Genomic Characterization of Methicillin-Susceptible Staphylococcus aureus Carriage in Patients on Home Parenteral Nutrition and Their Caregivers

In this prospective study, patients on home parenteral nutrition were twice as likely to be colonized with Staphylococcus aureus if their caregivers were carriers. Among S. aureus-positive patients and their caregivers, molecular analysis showed 68% genetically related strains. Despite decolonization, genetically related strains reappeared in 70% of patients.

Sex differences in the association between (sexual) abuse and lower urinary tract symptoms

OBJECTIVES

To study the possible association between (sexual) abuse and lower urinary tract symptoms (LUTS) in men and women. To study the differences in this association between men and women, and between the timing of the abuse.

SUBJECTS AND METHODS

A Dutch observational population-based cross-sectional study was used, based on self-administered questionnaires. Respondents were included if they had answered all questions about abuse and LUTS. Logistic regression was used to analyse the data.

RESULTS

Included were 558 men and 790 women, of whom 29% and 37%, respectively, reported a history of one of more types of abuse. Abuse was significantly associated with LUTS in both men (odds ratio [OR] 1.7; 1.2-2.5) and women (OR 1.4; 1.1-2.1). This association, testing by two-way interaction, was significantly stronger in men. No association was found between childhood abuse or adulthood abuse and LUTS, in men or women. The association of sexual abuse with LUTS was significant in both men (2.7; 1.4-5.2) and in women (1.5; 1.1-2.2), and this association (testing by two-way interaction) was significantly much stronger in men.

CONCLUSION

In men more than in women, a history of any type of abuse is associated with LUTS, regardless of whether the abuse occurred during childhood or adulthood. In both sexes, a history of sexual abuse is also associated with experiencing LUTS, with a much stronger association in men than in women. Patients, in particular male patients, presenting with LUTS should therefore be asked about sexual abuse in the past.

The United States reference values of the Bayley III motor scale are suitable in Suriname

To determine if the United States reference values of the Bayley Scales of Infant and Toddler Development, version III motor scale are suitable for Surinamese infants, we assessed 151 healthy infants at 3, 12, 24 and 36 months of age. The mean fine motor, gross motor, and composite scores of the total group did not significantly differ from the US norms, although some significant but not clinically relevant differences were found (lower fine motor scores at 12 months, lower gross motor and total composite scores at 24 months, and higher scores for gross motor and composite scores at 3 months).

Trends in low-value GP care during the COVID-19 pandemic: a retrospective cohort study

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.

Effects of Adherence to an mHealth Tool for Self-Management of COPD Exacerbations

Purpose

Poor adherence to COPD mobile health (mHealth) has been reported, but its association with exacerbation-related outcomes is unknown. We explored the effects of mHealth adherence on exacerbation-free weeks and self-management behavior. We also explored differences in self-efficacy and stages of grief between adherent and non-adherent COPD patients.

Patients and Methods

We conducted secondary analyses using data from a recent randomized controlled trial (RCT) that compared the effects of mHealth (intervention) with a paper action plan (comparator) for COPD exacerbation self-management. We used data from the intervention group only to assess differences in exacerbation-free weeks (primary outcome) between patients who were adherent and non-adherent to the mHealth tool. We also assessed differences in the type and timing of self-management actions and scores on self-efficacy and stages of grief (secondary outcomes). We used generalized negative binomial regression analyses with correction for follow-up length to analyze exacerbation-free weeks and multilevel logistic regression analyses with correction for clustering for secondary outcomes.

Results

We included data of 38 patients of whom 13 (34.2%) (mean (SD) age 69.2 (11.2) years) were adherent and 25 (65.8%) (mean (SD) age 68.7 (7.8) years) were non-adherent. Adherent patients did not differ from non-adherent patients in exacerbation-free weeks (mean (SD) 31.5 (14.5) versus 33.5 (10.2); p=0.63). Although statistically not significant, adherent patients increased their bronchodilator use more often and more timely, contacted a healthcare professional and/or initiated prednisolone and/or antibiotics more often, and showed at baseline higher scores of self-efficacy and disease acceptance and lower scores of denial, resistance, and sorrow, compared with non-adherent patients.

