality improvement, and for providing transparency of outcomes to stakeholders through public reporting. However, current knowledge of selecting and implementing PROMs for these purposes is scattered, and not readily available for clinicians and quality managers in healthcare organizations. The objective of this study is to develop a framework with tools to support the systematic selection, implementation and evaluation of PROs and PROMs in individual patient care, for quality improvement and public reporting. METHODS We developed the framework in a national project in the Netherlands following a user-centered design. The development process of the framework contained five iterative components: (a) identification of existing tools, (b) identification of user requirements and designing steps for selection and implementation of PROs and PROMs, (c) discussing a prototype of the framework during a national workshop, (d) developing a web version, (e) pre-testing of the framework. A total of 40 users with different perspectives (clinicians, patient representatives, quality managers, purchasers, researchers) have been consulted. RESULTS The final framework is presented as the PROM-cycle that consists of eight steps in four phases: (1) goal setting, (2) selecting PROs and PROMs, (3) developing and testing of quality indicator(s), (4) implementing and evaluating the PROM(s) and indicator(s). Users emphasized that the first step is the key element in which the why, for whom and setting of the PROM has to be defined. This information is decisive for the following steps. For each step the PROM-cycle provides guidance and tools, with instruments, checklists, methods, handbooks, and standards supporting the process. CONCLUSION We developed a framework to support the selection and implementation of PROs and PROMs. Each step provides guidance and tools to support the process. The PROM-cycle and its tools are publicly available and can be used by clinicians, quality managers, patient representatives and other experts involved in using PROMS. Through periodic evaluation and updates, tools will be added for national and international use of the PROM-cycle.
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Affiliation(s)
- Philip J van der Wees
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, the Netherlands.
| | - Eva W Verkerk
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, the Netherlands
| | - Marjolein E A Verbiest
- Tilburg University, Tilburg School of Social and Behavioral Sciences, Tilburg, The Netherlands
| | | | - Carla Bakker
- Leiden University Medical Center, Leiden, the Netherlands
- Netherlands Federation of University Medical Centres (NFU), Utrecht, the Netherlands
| | - Jozé Braspenning
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, the Netherlands
| | - Dolf de Boer
- Netherlands Institute for Health Services Research (Nivel), Utrecht, the Netherlands
| | - Caroline B Terwee
- Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ildikó Vajda
- VSOP Dutch Genetic Alliance, Soest, the Netherlands
- STZ-Dutch Association of Top Clinical Hospitals, Utrecht, the Netherlands
| | - Anna Beurskens
- Maastricht University, Maastricht, the Netherlands
- Zuyd University of applied sciences, Heerlen, the Netherlands
| | - Simone A van Dulmen
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, the Netherlands
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27
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Verburg AC, van Dulmen SA, Kiers H, Ypinga JH, Nijhuis-van der Sanden MW, van der Wees PJ. Development of a Standard Set of Outcome Domains and Proposed Measures for Chronic Obstructive Pulmonary Disease in Primary Care Physical Therapy Practice in the Netherlands: a Modified RAND/UCLA Appropriateness Method. Int J Chron Obstruct Pulmon Dis 2019; 14:2649-2661. [PMID: 31819398 PMCID: PMC6886541 DOI: 10.2147/copd.s219851] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 11/11/2019] [Indexed: 11/23/2022] Open
Abstract
Background Standardization of measures in a common set opens the opportunity to learn from differences in treatment outcomes which can be used for improving the quality of care. Furthermore, a standard set can provide the basis for development of quality indicators and is therefore useful for quality improvement and public reporting purposes. The aim of this study was to develop a standard set of outcome domains and proposed measures for patients with COPD in Dutch primary care physical therapy practice, including a proposal to stratify patients in subgroups. Material and methods A consensus-driven modified RAND-UCLA appropriateness method was conducted with relevant stakeholders (patients, physical therapists, researchers, policy makers and health insurers) in Dutch primary physical therapy care in eight steps: (1) literature search, (2) first online survey, (3) patient interviews, (4) expert meeting, resulting in a concept standard set and methods to identify subgroups' (5) consensus meeting, (6) expert meeting (7) second online survey and (8) final approval of an advisory board resulting of the approved standard set. Results Five outcome domains were selected for COPD: physical capacity, muscle strength, physical activity, dyspnea and quality of life. A total of 21 measures were rated and discussed. Finally, eight measures were included, of which four mandatory measures: Characteristics of practices and physical therapists, Clinical COPD Questionnaire (CCQ) for quality of life, Global Perceived Effect (GPE) for experience, 6-mins Walk Test (6-MWT) for physical capacity; two conditional measures: Hand-Held Dynamometer (HHD) (with Microfet™) for Quadriceps strength, Medical Research Council Dyspnea (MRC) for monitoring dyspnea; and two exploratory measures: Accelerometry for physical activity, and the Assessment of Burden of COPD tool (ABC). To identify subgroups, a method described in the Dutch standard of care from the Lung Alliance was included. Conclusion This study described the development of a standard set of outcome domains and proposed measures for patients with COPD in primary care physical therapy. Each measure was accepted for relevance and feasibility by the involved stakeholders. The set is currently used in daily practice and tested on validity and reliability in a pilot for the development of quality indicators.
