Patient involvement in rheumatoid arthritis care to improve disease activity-based management in daily practice: A randomized controlled trial

OBJECTIVE

To evaluate the effect of an intervention to improve disease activity-based management of RA in daily clinical practice by addressing patient level barriers.

METHODS

The DAS-pass strategy aims to increase patients' knowledge about DAS28 and to empower patients to be involved in treatment (decisions). It consists of an informational leaflet, a patient held record and guidance by a specialized rheumatology nurse. In a Randomized Controlled Trial, 199 RA patients were randomized 1:1 to intervention or control group. Outcome measures were patient empowerment (EC-17; primary outcome), attitudes towards medication (BMQ), disease activity (DAS28) and knowledge about DAS28.

RESULTS

Our strategy did not affect EC-17, BMQ, or DAS28 use. However it demonstrated a significant improvement of knowledge about DAS28 in the intervention group, compared to the control group. The intervention had an additional effect on patients with low baseline knowledge compared to patients with high baseline knowledge.

CONCLUSION

The DAS-pass strategy educates patients about (the importance of) disease activity-based management, especially patients with low baseline knowledge.

PRACTICE IMPLICATIONS

The strategy supports patient involvement in disease activity-based management of RA and can be helpful to reduce inequalities between patients in the ability to be involved in shared decision making.

Proxy indicators to estimate appropriateness of antibiotic prescriptions by general practitioners: a proof-of-concept cross-sectional study based on reimbursement data, north-eastern France 2017

Background

In most countries, including France, data on clinical indications for outpatient antibiotic prescriptions are not available, making it impossible to assess appropriateness of antibiotic use at prescription level.

Aim

Our objectives were to: (i) propose proxy indicators (PIs) to estimate appropriateness of antibiotic use at general practitioner (GP) level based on routine reimbursement data; and (ii) assess PIs’ performance scores and their clinimetric properties using a large regional reimbursement database.

Methods

A recent systematic literature review on quality indicators was the starting point for defining a set of PIs, taking French national guidelines into account. We performed a cross-sectional study analysing National Health Insurance data (available at prescriber and patient levels) on antibiotics prescribed by GPs in 2017 for individuals living in north-eastern France. We measured performance scores of the PIs and their case-mix stability, and tested their measurability, applicability, and room for improvement (clinimetric properties).

Results

The 3,087 GPs included in this study prescribed a total of 2,077,249 antibiotic treatments. We defined 10 PIs with specific numerators, denominators and targets. Performance was low for almost all indicators ranging from 9% to 75%, with values < 30% for eight of 10 indicators. For all PIs, we found large variation between GPs and patient populations (case-mix stability). Regarding clinimetric properties, all PIs were measurable, applicable, and showed high improvement potential.

Conclusions

The set of 10 PIs showed satisfactory clinimetric properties and might be used to estimate appropriateness of antibiotic prescribing in primary care, in an automated way within antibiotic stewardship programmes.

Cost-effectiveness of five different anti-tumour necrosis factor tapering strategies in rheumatoid arthritis: a modelling study

Objective: To investigate the cost-effectiveness of five different tumour necrosis factor inhibitor tapering strategies in patients with rheumatoid arthritis (RA) and stable low disease activity, using a modelling design.Method: Using Markov models based on data from the DRESS and STRASS randomized controlled trials, and the Nijmegen RA cohort, five tapering strategies for etanercept and adalimumab were tested against continuation: 1, four-step tapering (DRESS strategy); 2, five-step tapering; 3, tapering without withdrawal; 4, use of a stricter flare criterion; and 5, use of a theoretical predictor for successful tapering. We also examined how well a biomarker should be able to predict in order for strategy 5 to become cost-effective compared to the other strategies.Results: All examined tapering strategies were cost saving (range: EUR 5128 to 7873) but yielded more short-lived flares compared to continuation. The change in utilities compared to continuation was minimal and not clinically relevant (range: -0.005 to 0.007 quality-adjusted life-years). Strategy 1 was cost-effective compared to all other strategies [highest incremental net monetary benefit (iNMB)]. However, there was a large overlap in credible intervals, especially between strategies 1 and 2. Scenario analyses showed that 50% reduction of drug prices would result in the highest iNMB for strategy 2. A biomarker only becomes cost-effective when it is inexpensive and has a sensitivity and specificity of at least 84%.Conclusion: Because our study showed a comparable iNMB for tapering in four or five steps (including discontinuation), we recommend a choice between these strategies, based on shared decision making.