Conclusion

Adherence to mHealth may be positively associated with COPD exacerbation self-management behavior, self-efficacy and disease acceptance, but its association with exacerbation-free weeks remains unclear. Our results should be interpreted with caution by this pilot study's explorative nature and small sample size.

Patient factors associated with conveyance decision-making by Emergency Medical Services professionals in patients with a syncope: a cross-sectional factorial survey design

BACKGROUND

The clinical decision-making of non-conveyance is perceived as complex and difficult by emergency medical services (EMS) professionals. Patients with a transient loss of consciousness (TLOC) based on syncope constitute a significant part of the non-conveyance population. Risk stratification is the basis of the clinical decision-making process by EMS professionals. This risk stratification is based on various patient factors. This study aimed to explore patient factors significantly associated with conveyance decision-making by EMS professionals in patients with a TLOC based on syncope.

METHODS

A cross-sectional vignette study with a factorial survey design was conducted. Patient factors were derived from the "National Protocol Ambulance Care", and all possible combinations of these factors and underlying categories were combined, resulting in 256 unique vignettes (2*4*4*4*2 = 256). Patient factors presented either low-risk or high-risk factors for adverse events. Data were collected through an online questionnaire, in which participants received a random sample of 15 vignettes. For each vignette, the respondent indicated whether the patient would need to be conveyed to the emergency department or not. A multilevel logistic regression analysis with stepwise backward elimination was performed to analyse factors significantly associated with conveyance decision-making. In the logistic model, we modelled the probability of non-conveyance.

RESULTS

110 respondents were included, with 1646 vignettes being assessed. Mean age 45.5 (SD 9.3), male gender 63.6%, and years of experience 13.2 (SD 8.9). Multilevel analysis showed two patient factors contributing significantly to conveyance decision-making: 'red flags' and 'prehospital electrocardiogram (ECG)'. Of these patient factors, three underlying categories were significantly associated with non-conveyance: 'sudden cardiac death < 40 years of age in family history' (OR 0.33, 95% CI 0.22-0.50; p < 0.001), 'cardiovascular abnormalities, pulmonary embolism or pulmonary hypertension in the medical history' (OR 0.62, 95% CI 0.43-0.91; p = 0.01), and 'abnormal prehospital ECG' (OR 0.54, 95% CI 0.41-0.72; p < 0.001).

CONCLUSION

Sudden cardiac death < 40 years of age in family history, medical history, and abnormal ECG are significantly negatively associated with non-conveyance decision-making by EMS professionals in patients with a TLOC based on syncope. Low-risk factors do not play a significant role in conveyance decision-making.

Randomized clinical trial: Long-term Staphylococcus aureus decolonization in patients on home parenteral nutrition

BACKGROUND & AIMS

Staphylococcus aureus decolonization has proven successful in prevention of S. aureus infections and is a key strategy to maintain venous access and avoid hospitalization in patients receiving home parenteral nutrition (HPN). We aimed to determine the most effective and safe long-term S. aureus decolonization regimen.

METHODS

A randomized, open-label, multicenter clinical trial was conducted. Adult intestinal failure patients with HPN support and carrying S. aureus were randomly assigned to a 'continuous suppression' (CS) strategy, a repeated chronic topical antibiotic treatment or a 'search and destroy' (SD) strategy, a short and systemic antibiotic treatment. Primary outcome was the proportion of patients in whom S. aureus was totally eradicated during a 1-year period. Secondary outcomes included risk factors for decolonization failure and S. aureus infections, antimicrobial resistance, adverse events, patient compliance and cost-effectivity.

RESULTS

63 participants were included (CS 31; SD 32). The mean 1-year S. aureus decolonization rate was 61% (95% CI 44, 75) for the CS group and 39% (95% CI 25, 56) for the SD group with an OR of 2.38 (95% CI 0.92, 6.11, P = 0.07). More adverse effects occurred in the SD group (P = 0.01). Predictors for eradication failure were a S. aureus positive caregiver and presence of a (gastro)enterostomy.

CONCLUSION

We did not demonstrate an increased efficacy of a short and systemic S. aureus decolonization strategy over a continuous topical suppression treatment. The latter may be the best option for HPN patients as it achieved a higher long-term decolonization rate and was well-tolerated (NCT03173053).