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Affiliation(s)
- Arie C Verburg
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, Netherlands
| | - Simone A van Dulmen
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, Netherlands
| | - Henri Kiers
- Utrecht University of Applied Sciences, Institute of Human Movement Studies, Utrecht, Netherlands.,Association for Quality in Physical Therapy (SKF), Zwolle, Netherlands
| | | | | | - Philip J van der Wees
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, Netherlands
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28
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Meerhoff GA, van Dulmen SA, Maas MJ, Bakker-Jacobs A, Nijhuis-Van der Sanden MW, van der Wees PJ. Exploring the perspective of patients with musculoskeletal health problems in primary care on the use of patient-reported outcome measures to stimulate quality improvement in physiotherapist practice; a qualitative study. Physiother Theory Pract 2019; 37:993-1004. [PMID: 31635516 DOI: 10.1080/09593985.2019.1678205] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Background: Patient-reported outcome measures (PROMs) in clinical practice might enhance patient- centeredness and effectiveness of physiotherapy practice. Although patients have a crucial role in using PROMs, little is known about their perspective on its usefulness.Purpose: Explore the perspective of patients with musculoskeletal health problems on using PROMs for quality improvement in primary care physiotherapy practice, and determine what barriers and facilitators patients perceive.Methods: Semi-structured interviews were performed in 21 patients recruited from primary care physiotherapy practice and analyzed using theoretical thematic analysis. Barriers and facilitators on PROMs implementation were categorized into four predefined domains conform.Results: Across all domains, three major themes were identified: 1) Practicality; 2) Interaction with the physiotherapist for decision-making; and 3) Sharing information outside the clinical context. Generally, PROMs were perceived practically applicable instruments with added value to the interaction with the physiotherapist for shared decision-making and for stimulating quality improvement. The perceived barriers were: difficulties in administering PROMs for patients with poor computer skills, suboptimal efficiency when PROMs were administered at the expense of the consultation, the insufficient added value of PROMs for patients with recurrent health problems, and reluctance about sharing aggregated data for accountability purposes.Limitations: The dependence on the participating physiotherapists in patient recruitment might have resulted in selection bias.Conclusion: Patients perceive that using PROMs has an added value in primary care physiotherapy practice. Optimizing implementation using tailored implementation strategies related to the identified barriers in all four domains might further improve the use of PROMs in clinical practice.