Perioperative diabetes care: development and validation of quality indicators throughout the entire hospital care pathway

BACKGROUND

In this study, we aim to develop a set of quality indicators for optimal perioperative diabetes care throughout the hospital care pathway and to gain insight into the feasibility of the indicator set in daily clinical practice by assessing the clinimetric properties of the indicators in a practice test.

METHODS

A literature-based modified Delphi method was used to develop a set of quality indicators. To assess clinimetric properties of each indicator (measurability, applicability, reliability, improvement potential and case-mix stability), a practice test was performed in six Dutch hospitals using a sample of 389 major surgery patients with diabetes who underwent abdominal, cardiac or large joint orthopaedic surgery.

RESULTS

We developed a set of 36 quality indicators for perioperative diabetes care. The practice test showed that one indicator was inapplicable, and nine indicators were unmeasurable. Interobserver reliability was good (0.61≤k≤0.8) for all indicators except for one with moderate (0.41≤k≤0.6) interobserver reliability. Improvement potential was low (<10%) for five indicators. Twenty-one indicators, including three outcome indicators, nine process indicators and nine structure indicators, could be used to assess the quality of care delivered in our six study hospitals.

CONCLUSION

We developed a face and content valid set of quality indicators for optimal perioperative diabetes care throughout the hospital care pathway, using a rigorous and systematic approach. The results from our practice test show that it is essential to subject indicators to a practice test before applying them for quality improvement purposes.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT01610674.

Short- and long-term effects of a quality improvement collaborative on diabetes management

Introduction

This study examined the short- and long-term effects of a quality improvement collaborative on patient outcomes, professional performance, and structural aspects of chronic care management of type 2 diabetes in an integrated care setting.

Methods

Controlled pre- and post-intervention study assessing patient outcomes (hemoglobin A1c, cholesterol, blood pressure, weight, blood lipid levels, and smoking status), professional performance (guideline adherence), and structural aspects of chronic care management from baseline up to 24 months. Analyses were based on 1,861 patients with diabetes in six intervention and nine control regions representing 37 general practices and 13 outpatient clinics.

Results

Modest but significant improvement was seen in mean systolic blood pressure (decrease by 4.0 mm Hg versus 1.6 mm Hg) and mean high density lipoprotein levels (increase by 0.12 versus 0.03 points) at two-year follow up. Positive but insignificant differences were found in hemoglobin A1c (0.3%), cholesterol, and blood lipid levels. The intervention group showed significant improvement in the percentage of patients receiving advice and instruction to examine feet, and smaller reductions in the percentage of patients receiving instruction to monitor blood glucose and visiting a dietician annually. Structural aspects of self-management and decision support also improved significantly.

Conclusions

At a time of heightened national attention toward diabetes care, our results demonstrate a modest benefit of participation in a multi-institutional quality improvement collaborative focusing on integrated, patient-centered care. The effects persisted for at least 12 months after the intervention was completed.

Trial number

http://clinicaltrials.gov Identifier: NCT 00160017

Factors influencing success in quality-improvement collaboratives: development and psychometric testing of an instrument

Background

To increase the effectiveness of quality-improvement collaboratives (QICs), it is important to explore factors that potentially influence their outcomes. For this purpose, we have developed and tested the psychometric properties of an instrument that aims to identify the features that may enhance the quality and impact of collaborative quality-improvement approaches. The instrument can be used as a measurement instrument to retrospectively collect information about perceived determinants of success. In addition, it can be prospectively applied as a checklist to guide initiators, facilitators, and participants of QICs, with information about how to perform or participate in a collaborative with theoretically optimal chances of success. Such information can be used to improve collaboratives.