How to use quality indicators for antimicrobial stewardship in your hospital: a practical example on outpatient parenteral antimicrobial therapy

BACKGROUND

Antimicrobial stewardship (AMS) teams are responsible for performing an AMS programme in their hospitals that aims to improve the quality of antibiotic use. Measuring the quality of antimicrobial use is a core task of a stewardship team. Measurement provides insight into the current quality of antibiotic use and allows for the establishment of goals for improvement. Yet, a practical description of how such a quality measurement using quality indicators (QIs) should be performed is lacking.

OBJECTIVES

To provide practical guidance on how a stewardship team can use QIs to measure the quality of antibiotic use in their hospital and identify targets for improvement.

SOURCES

General principles from implementation science, peer-reviewed publications, and experience from clinicians and researchers with AMS experience.

CONTENT

We provide step-by-step guidance on how AMS teams can use QIs to measure the quality of antibiotic use. The principles behind each step are explained and illustrated with the description and results of an audit of patients receiving outpatient parenteral antimicrobial therapy in four Dutch hospitals.

IMPLICATIONS

Improving the quality of antibiotic use is impossible without first gaining insight into that quality by performing a measurement with validated QIs. This step-by-step practice example of how to use quality indicators in a hospital will help AMS teams to identify targets for improvement. This enables them to perform their AMS programme more effectively and efficiently.

First step in implementation of opportunistic salpingectomy for prevention of ovarian cancer: Current care and its determinants

INTRODUCTION

Opportunistic salpingectomy (OS) refers to additional removal of the fallopian tubes during abdominal surgery performed for another medical indication, as prevention for ovarian cancer. As OS has been inconsistently implemented, its clinical practice varies worldwide. To reduce this variation, insight is required into current clinical practice and its determinants. Therefore, the study aim was to determine the implementation of counseling and performance of OS between 2015 and 2018, and its patient, surgical, physician, and hospital characteristics.

MATERIAL AND METHODS

Retrospective study using electronic medical records from six different Dutch hospitals: two academic, two large teaching, and two non-teaching hospitals. Patients were considered eligible for OS if they underwent elective non-obstetric abdominal surgery for a gynecological indication from January 2015 through December 2018. Primary outcomes were uptake of counseling and performance of OS. Multilevel multivariable logistic regression analyses were conducted to identify characteristics associated with OS.

RESULTS

A total of 3214 patients underwent elective non-obstetric abdominal surgery for a gynecological indication and were eligible for OS. Counseling on OS increased significantly from 2.9% in 2015 to 29.4% in 2018. In this period, 440 patients were counseled on OS, of which 95.9% chose OS. Performance of OS increased significantly from 6.9% in 2015 to 44.5% in 2018. Counseling for and performance of OS were more likely in patients who had surgery by laparoscopic approach, were counseled by a gynecological resident, or had more than three contact moments before surgery. Additionally, OS was less likely in patients who had vaginal surgery.

CONCLUSIONS

Although the uptake of OS increased from 2015 to 2018, the majority of patients who were eligible for OS were not counseled and did not undergo OS. Its clinical practice varies on patient, surgery, and physician characteristics. Therefore, an implementation strategy tailored to associated determinants is recommended.

Help-seeking behaviour in primary care of men and women with a history of abuse: A Dutch cohort study

Background

Previous studies show an association between a history of abuse and higher care demand. However, studies in general practice regarding help-seeking behaviour by patients (mainly male patients) with a history of abuse are scarce.

Objectives

To analyse help-seeking behaviour in general practice of men and women with a history of abuse.

Methods

A cohort study using data from a Dutch primary care registration network from 2015 to 2019. We included all patients aged ≥ 18 years who indicated on a questionnaire that they did or did not have a history of abuse. We analysed differences in contact frequency, types of contact, reason for encounter and diagnoses between men and women with or without a history of abuse.

Results

The questionnaire had a response rate of 59% and resulted in 11,140 patients, of which 1271 indicated a history of abuse. Men and women with a history of abuse contact the general practitioner (GP) 1.5 times (95% CI 1.42–1.60) more often than men and women without a history of abuse, especially for psychological (rate ratio 1.97, 95% CI 1.79–2.17) and social (rate ratio 1.93, 95% CI 1.68–2.22) problems. Moreover, when diagnosed with a psychological or social problem, patients with a history of abuse contact the GP twice more often for these problems.