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Affiliation(s)
- Guus A Meerhoff
- Radboud University Medical Centre, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, Netherlands.,Quality Department, Royal Dutch Society for Physiotherapy (KNGF), Amersfoort, Netherlands
| | - Simone A van Dulmen
- Radboud University Medical Centre, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, Netherlands
| | - Marjo J Maas
- Radboud University Medical Centre, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, Netherlands.,HAN University of Applied Sciences, Institute of Health Studies, Nijmegen, Netherlands
| | - Annick Bakker-Jacobs
- Radboud University Medical Centre, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, Netherlands
| | | | - Philip J van der Wees
- Radboud University Medical Centre, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, Netherlands
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Verkerk EW, Tanke MAC, Kool RB, van Dulmen SA, Westert GP. Limit, lean or listen? A typology of low-value care that gives direction in de-implementation. Int J Qual Health Care 2019; 30:736-739. [PMID: 29741672 PMCID: PMC6307334 DOI: 10.1093/intqhc/mzy100] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 04/24/2018] [Indexed: 12/20/2022] Open
Abstract
Background Overuse of unnecessary care is widespread around the world. This so-called low-value care provides no benefit for the patient, wastes resources and can cause harm. The concept of low-value care is broad and there are different reasons for care to be of low-value. Hence, different strategies might be necessary to reduce it and awareness of this may help in designing a de-implementation strategy. Based on a literature scan and discussions with experts, we identified three types of low-value care. Results The type ineffective care is proven ineffective, such as antibiotics for a viral infection. Inefficient care is in essence effective, but is of low-value through inefficient provision or inappropriate intensity, such as chronic benzodiazepine use. Unwanted care is in essence appropriate for the clinical condition it targets, but is low-value since it does not fit the patients’ preferences, such as a treatment aimed to cure a patient that prefers palliative care. In this paper, we argue that these three types differ in their most promising strategy for de-implementation and that our typology gives direction in choosing whether to limit, lean or listen. Conclusion We developed a typology that provides insight in the different reasons for care to be of low-value. We believe that this typology is helpful in designing a tailor-made strategy for reducing low-value care.
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Affiliation(s)
- Eva W Verkerk
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Marit A C Tanke
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Rudolf B Kool
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Simone A van Dulmen
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Gert P Westert
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
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Verkerk EW, Huisman-de Waal G, Vermeulen H, Westert GP, Kool RB, van Dulmen SA. Low-value care in nursing: A systematic assessment of clinical practice guidelines. Int J Nurs Stud 2018; 87:34-39. [DOI: 10.1016/j.ijnurstu.2018.07.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 06/29/2018] [Accepted: 07/02/2018] [Indexed: 11/28/2022]
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Crins MHP, van der Wees PJ, Klausch T, van Dulmen SA, Roorda LD, Terwee CB. Psychometric properties of the PROMIS Physical Function item bank in patients receiving physical therapy. PLoS One 2018; 13:e0192187. [PMID: 29432433 PMCID: PMC5809015 DOI: 10.1371/journal.pone.0192187] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 01/19/2018] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES The Patient-Reported Outcomes Measurement Information System (PROMIS) is a universally applicable set of instruments, including item banks, short forms and computer adaptive tests (CATs), measuring patient-reported health across different patient populations. PROMIS CATs are highly efficient and the use in practice is considered feasible with little administration time, offering standardized and routine patient monitoring. Before an item bank can be used as CAT, the psychometric properties of the item bank have to be examined. Therefore, the objective was to assess the psychometric properties of the Dutch-Flemish PROMIS Physical Function item bank (DF-PROMIS-PF) in Dutch patients receiving physical therapy. DESIGN Cross-sectional study. SETTING AND PARTICIPANTS 805 patients >18 years, who received any kind of physical therapy in primary care in the past year, completed the full DF-PROMIS-PF (121 items). METHODS Unidimensionality was examined by Confirmatory Factor Analysis and local dependence and monotonicity were evaluated. A Graded Response Model was fitted. Construct validity was examined with correlations between DF-PROMIS-PF T-scores and scores on two legacy instruments (SF-36 Health Survey Physical Functioning scale [SF36-PF10] and the Health Assessment Questionnaire Disability-Index [HAQ-DI]). Reliability (standard errors of theta) was assessed. RESULTS The results for unidimensionality were mixed (scaled CFI = 0.924, TLI = 0.923, RMSEA = 0.045, 1th factor explained 61.5% of variance). Some local dependence was found (8.2% of item pairs). The item bank showed a broad coverage of the physical function construct (threshold-parameters range: -4.28-2.33) and good construct validity (correlation with SF36-PF10 = 0.84 and HAQ-DI = -0.85). Furthermore, the DF-PROMIS-PF showed greater reliability over a broader score-range than the SF36-PF10 and HAQ-DI. CONCLUSIONS The psychometric properties of the DF-PROMIS-PF item bank are sufficient. The DF-PROMIS-PF can now be used as short forms or CAT to measure the level of physical function of physiotherapy patients.