Methods

We developed an instrument with content validity based on literature and the opinions of QIC experts. We collected data from 144 healthcare professionals in 44 multidisciplinary improvement teams participating in two QICs and used exploratory factor analysis to assess the construct validity. We used Cronbach's alpha to ascertain the internal consistency.

Results

The 50-item instrument we developed reflected expert-opinion-based determinants of success in a QIC. We deleted nine items after item reduction. On the basis of the factor analysis results, one item was dropped, which resulted in a 40-item questionnaire. Exploratory factor analysis showed that a three-factor model provided the best fit. The components were labeled 'sufficient expert team support', 'effective multidisciplinary teamwork', and 'helpful collaborative processes'. Internal consistency reliability was excellent (alphas between .85 and .89).

Conclusions

This newly developed instrument seems a promising tool for providing healthcare workers and policy makers with useful information about determinants of success in QICs. The psychometric properties of the instrument are satisfactory and warrant application either as an objective measure or as a checklist.

Effects of a multi-faceted program to increase influenza vaccine uptake among health care workers in nursing homes: A cluster randomised controlled trial

Despite the recommendation of the Dutch association of nursing home physicians (NVVA) to be immunized against influenza, vaccine uptake among HCWs in nursing homes remains unacceptably low. Therefore we conducted a cluster randomised controlled trial among 33 Dutch nursing homes to assess the effects of a systematically developed multi-faceted intervention program on influenza vaccine uptake among HCWs. The intervention program resulted in a significantly higher, though moderate, influenza vaccine uptake among HCWs in nursing homes. To take full advantage of this measure, either the program should be adjusted and implemented over a longer time period or mandatory influenza vaccination should be considered.

Adherence to guidelines on cervical cancer screening in general practice: programme elements of successful implementation

BACKGROUND

There is still only limited understanding of whether and why interventions to facilitate the implementation of guidelines for improving primary care are successful. It is therefore important to look inside the 'black box' of the intervention, to ascertain which elements work well or less well.

AIM

To assess the associations of key elements of a nationwide multifaceted prevention programme with the successful implementation of cervical screening guidelines in general practice.

DESIGN OF STUDY

A nationwide prospective cohort study.

SETTING

A random sample of one-third of all 4,758 general practices in The Netherlands (n = 1,586).

METHOD

General practitioners (GPs) in The Netherlands were exposed to a two-and-a-half-year nationwide multifaceted prevention programme to improve the adherence to national guidelines for cervical cancer screening. Adherence to guidelines at baseline and after the intervention and actual exposure to programme elements were assessed in the sample using self-administered questionnaires.

RESULTS

Both baseline and post-measurement questionnaires were returned by 988 practices (response rate = 62%). No major differences in baseline practice characteristics between study population, non-responders, and all Netherlands practices were observed. After the intervention all practices improved markedly (P<0.001) in their incorporation of nine out of 10 guideline indicators for effective cervical screening into practice. The most important elements for successful implementation were: specific software modules (odds ratios and 95% confidence intervalsfor all nine indicators ranged from OR = 1.85 [95% CI = 1.24-2.77] to OR = 10.2 [95% CI = 7.58-14.1]); two or more 'practice visits' by outreach visitors (ORs and 95% CIs for six indicators ranged from OR = 1.46 [95% CI= 1.01-2.12] to OR = 2.35 [95% CI = 1.63-3.38]); and an educational programme for practice assistants (ORs and 95% CIs for four indicators ranged from OR = 1.57 [95% CI = 1.00-1.92] to OR = 1.90 [95% CI = 1.25-2.88]).

CONCLUSION

A multifaceted programme targeting GPs, including facilitating software modules, outreach visits, and educational sessions for PAs, contributes to the successful implementation of national guidelines for cervical screening.

Blood pressure control in treated hypertensive patients: clinical performance of general practitioners

BACKGROUND

The blood pressure of many treated hypertensive patients remains above recommended target levels. This discrepancy may be related to general practitioners' (GPs') actions.

AIM

To assess clinical performance of GPs in blood pressure control in treated hypertensive patients and to explore the influence of patient and GP characteristics on clinical performance.