Conclusion

Compared to men and women without a history of abuse, men and women with a history of abuse visit their GP more often, particularly for psychological and social problems.

Nationwide implementation of a multifaceted, tailored strategy to improve uptake of standardized structured reporting in oncological pathology: An effect and process evaluation

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Background: Implementation strategies improve guideline adherence. Effect and process evaluations are conducted to provide insights into success or failure of implementation strategies. We conducted both evaluations to determine nationwide implementation of standardized structured reporting (SSR) in pathology, to facilitate optimal treatment decisions in oncology care. Methods: We conducted an interrupted time series analysis to evaluate the effect of a fully digital nationwide implementation strategy on SSR use in pathology laboratories. We further conducted a process evaluation to evaluate the exposure to the strategy elements, the experiences of the users with the implementation strategy and remaining barriers of SSR implementation. We also tested whether being exposed to a specific element of the strategy resulted in more increase of average SSR use. Results: There was a significant increase in average SSR use directly after the strategy introduction for reporting of gastrointestinal ( p =.018) and urological ( p =.003) oncological diagnoses. A significant increase was present for all oncological resections as a group ( p =.007). The “Feedback button”, an option within the templates used for standardized structured reporting to provide feedback to the provider and one of the elements of the implementation strategy, was most frequently used by the SSR users and effectiveness results showed that it increased average SSR use after strategy introduction. Remaining barriers most related to rigidity, time consumption and content of SSR. Conclusions: Nationwide SSR implementation improved for specific tumor types and retrieval methods. Next step will be to further improve the use of SSR, and simultaneously, to further develop potential benefits of high SSR use, focusing on re-using discrete pathology data. In this way, we can eventually facilitate proper treatment decisions in oncology.

Nationwide implementation of a multifaceted tailored strategy to improve uptake of standardized structured reporting in pathology: an effect and process evaluation

Background

Implementation strategies are aimed at improving guideline adherence. Both effect and process evaluations are conducted to provide insights into the success or failure of these strategies. In our study, we evaluate the nationwide implementation of standardized structured reporting (SSR) in pathology.

Methods

An interrupted time series analysis was conducted to evaluate the effect of a previously developed implementation strategy, which consisted of various digitally available elements, on SSR in pathology laboratories. A segmented regression analysis was performed to analyze the change in mean SSR percentages directly after the strategy introduction for pathology reporting and specific subcategories. In addition, we analyzed the change in trend in the weekly percentages after strategy introduction, also for subgroups of tumor groups, retrieval methods, and type of laboratory. The change in SSR use after the strategy introduction was determined for all pathology laboratories. We further conducted a process evaluation in which the exposure to the strategy elements was determined. Experiences of the users with all strategy elements and the remaining barriers and potential strategy elements were evaluated through an eSurvey. We also tested whether exposure to a specific element and a combination of elements resulted in a higher uptake of SSR after strategy introduction.

Results

There was a significant increase in an average use of SSR after the strategy introduction for reporting of gastrointestinal (p=.018) and urological (p=.003) oncological diagnoses. A significant increase was present for all oncological resections as a group (p=.007). Thirty-three out of 42 pathology laboratories increased SSR use after the strategy introduction. The “Feedback button”, an option within the templates for SSR to provide feedback to the provider and one of the elements of the implementation strategy, was most frequently used by the SSR users, and effectiveness results showed that it increased average SSR use after the strategy introduction. Barriers were still present for SSR implementation.

Conclusions

Nationwide SSR implementation improved for specific tumor groups and retrieval methods. The next step will be to further improve the use of SSR and, simultaneously, to further develop potential benefits of high SSR use, focusing on re-using discrete pathology data. In this way, we can facilitate proper treatment decisions in oncology.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01224-5.