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Affiliation(s)
- Martine H P Crins
- Amsterdam Rehabilitation Research Center | Reade, Amsterdam, The Netherlands
| | | | - Thomas Klausch
- Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Leo D Roorda
- Amsterdam Rehabilitation Research Center | Reade, Amsterdam, The Netherlands
| | - Caroline B Terwee
- Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
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Meerhoff GA, van Dulmen SA, Maas MJM, Heijblom K, Nijhuis-van der Sanden MWG, Van der Wees PJ. Development and Evaluation of an Implementation Strategy for Collecting Data in a National Registry and the Use of Patient-Reported Outcome Measures in Physical Therapist Practices: Quality Improvement Study. Phys Ther 2017; 97:837-851. [PMID: 28789466 DOI: 10.1093/ptj/pzx051] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 05/03/2017] [Indexed: 11/13/2022]
Abstract
BACKGROUND In 2013, the Royal Dutch Society for Physical Therapy launched the program "Quality in Motion." This program aims to collect data from electronic health record systems in a registry that is fed back to physical therapists, facilitating quality improvement. PURPOSE The purpose of this study was to describe the development of an implementation strategy for the program and to evaluate the feasibility of building a registry and implementing patient-reported outcome measures (PROMs) in physical therapist practices. METHODS A stepwise approach using mixed methods was established in 3 consecutive pilots with 355 physical therapists from 66 practices. Interim results were evaluated using quantitative data from a self-assessment questionnaire and the registry and qualitative data from 21 semistructured interviews with physical therapists. Descriptive statistics and McNemar's symmetry chi-squared test were used to summarize the feasibility of implementing PROMs. RESULTS PROMs were selected for the 5 most prevalent musculoskeletal conditions in Dutch physical therapist practices. A core component of the implementation strategy was the introduction of knowledge brokers to support physical therapists in establishing the routine use of PROMs in clinical practice and to assist in executing peer assessment workshops. In February 2013, 30.3% of the physical therapist practices delivered 4.4 completed treatment episodes per physical therapist to the registry; this increased to 92.4% in November 2014, delivering 54.1 completed patient episodes per physical therapist. Pre- and posttreatment PROM use increased from 12.2% to 39.5%. LIMITATIONS It is unclear if the participating physical therapists reflect a representative sample of Dutch therapists. CONCLUSION Building a registry and implementing PROMs in physical therapist practices are feasible. The routine use of PROMs needs to increase to ensure valid feedback of outcomes. Using knowledge brokers is promising for implementing the program via peer assessment workshops.
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Affiliation(s)
- Guus A Meerhoff
- IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands and Strategy and Development Department, Royal Dutch Society for Physical Therapy, Amersfoort, The Netherlands
| | - Simone A van Dulmen
- IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center and Strategy and Development Department, Royal Dutch Society for Physical Therapy
| | - Marjo J M Maas
- IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center and Institute of Health Studies, HAN University of Applied Sciences
| | - Karin Heijblom
- Strategy and Development Department, Royal Dutch Society for Physical Therapy
| | | | - Philip J Van der Wees
- IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center
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Wammes JJG, van den Akker-van Marle ME, Verkerk EW, van Dulmen SA, Westert GP, van Asselt ADI, Kool RB. Identifying and prioritizing lower value services from Dutch specialist guidelines and a comparison with the UK do-not-do list. BMC Med 2016; 14:196. [PMID: 27884150 PMCID: PMC5123317 DOI: 10.1186/s12916-016-0747-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Accepted: 11/10/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The term 'lower value services' concerns healthcare that is of little or no value to the patient and consequently should not be provided routinely, or not be provided at all. De-adoption of lower value care may occur through explicit recommendations in clinical guidelines. The present study aimed to generate a comprehensive list of lower value services for the Netherlands that assesses the type of care and associated medical conditions. The list was compared with the NICE do-not-do list (United Kingdom). Finally, the feasibility of prioritizing the list was studied to identify conditions where de-adoption is warranted. METHODS Dutch clinical guidelines (published from 2010 to 2015) were searched for lower value services. The lower value services identified were categorized by type of care (diagnostics, treatment with and without medication), type of lower value service (not routinely provided or not provided at all), and ICD10 codes (international classification of diseases). The list was prioritized per ICD10 code, based on the number of lower value services per ICD10 code, prevalence, and burden of disease. RESULTS A total of 1366 lower value services were found in the 193 Dutch guidelines included in our study. Of the lower value services, 30% covered diagnostics, 29% related to surgical and medical treatment without drugs primarily, and 39% related to drug treatment. The majority (77%) of all lower value services was on care that should not be offered at all, whereas the other 23% recommended on care that should not be offered routinely. ICD10 chapters that included most lower value services were neoplasms and diseases of the nervous system. Dutch guidelines appear to contain more lower value services than UK guidelines. The prioritization processes revealed several conditions, including back pain, chronic obstructive pulmonary disease, and ischemic heart diseases, where lower value services most likely occur and de-adoption is warranted. CONCLUSIONS In this study, a comprehensive list of lower value services for Dutch hospital care was developed. A feasible method for prioritizing lower value services was established. Identifying and prioritizing lower value services is the first of several necessary steps in reducing them.