DESIGN OF STUDY

Cross-sectional study conducted on 195 GPs with invitations to participate made via bulletins and by letter.

SETTING

One hundred and thirty-two practices in the southern half of The Netherlands from November 1996 to April 1997.

METHOD

Performance criteria were selected from Dutch national hypertension guidelines for general practice. GPs completed self-report forms immediately after follow-up visits of hypertensive patients treated with antihypertensive medication.

RESULTS

The GPs recorded 3526 follow-up visits. In 63% of these consultations the diastolic blood pressure (DBP) was 90 mmHg or above. The median performance rates of the GPs were less than 51% for most of the recommended actions, even at a DBP of > or = 100 mmHg. Performance of non-pharmacological actions increased gradually with increasing DBP; prescribing an increase in antihypertensive medication and making a follow-up appointment scheduled within six weeks rose steeply at a DBP of > or = 100 mmHg. Patient and GP characteristics contributed little to clinical performance. Action performance rates varied considerably between GPs.

CONCLUSION

GPs seem to target their actions at a DBP of below 100 mmHg, whereas guidelines recommend targeting at a DBP of below 90 mmHg.

Interventions to implement prevention in primary care

BACKGROUND

Primary care physicians hold a strategic position in delivering preventive services. However discrepancies exist between evidence based guidelines and practice.

OBJECTIVES

To assess the effects of interventions to improve the delivery of preventive services in primary care.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group specialised register (November 1995; August 1999), MEDLINE (1980 to 1995) and hand searched relevant journals.

SELECTION CRITERIA

Randomised trials, controlled before and after studies, and interrupted time series analyses of interventions to improve preventive services by primary care professionals responsible for patient care.

DATA COLLECTION AND ANALYSIS

Two researchers independently extracted data and assessed study quality.

MAIN RESULTS

Fifty-five studies were included, involving more than 2000 health professionals and 99,000 people, with 83 comparisons between intervention and control groups. Post intervention differences between intervention and control groups varied widely within and across categories of interventions. Most interventions were found to be effective in some studies, but not in others. Five comparisons of group education versus no intervention showed absolute change of preventive services varying between -4% and +31%. Nine comparisons of physician reminders versus no intervention showed absolute change of preventive services varying between 5% and 24%. Fourteen comparisons of multifaceted interventions versus no intervention showed absolute change of preventive services varying between -3% and +64%. Six comparisons of multifaceted interventions versus group education reported absolute changes varying between -31% and +28%. All these comparisons used randomised groups. Ten comparisons of multifaceted interventions versus no intervention used non-randomised groups and showed absolute change of preventive services varying between -5% and +21%. The remaining planned comparisons within categories of interventions contained less than five comparisons.

REVIEWER'S CONCLUSIONS

There is currently no solid basis for assuming that a particular intervention or package of interventions will work. Effective interventions to increase preventive activities in primary care exist, but there is considerable variation in the level of change achieved, with effect sizes usually small or moderate. Tailoring interventions to address specific barriers to change in a particular setting is probably important. Multifaceted interventions may be more effective than single interventions, because more barriers to change can be addressed. Future research should analyse barriers to change and interventions to implement preventive services in more detail, to clarify how interventions relate to specific barriers. Since more complex interventions are likely to be more effective but also more costly, economic evaluations should also be included.

Cardiovascular risk detection and intervention in general practice: the patients' views

OBJECTIVE

To assess patients' views on the organization of (cardiovascular) preventive care.

DESIGN

Prospective questionnaire survey with measurements shortly after risk assessment (T1) and after 1 year of risk intervention (T2).

SETTING

Twenty-seven general practices participating in a project to enhance systematic cardiovascular disease prevention in two regions in The Netherlands.

STUDY PARTICIPANTS

Two-hundred and ninety-eight successive patients aged 30-60 years identified with an elevated cardiovascular risk.

MAIN OUTCOME MEASURES

Organizational aspects such as the acceptability of the care provider, practicality of special clinics, accessibility of the practice for routine care.