Reduction of Gastrointestinal Bleeding in Patients With Heyde Syndrome Undergoing Transcatheter Aortic Valve Implantation

BACKGROUND

Heyde syndrome is the co-occurrence of aortic stenosis and gastrointestinal bleeding secondary to angiodysplasias. Surgical aortic valve replacement effectively reduces bleeding, but the effects of transcatheter aortic valve implantation (TAVI) are largely unknown. This study aimed to describe the reduction of gastrointestinal bleeding in patients with Heyde syndrome after TAVI and to identify the factors associated with rebleeding.

METHODS

We enrolled patients with Heyde syndrome from a prospective TAVI registry. Gastrointestinal bleeding episodes were assessed by the Bleeding Academic Research Consortium classification, and cumulative incidence functions were used to calculate cessation rates. Factors potentially associated with rebleeding were analyzed using logistic regression. Differences between Heyde and non-Heyde patients were assessed through a case-cohort study.

RESULTS

Between December 2008 and June 2020, 1111 patients underwent TAVI. There were 70 patients with Heyde syndrome (6.3%). In the first year following TAVI, gastrointestinal bleeding ceased in 46 of 70 patients (62% [95% CI, 50%-74%]). Bleeding episodes decreased from 3.2 (95% CI, 2.5-4.2) to 1.6 ([95% CI, 1.2-2.2] P=0.001) and hemoglobin levels increased from 10.3 (95% CI, 10.0-10.8) to 11.3 (95% CI, 10.8-11.6) g/dL (P=0.007). Between 1 and 5 years after TAVI (35 [interquartile range, 21-51] months), 53 of 62 patients (83% [95% CI, 72%-92%]) no longer experienced gastrointestinal bleeding. Paravalvular leakage (≥mild) was associated with rebleeding risk (odds ratio, 3.65 [95% CI, 1.36-9.80]; P=0.010). Periprocedural bleeding was more common in Heyde than in control patients (adjusted odds ratio, 2.55 [95% CI, 1.37-4.73]; P=0.003).

CONCLUSIONS

Patients with Heyde syndrome are at increased risk for periprocedural bleeding. Post-TAVI, gastrointestinal bleeding disappears in the majority of patients. Paravalvular leakage may curtail these clinical benefits.

Impact of Q-fever on physical and psychosocial functioning until 8 years after Coxiella burnetii infection: An integrative data analysis

Background

This study aimed to determine short- and long-term physical and psychosocial impact of Coxiella burnetii infection in three distinct entities: Q-fever fatigue syndrome (QFS), chronic Q-fever, and patients with past acute Q-fever without QFS or chronic Q-fever.

Methods

Integrative data analysis was performed, combining original data from eight studies measuring quality of life (QoL), fatigue, physical and social functioning with identical validated questionnaires, from three months to eight years after onset infection. Linear trends in each outcome were compared between Q-fever groups using multilevel linear regression analyses to account for repeated measures within patients.

Results

Data included 3947 observations of 2313 individual patients (228 QFS, 135 chronic Q-fever and 1950 patients with past acute Q-fever). In the first years following infection, physical and psychosocial impact was highest among QFS patients, and remained high without significant improvements over time. In chronic Q-fever patients, QoL and physical functioning worsened significantly over time. Levels of fatigue and social participation in patients with past acute Q-fever improved significantly over time.

Conclusion

The impact differs greatly between the three Q-fever groups. It is important that physicians are aware of these differences, in order to provide relevant care for each patient group.

The usefulness of uroflowmetry and ultrasound bladder scanning as diagnostic tools in primary care for new male patients with lower urinary tract symptoms; a cluster randomized controlled trial

BACKGROUND

Uroflowmetry and ultrasound scanning of the post-void residual volume are diagnostic instruments in specialist urological care of men referred with lower urinary tract symptoms (LUTS). We hypothesized that implementing uroflowmetry and post-void ultrasound bladder scanning in primary care for men with LUTS will reduce the number of referrals to urologists.

OBJECTIVE

To assess the effect on referrals to urologists for new male patients over 50 years of age with LUTS when performing uroflowmetry and post-void ultrasound bladder scanning in primary care.

METHODS

A cluster randomized controlled trial was conducted among Dutch general practitioners (GPs). The GPs enrolled male patients with the first-time presentation of LUTS, these were randomized to primary-care treatment with or without uroflowmetry and post-void bladder scanning. Primary outcome: percentage of patients referred to urologists within 3 and 12 months. Secondary outcomes: changes in the International Prostate Symptom Score (IPSS) and the IPSS-Quality of Life, patient satisfaction and urologic medication usage after 12 months.