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Affiliation(s)
- Joost Johan Godert Wammes
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, 114 IQ Healthcare, PO Box 9101, Nijmegen, 6500, HB, The Netherlands.
| | - M Elske van den Akker-van Marle
- Department of Medical Decision Making, Leiden University Medical Centre, Albinusdreef 2, Postbus 9600, Leiden, 2300, RC, The Netherlands
| | - Eva W Verkerk
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, 114 IQ Healthcare, PO Box 9101, Nijmegen, 6500, HB, The Netherlands
| | - Simone A van Dulmen
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, 114 IQ Healthcare, PO Box 9101, Nijmegen, 6500, HB, The Netherlands
| | - Gert P Westert
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, 114 IQ Healthcare, PO Box 9101, Nijmegen, 6500, HB, The Netherlands
| | - Antoinette D I van Asselt
- Department of Epidemiology, University Medical Centre Groningen, Groningen, The Netherlands.,Department of Pharmacy, University of Groningen, Antonius Deusinglaan 1, Groningen, 9713, AV, The Netherlands
| | - R B Kool
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, 114 IQ Healthcare, PO Box 9101, Nijmegen, 6500, HB, The Netherlands
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Scholte M, van Dulmen SA, Neeleman-Van der Steen CWM, van der Wees PJ, Nijhuis-van der Sanden MWG, Braspenning J. Data extraction from electronic health records (EHRs) for quality measurement of the physical therapy process: comparison between EHR data and survey data. BMC Med Inform Decis Mak 2016; 16:141. [PMID: 27825333 PMCID: PMC5101697 DOI: 10.1186/s12911-016-0382-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 11/02/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND With the emergence of the electronic health records (EHRs) as a pervasive healthcare information technology, new opportunities and challenges for use of clinical data for quality measurements arise with respect to data quality, data availability and comparability. The objective of this study is to test whether data extracted from electronic health records (EHRs) was of comparable quality as survey data for the calculation of quality indicators. METHODS Data from surveys describing patient cases and filled out by physiotherapists in 2009-2010 were used to calculate scores on eight quality indicators (QIs) to measure the quality of physiotherapy care. In 2011, data was extracted directly from EHRs. The data collection methods were evaluated for comparability. EHR data was compared to survey data on completeness and correctness. RESULTS Five of the eight QIs could be extracted from the EHRs. Three were omitted from the indicator set, as they proved too difficult to be extracted from the EHRs. Another QI proved incomparable due to errors in the extraction software of some of the EHRs. Three out of four comparable QIs performed better (p < 0.001) in EHR data on completeness. EHR data also proved to be correct; the relative change in indicator scores between EHR and survey data were small (<5 %) in three out of four QIs. CONCLUSION Data quality of EHRs was sufficient to be used for the calculation of QIs, although comparability to survey data was problematic. Standardization is needed, not only to be able to compare different data collection methods properly, but also to compare between practices with different EHRs. EHRs have the option to administrate narrative data, but natural language processing tools are needed to quantify these text boxes. Such development, can narrow the comparability gap between scoring QIs based on EHR data and based on survey data. EHRs have the potential to provide real time feedback to professionals and quality measurements for research, but more effort is needed to create unambiguous and uniform information and to unlock written text in a standardized manner.