RESULTS

Most of the respondents (74%) had no preference for a care provider in cardiovascular preventive care and only a few patients (3%) reported having little confidence in the expertise of the practice assistant to provide such care. The vast majority (88%) considered special preventive clinics to be practical, especially at T1. Most of the respondents (76%) did not report a decline in the accessibility of their practice for routine care. These outcome measures were not affected by age, sex, educational level or the number of risk factors measured during 1 year of risk intervention.

CONCLUSION

Most patients did not have any major objections against the organization of preventive care through opportunistic case finding and risk monitoring in special preventive clinics managed by the practice assistant.

Attendance to cervical cancer screening in family practices in The Netherlands

BACKGROUND

The effectiveness of three different organizational approaches to cervical cancer screening (community based, family practice based, and a combination) was evaluated in nationally representative family practices.

METHOD

We selected 122 family practices with a computerized sex-age register from a database of 1, 251 family practices, representative of all 4,758 family practices in The Netherlands. Approximately 40 practices were linked with each approach. We measured the attendance, the reasons for nonattendance, and the influence of a reminder on the attendance of women invited for cervical screening in September, October, and November 1996. The patients were grouped according to age. A cross-sectional design was used for the study.

RESULTS

For younger women, the total attendance rate, coverage (percentage of women "protected" against cervical cancer), and control rate (percentage of women with medical reasons for nonattendance or postponement of the smear) were highest in practices using the family practice-based approach (68, 77, and 90%, respectively) and lowest in practices with the community-based approach (53, 62, and 68%, respectively). For older women, the family practice-based approach and the combination approach were associated with attendance rates significantly higher than those for the community-based approach (approximately 60, 80, and 80% vs 47, 67, and 70%, respectively). A reminder sent by the family physician to women not responding to an initial invitation increased the attendance rate by 7 to 11% in both age categories, depending on who had sent the first invitation.

CONCLUSION

A family practice-based cervical screening approach appeared to be the most effective at a national level, achieving the highest attendance rate, coverage, and control rate.

Improving population-based cervical cancer screening in general practice: effects of a national strategy

OBJECTIVE

To assess the effects of a Dutch national prevention programme, aimed at general practitioners (GPs), on the adherence to organizational guidelines for effective cervical cancer screening in general practice. To identify the characteristics of general practices determining success.

DESIGN

A prospective questionnaire study with pre- and post-measurement (before and 15 months after the introduction of the national programme).

SETTING AND STUDY PARTICIPANTS

A random sample of one-third of all 4758 Dutch general practices. One GP was asked to participate per practice.

INTERVENTION

A national GP prevention programme to improve population-based prevention of cervical cancer combining various methods for quality improvement in general practice, performed on a national, district and practice level. Outreach visitors were a key strategy in bringing about behavioural changes.

MAIN OUTCOME MEASURES

The proportion of practices adhering to 10 recommendations (in four guidelines) to organize effective cervical cancer screening.

RESULTS

After 15 months, all Dutch practices showed significant improvement in adherence to nine out of 10 recommendations. Two recommendations, in particular 'identifying women who should be medically excluded from screening' and 'sending a reminder to non-compliers' showed the largest absolute increases of 26% and 33%, respectively. Besides more intensive support of outreach visitors, practice characteristics such as 'computerization' and 'delegation of many clinical tasks to the practice assistant' were important in improving the adherence to guidelines.

CONCLUSION

The national programme, with a combination of various methods for quality improvement, appeared to be effective in improving the organization of cervical screening in general practice. Computerization and, to a lesser extent, delegation of many clinical tasks to the practice assistant and more intensive support to practices, positively influenced the effectiveness of the national programme.

Interventions to improve the delivery of preventive services in primary care

OBJECTIVES

This review was conducted to determine the effectiveness of different interventions to improve the delivery of preventive services in primary care.

METHODS

MEDLINE searches and manual searches of 21 scientific journals and the Cochrane Effective Professional and Organization of Care of trials were used to identify relevant studies. Randomized controlled trials and controlled before-and-after studies were included if they focused on interventions designed to improve preventive activities by primary care clinicians. Two researchers independently assessed the quality of the studies and extracted data for use in constructing descriptive overviews.