RESULTS

Four GPs were randomly assigned to the intervention group (132 patients) and seven to the control group (212 patients). The percentage of patients referred to urologists did not differ significantly between the intervention group vs the control group: within 3 months 19.7% versus 10.4% (OR 1.9, 95% CI 0.8 to 5.0), and within 12 months 28.8% versus 21.2% (OR 1.5, 95% CI 0.9 to 2.5).

CONCLUSIONS

Performing uroflowmetry and ultrasound bladder scanning in primary care as additional diagnostic tools do not reduce the number of referrals to urologists. We do not recommend using these diagnostic tools in general practice in the diagnostic work-up of these patients.

Comparing success rates in central venous catheter salvage for catheter-related bloodstream infections in adult patients on home parenteral nutrition: a systematic review and meta-analysis

BACKGROUND

Catheter-related bloodstream infection (CRBSI) is a life-threatening complication of parenteral nutrition. Therefore, optimal management, ideally with catheter salvage, is required to maintain long-term venous access.

OBJECTIVES

We aimed to evaluate successful catheter salvage rates in patients on home parenteral nutrition (HPN).

METHODS

Studies were retrieved from medical databases, conference proceedings, and article reference lists. Data were collected relating to clinical outcomes of 3 treatments: systemic antibiotics, antimicrobial lock therapy (ALT), and catheter exchange. ORs and 95% CIs were calculated from a mixed logistic effects model.

RESULTS

From 10,036 identified publications, 28 met the inclusion criteria (22 cohort studies, 5 case-control studies, and 1 randomized clinical trial), resulting in a total of 4911 CRBSIs. To achieve successful catheter salvage, the addition of an antimicrobial lock solution was superior to systemic antibiotics alone (OR: 1.75; 95% CI: 1.21, 2.53; P = 0.003). Recurrence of infection was less common in studies that used ALT than in those that used systemic antibiotics alone (OR: 0.26; 95% CI: 0.11, 0.61; P = 0.002). The catheter exchange group was excluded from multilevel regression analysis because only 1 included study applied this treatment. Successful salvage rates were highest for coagulase-negative staphylococci, followed by Gram-negative rods and Staphylococcus aureus .

CONCLUSIONS

The addition of an antimicrobial lock solution seems beneficial for successful catheter salvage in HPN-dependent patients with a CRBSI. Future prospective randomized studies should identify the most effective and pathogen-specific strategy.This review was registered at www.crd.york.ac.uk/PROSPERO as CRD42018102959.

Sex differences in incidence of respiratory symptoms and management by general practitioners

BACKGROUND

Differences between women and men play an important role in lung physiology and epidemiology of respiratory diseases, but also in the health care processes.

OBJECTIVE

To analyse sex differences in patients encountering their general practitioner (GP) with respiratory symptoms with regard to incidence, GP's management and final diagnoses.

METHODS

Retrospective cohort study, using data of the Dutch Practice Based Research Network. All patients who encountered their GP from 01-07-2013 until 30-06-2018 with a new episode of care starting with a reason for encounter in the respiratory category (R) of the ICPC-2 classification were included (n = 16 773). Multi-level logistic regression was used to analyse influence of patients' sex on management of GPs with adjustment for possible confounders.

RESULTS

We found a significant higher incidence of respiratory symptoms in women than in men: 230/1000 patient years [95% confidence interval (CI) 227-232] and 186/1000 patient years (95% CI 183-189), respectively. When presenting with cough, GPs are more likely to perform physical examination [odds ratio (OR) 1.22; 95% CI 1.11-1.35] and diagnostic radiology (OR 1.25; 95% CI 1.08-1.44), but less likely to prescribe medication (OR 0.88; 95% CI 0.82-0.95) in men. When visiting the GP with dyspnoea, men more often undergo diagnostic imaging (OR 1.32; 95% CI 1.05-1.66) and are more often referred to a specialist (OR 1.35; 95% CI 1.13-1.62).