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Affiliation(s)
- Marijn Scholte
- Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare, Radboud University Medical Center, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands. .,Present address: Faculty of Social Sciences, Department of Sociology, Radboud University, Thomas van Aquinostraat 6, 6525 GD, Nijmegen, The Netherlands.
| | - Simone A van Dulmen
- Research Institute for Health Sciences, Scientific Institute for Quality of Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Philip J van der Wees
- Research Institute for Health Sciences, Scientific Institute for Quality of Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maria W G Nijhuis-van der Sanden
- Research Institute for Health Sciences, Scientific Institute for Quality of Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jozé Braspenning
- Research Institute for Health Sciences, Scientific Institute for Quality of Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
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van Dulmen SA, van der Wees PJ, Bart Staal J, Braspenning JCC, Nijhuis-van der Sanden MWG. Patient reported outcome measures (PROMs) for goalsetting and outcome measurement in primary care physiotherapy, an explorative field study. Physiotherapy 2016; 103:66-72. [PMID: 27033783 DOI: 10.1016/j.physio.2016.01.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 01/05/2016] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Routine use of patient reported outcome measures (PROMs) may provide an effective way of monitoring patient valued outcomes. In this study we explored (1) the current use of PROMs; (2) to what extent the goals correspond with the selected PROMs; (3) the health outcomes based on PROMs. DESIGN Observational clinical cohort study. SETTING Dutch primary care physiotherapy practices (n=43). PARTICIPANTS Patients (n=299) with neck pain or low back pain. MAIN OUTCOME MEASURES The number of PROMs used per patient were calculated. The International Classification of Functioning, Disability and Health was used to map the patients' goals and the percentages of PROMS selected that match the domains of the goals were calculated. Health outcomes were assessed using two approaches for estimating the minimal clinically important difference (MCID). RESULTS Repeated measurements with the Visual Analogue Scale, the Patient Specific Complaints questionnaire, the Quebec Back Pain Disability Scale, or the Neck Disability Index were completed by more than 60% of the patients. The PROMs used matched in 46% of the cases with goals for pain improvement, and in 43% with goals set at activity/participation level. The mean differences between baseline and follow up scores for all PROMs were statistically significant. Improvements of patients based on MCID varied from 57% to 90%. CONCLUSIONS PROMs were used in the majority of the patients, showed improved health outcomes and fitted moderately with goals. The results of this study can be used for future research assessing the routine use of outcome measurements with PROMs.
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Affiliation(s)
- Simone A van Dulmen
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands.
| | - Philip J van der Wees
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands
| | - J Bart Staal
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands; School for Physical Therapy, University of Applied Sciences Nijmegen, The Netherlands
| | - J C C Braspenning
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands
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Maas MJM, van Dulmen SA, Sagasser MH, Heerkens YF, van der Vleuten CPM, Nijhuis-van der Sanden MWG, van der Wees PJ. Critical features of peer assessment of clinical performance to enhance adherence to a low back pain guideline for physical therapists: a mixed methods design. BMC Med Educ 2015; 15:203. [PMID: 26563246 PMCID: PMC4643538 DOI: 10.1186/s12909-015-0484-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 11/03/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND Clinical practice guidelines are intended to improve the process and outcomes of patient care. However, their implementation remains a challenge. We designed an implementation strategy, based on peer assessment (PA) focusing on barriers to change in physical therapy care. A previously published randomized controlled trial showed that PA was more effective than the usual strategy "case discussion" in improving adherence to a low back pain guideline. Peer assessment aims to enhance knowledge, communication, and hands-on clinical skills consistent with guideline recommendations. Participants observed and evaluated clinical performance on the spot in a role-play simulating clinical practice. Participants performed three roles: physical therapist, assessor, and patient. This study explored the critical features of the PA program that contributed to improved guideline adherence in the perception of participants. METHODS Dutch physical therapists working in primary care (n = 49) organized in communities of practice (n = 6) participated in the PA program. By unpacking the program we identified three main tasks and eleven subtasks. After the program was finished, a questionnaire was administered in which participants were asked to rank the program tasks from high to low learning value and to describe their impact on performance improvement. Overall ranking results were calculated. Additional semi-structured interviews were conducted to elaborate on the questionnaires results and were transcribed verbatim. Questionnaires comments and interview transcripts were analyzed using template analysis. RESULTS Program tasks related to performance in the therapist role were perceived to have the highest impact on learning, although task perceptions varied from challenging to threatening. Perceptions were affected by the role-play format and the time schedule. Learning outcomes were awareness of performance, improved attitudes towards the guideline, and increased self-efficacy beliefs in managing patients with low back pain. Learning was facilitated by psychological safety and the quality of feedback. CONCLUSION The effectiveness of PA can be attributed to the structured and performance-based design of the program. Participants showed a strong cognitive and emotional commitment to performing the physical therapist role. That might have contributed to an increased awareness of strength and weakness in clinical performance and a motivation to change routine practice.