RESULTS

The 58 studies included comprised 86 comparisons between intervention and control groups. Postintervention differences between intervention and control groups varied widely within and across categories of interventions. Most interventions were found to be effective in some studies, but not effective in other studies.

CONCLUSIONS

Effective interventions to increase preventive activities in primary care are available. Detailed studies are needed to identify factors that influence the effectiveness of different interventions.

Tailored outreach visits as a method for implementing guidelines and improving preventive care

OBJECTIVES

Authors of successful outreach visit studies stress the importance of tailoring the intervention to the unique attributes and needs of each practice. For a better understanding of the outreach visit method, the tailoring mechanism is explored in this article. The variation among practices in preventive outreach visits to implement guidelines and characteristics that determine the variation (baseline adherence to organizational guidelines, practice and visitor characteristics) are described. We explored whether and how many visits were paid to practices that showed no increase in adherence to guidelines.

SETTING AND STUDY PARTICIPANTS

For 18 months, six trained nurse visitors assisted 33 family practices in implementing a set of guidelines to organize a program for cardiovascular disease prevention.

MEASURES

Visit and consultative action parameters (number and duration of visits, duration of training and of conferring) and increase in adherence to organizational guidelines after 18 months of assistance compared to baseline adherence.

RESULTS

Practices differed considerably concerning the visit and consultative action parameters. Exploratory multiple regression analysis showed that baseline adherence to guidelines, and practice and visitor characteristics were related to the number of visits. Visitor characteristics were strongly related to the total time spent on visits, training, and conferring.

DISCUSSION

Our findings confirm that, concerning the number of visits, assistance is primarily adapted to the unique attributes of each clinic. It may be useful, from the viewpoint of cost-effectiveness, to standardize the performance of visitors somewhat more with regard to the visit length. The tailoring mechanism resulted in time well spent in assisting practices. We hope that our results contribute to the further development of the outreach method.

Do general practices adhere to organizational guidelines for effective cervical cancer screening?

BACKGROUND

Well-organized cervical screening has been shown to be effective in the reduction of both morbidity and mortality from cancer of the uterine cervix. In The Netherlands, the GP plays an important role in the cervical screening. The question is whether the general practices are able to organize an effective cervical cancer screening.

OBJECTIVES

We explored the extent to which Dutch general practices adhere to organizational guidelines for effective population-based prevention of cervical cancer and which practice characteristics are important for this adherence.

METHODS

A postal survey was conducted in a random sample of one-third of all 4758 Dutch general practices. Two sets of information were collected: practice characteristics and adherence to four organizational guidelines for effective cervical screening concerning inviting the women, monitoring attendance and sending reminders, organizing the taking of the smear and follow-up monitoring.

RESULTS

A total of 1251 (79%) general practices returned a questionnaire; 90 questionnaires were excluded from analyses owing to missing data. The 1161 practices were representative of the Netherlands. A minority of the practices adhered to the four guidelines (in total, ten recommendations). The presence of the practice characteristics 'a general practice-based inviting system', 'a high delegation index' (delegating many tasks to the assistants) and a 'computerized patient information recording system' were positively associated with the adherence to most of the guidelines.

CONCLUSION

This study showed that most of the Dutch general practices are not yet ready to organize an effective cervical cancer screening system. A general practice-based inviting system, a high delegation index and a computerized patient information recording system proved to be important for the adherence to the guidelines. In order to organize a cervical screening programme to achieve optimal effectiveness, emphasis should be placed on the adherence to the four guidelines described in this study and on stimulating a general practice-based inviting system, delegation to the practice assistant and computerization.

Relationship between practice organization and cardiovascular risk factor recording in general practice

BACKGROUND

Research findings suggest that the level of cardiovascular risk factor recording in general practice is not yet optimal. Several studies indicate a relation between the organization of cardiovascular disease prevention at practice level and cardiovascular risk factor recording.

AIM

To explore the relation between the organization of cardiovascular disease prevention and risk factor recording in general practice.

METHOD

A cross-sectional study was conducted using data on adherence to selected practice guidelines and on cardiovascular risk factor recording from 95 general practices. Practice guidelines were developed beforehand in a consensus procedure. Adherence was assessed by means of a questionnaire and practice observations. Risk factor recording was assessed by an audit of 50 medical records per practice.