CONCLUSIONS

Women encounter their GP more frequently with respiratory symptoms than men and GPs perform more diagnostic investigations in men. We suggest more research in general practice focussing on sex differences and possible confounders.

The Prevalence and Determinants of Neuropsychiatric Symptoms in People With Acquired Brain Injury in Nursing Homes

OBJECTIVES

Establishing the prevalence and determinants of neuropsychiatric symptoms (NPS) in patients with acquired brain injury (ABI) in nursing homes.

DESIGN

Cross-sectional, observational study.

SETTING AND PARTICIPANTS

Patients 18-65 years old with ABI in special care units in Dutch nursing homes.

METHODS

Nursing homes were recruited through the national expertise network for patients with severe ABI, regional brain injury teams, and by searching the Internet. Patient characteristics were collected through digital questionnaires. NPS were assessed with the Neuropsychiatric Inventory-Nursing Home version (NPI-NH) and the Cohen-Mansfield Agitation Inventory (CMAI), cognition with the Mini-Mental State Examination, and activities of daily living with the Disability Rating Scale. Psychotropic drug use (PDU) was retrieved from the electronic prescription system. Individual NPS were clustered. Associations between determinants and NPS were examined using multilevel multivariate linear regression models.

RESULTS

In a population of 118 patients from 12 nursing homes, 73.7% had 1 or more clinically relevant NPS and 81.3% 1 or more agitated behaviors. The most common NPS were agitation, in particular aberrant motor behavior (24.6%), repetitious sentences/questions (35.5%), and constant requests for attention (34.6%), verbal (33.6%) and physical (50.5%) aggression, and irritability (28.0%). Male patients were more likely to display hyperactivity. Being married was associated with less verbally agitated behavior and pain was associated with a higher CMAI total score. PDU increased the likelihood of a higher NPI-NH total score.

CONCLUSIONS AND IMPLICATIONS

NPS are common in patients with ABI ≤65 years of age residing in nursing homes. This is a first step to fill in the knowledge gap concerning NPS in this population. An increasing number of patients with severe ABI may survive the acute phase and will reside many years in nursing homes. It is important to shed more light on these NPS, with regard to course, magnitude, and severity, to ultimately develop appropriate care for this vulnerable group of patients.

Cardiovascular risk screening of patients with serious mental illness or use of antipsychotics in family practice

Background

Patients with serious mental illness (SMI) and patients on antipsychotics (AP) have an elevated risk for cardiovascular diseases. In the Netherlands, the mental healthcare for these patients is increasingly taken care of by family practitioners (FP) as a result of a shift from secondary to primary care. Therefore, it is essential to increase our knowledge regarding the characteristics of this patient group and the (somatic) care provided by their FPs. The aim was to examine the rate of cardiovascular risk screening in patients with SMI or the use of AP in family practice.

Methods

We performed a retrospective cohort study of 151.238 patients listed in 24 family practices in the Netherlands.

From electronic medical records we extracted data concerning diagnoses, measurement values of CVR factors, medication and frequency of visits over a 2 year period. Primary outcome was the rate of patients who were screened for CVR factors. We compared three groups: patients with SMI/AP without diabetes or CVD (SMI/AP-only), patients with SMI/AP and diabetes mellitus (SMI/AP + DM), patients with SMI/AP and a history of cardiovascular disease (SMI/AP + CVD). We explored factors associated with adequate screening using multilevel logistic regression.

Results

We identified 1705 patients with SMI/AP, 834 with a SMI diagnosis, 1150 using AP. The screening rate for CVR in the SMI/AP-only group (n = 1383) was adequate in 8.5%. Screening was higher in the SMI/AP − +DM (n = 206, 68.4% adequate, OR 24.6 (95%CI, 17.3–35.1) and SMI/AP + CVD (n = 116, 26.7% adequate, OR 4.2 (95%CI, 2.7–6.6). A high frequency of visits, age, the use of AP and a diagnosis of COPD were associated with a higher screening rate. In addition we also examined differences between patients with SMI and patients using AP without SMI.

Conclusion

CVR screening in patients with SMI/AP is performed poorly in Dutch family practices. Acceptable screening rates were found only among SMI/AP patients with diabetes mellitus as comorbidity. The finding of a large group of AP users without a SMI diagnosis may indicate that FPs often prescribe AP off-label, lack information about the diagnosis, or use the wrong code.