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Affiliation(s)
- Marjo J M Maas
- HAN University of Applied Sciences, Institute for Health Studies, Kapittelweg 33, 5425 EN, Nijmegen, The Netherlands.
- Radboud University Medical Center, Institute for Health Sciences, IQ healthcare, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands.
| | - Simone A van Dulmen
- Radboud University Medical Center, Institute for Health Sciences, IQ healthcare, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands.
| | - Margaretha H Sagasser
- Radboud University Medical Center Department of Primary and Community Care, Nijmegen, The Netherlands.
| | - Yvonne F Heerkens
- HAN University of Applied Sciences, Institute for Health Studies, Kapittelweg 33, 5425 EN, Nijmegen, The Netherlands.
- Dutch Institute of Allied Health Care, Amersfoort, The Netherlands.
| | - Cees P M van der Vleuten
- Maastricht University, Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences, Maastricht, The Netherlands.
| | - Maria W G Nijhuis-van der Sanden
- Radboud University Medical Center, Institute for Health Sciences, IQ healthcare, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands.
| | - Philip J van der Wees
- Radboud University Medical Center, Institute for Health Sciences, IQ healthcare, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands.
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van Dulmen SA, Lukersmith S, Muxlow J, Santa Mina E, Nijhuis-van der Sanden MWG, van der Wees PJ. Supporting a person-centred approach in clinical guidelines. A position paper of the Allied Health Community - Guidelines International Network (G-I-N). Health Expect 2013; 18:1543-58. [PMID: 24118821 DOI: 10.1111/hex.12144] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2013] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND A person-centred approach in the context of health services delivery implies a biopsychosocial model focusing on all factors that influence the person's health and functioning. Those wishing to monitor change should consider this perspective when they develop and use guidelines to stimulate active consideration of the person's needs, preferences and participation in goal setting, intervention selection and the use of appropriate outcome measures. OBJECTIVE To develop a position paper that promotes a person-centred approach in guideline development and implementation. DESIGN, SETTING AND PARTICIPANTS We used three narrative discussion formats to collect data for achieving consensus: a nominal group technique for the Allied Health Steering Group, an Internet discussion board and a workshop at the annual G-I-N conference. We analysed the data for relevant themes to draft recommendations. RESULTS We built the position paper on the values of the biopsychosocial model. Four key themes for enhancing a person-centred approach in clinical guidelines emerged: (i) use a joint definition of health-related quality of life as an essential component of intervention goals, (ii) incorporate the International Classification of Functioning, Disability and Health (ICF) as a framework for considering all domains related to health, (iii) adopt a shared decision-making method, and (iv) incorporate patient-reported health outcome measures. The position statement includes 14 recommendations for guideline developers, implementers and users. CONCLUSION This position paper describes essential elements for incorporating a person-centred approach in clinical guidelines. The consensus process provided information about barriers and facilitators that might help us develop strategies for implementing person-centred care.
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Affiliation(s)
- Simone A van Dulmen
- Radboud University Nijmegen Medical Centre, Scientific Institute for Quality of Healthcare, Nijmegen, The Netherlands
| | | | | | - Elaine Santa Mina
- Daphne Cockwell School of Nursing, Ryerson University Toronto, Toronto, ON, Canada
| | | | - Philip J van der Wees
- Radboud University Nijmegen Medical Centre, Scientific Institute for Quality of Healthcare, Nijmegen, The Netherlands
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