RESULTS

Factor analysis of risk factor recording revealed three dimensions explaining 76% of the variance: recording of health-related behaviour, recording of clinical parameters, and recording of medical background parameters. Adherence to the guideline 'proactively invite patients to attend for assessment of cardiovascular risk' was related to a higher recording level in all three dimensions. Practice characteristics did not show a consistent relationship to the level of risk factor recording.

CONCLUSION

This study indicates that the presence of a system of proactive invitation was related to the recording of cardiovascular risk factors in medical records in general practice.

Barriers to preventive care in general practice: the role of organizational and attitudinal factors

BACKGROUND

There are numerous barriers to preventive care. In this paper we focus on barriers related to the organization of preventive services and to the general practitioners' (GPs') attitudes and self-efficacy expectations. The prevention of cardiovascular disease was taken as a case study.

AIM

To study the organization of cardiovascular services and the attitudes and self-efficacy expectations of GPs, the relationships that exist between these factors, and the influence of practice and provider characteristics.

METHOD

A survey was conducted among 95 general practices with 195 GPs.

RESULTS

Few practices were sufficiently well-organized to provide effective preventive services. Seventy per cent of the GPs had positive self-efficacy expectations. Thirty to fifty per cent had positive attitudes. Few relationships were found between the organization of services and positive attitudes or expectations. Moreover, few relationships were found between practice and provider characteristics and barriers studied. List size played some role in the presence of barriers.

CONCLUSION

Barriers to prevention exist. Even a positive attitude or self-efficacy expectation does not automatically coincide with a practice organization equipped for prevention. Changing attitudes is probably not enough. Efforts have to be directed at the organization of services.

Changing preventive practice: a controlled trial on the effects of outreach visits to organise prevention of cardiovascular disease

OBJECTIVES

To assess the effects of outreach visits by trained nurse facilitators on the organisation of services used to prevent cardiovascular disease. To identify the characteristics of general practices that determined success.

DESIGN

A non-randomised controlled trial of two methods of implementing guidelines to organise prevention of cardiovascular disease: an innovative outreach visit method compared with a feedback method. The results in both groups were compared with data from a control group.

SETTING AND SUBJECTS

95 general practices in two regions in The Netherlands.

INTERVENTIONS

Trained nurse facilitators visited practices, focusing on solving problems in the organisation of prevention. They applied a four step model in each practice. The number of visits depended on the needs of the practice team. The feedback method consisted of the provision of a feedback report with advice specific to each practice and standardised instructions.

MAIN OUTCOME MEASURES

The proportion of practices adhering to 10 different guidelines. Guidelines were on the detection of patients at risk, their follow up, the registration of preventive activities, and teamwork within the practice.

RESULTS

Outreach visits were more effective than feedback in implementing guidelines to organise prevention. Within the group with outreach visits, the increase in the number of practices adhering to the guidelines was significant for six out of 10 guidelines. Within the feedback group, a comparison of data before and after intervention showed no significant differences. Partnerships and practices with a computer changed more.

CONCLUSION

Outreach visits by trained nurse facilitators proved to be effective in implementing guidelines within general practices, probably because their help was practical and designed for the individual practice, guided by the wishes and capabilities of the practice team.

Validity and reliability of a questionnaire on fecundability

The validity of a short questionnaire on fertility problems was tested on a group of 151 moderately educated women who had participated in a prospective study on early pregnancy failure some years before. Part of this group was approached by a personal interview, another part by telephone interviews and a third part was sent a questionnaire by mail. Reliability was tested on another population of 89 women with at least one child. The questionnaire was presented to these women twice with an interval of 3-5 weeks. The validity study showed no systematic errors for either of the approaches. Random errors were fairly large except for the personal interviews. The reliability showed great stability for the telephone interviews as well as for the mailed questionnaire. It is concluded that the questionnaire performs reasonably well, but on some items the draft questionnaire should be rephrased. The choice of a specific approach to the study population depends on the research question.