Work-relatedness of the presented health problem and sickness absence

BACKGROUND

Perception by workers of their health problems as work-related is possibly associated with sickness absence (SA). The aim of this study was to to study the relationship between perceived work-relatedness of health problems and SA among workers who visit their GP, taking the influence of other potential determinants into account and to study the influence of these determinants on SA. Design and setting prospective cohort study in 32 Dutch GP practices.

METHODS

A secondary analysis of RCT data among workers, aged 18-63 years, who visited their GP. We measured self-reported SA days in 12 months and high SA (>20 days in 12 months) and compared workers who perceived work-relatedness (WR+) with workers who did not (WR-). With multivariable linear and logistic regression models, we analyzed the influence of age, gender, experienced health, chronic illness, prior SA, number of GP consultations and perceived work ability.

RESULTS

We analyzed data of 209 workers, 31% perceived work-relatedness. Geometric mean of SA days was 1.6 (95% CI: 0.9-3.0) for WR+- workers and 1.2 (95% CI: 0.8-1.8) for WR- workers (P = 0.42). Incidence of high SA was 21.5 and 13.3%, respectively (odds ratio 1.79; 95% CI: 0.84-3.84). SA was positively associated with chronic illness, prior SA, low perceived work ability and age over 50.

CONCLUSIONS

Perceived work-relatedness was not associated with SA. SA was associated with chronic illness, prior SA, low perceived work ability and age over 50.

Is the plasma aldosterone-to-renin ratio associated with blood pressure response to treatment in general practice?

BACKGROUND

Individualized antihypertensive treatment based on specific biomarkers such as renin may lead to more effective blood pressure control in patients with newly diagnosed essential hypertension. Recent studies suggested that the plasma aldosterone-to-renin ratio (ARR) may also be a candidate predictor for this purpose.

OBJECTIVE

To assess whether the ARR is associated with the blood pressure response to antihypertensive treatment in patients with newly diagnosed hypertension.

METHODS

In this prospective cohort study in primary care, we determined the ARR in patients with newly diagnosed hypertension prior to starting treatment. Treatment was categorized in five groups: no medication, use of angiotensin-converting-enzyme inhibitor or angiotensin receptor blocker, use of calcium channel blocker, use of diuretic, or use of beta blocker. We examined the relation between the ARR and blood pressure response within 1 year of treatment, taking into account the type of antihypertensive treatment and adjusting for gender, age, baseline blood pressure, and comorbidity.

RESULTS

Out of 304 patients, we used 947 measurements (727 no medication, 220 medication) for analysis. There was no association between the ARR and the response in blood pressure, and this applied to each treatment group. Target blood pressure, defined as systolic blood pressure <140 mmHg, was reached in 31% of patients. There was no association between the ARR and reaching target blood pressure (OR 1.002, 95% CI 0.983-1.022).

CONCLUSION

The ARR is not associated with the response in blood pressure within 1 year of antihypertensive treatment in primary care.

The association between patients' expectations and experiences of task-, affect- and therapy-oriented communication and their anxiety in medically unexplained symptoms consultations

Background

It is unknown whether patients with medically unexplained symptoms (MUS) differ from patients with medically explained symptoms (MES) regarding their expectations and experiences on task‐oriented communication (ie, communication in which the primary focus is on exchanging medical content), affect‐oriented communication (ie, communication in which the primary focus is on the emotional aspects of the interaction) and therapy‐oriented communication (ie, communication in which the primary focus is on therapeutic aspects) of the consultation and the extent to which GPs meet their expectations.

Objective

This study aims to explore (a) differences in patients’ expectations and experiences in consultations with MUS patients and patients with MES and (b) the influence of patients’ experiences in these consultations on their post‐visit anxiety level.

Study design

Prospective cohort.

Setting

Eleven Dutch general practices.

Measurements

Patients completed the QUOTE‐COMM (Quality Of communication Through the patients’ Eyes) questionnaire before and after the consultation to assess their expectations and experiences and these were related to changes in patients’ state anxiety (abbreviated State‐Trait Anxiety Inventory; STAI).

Results

Expectations did not differ between patients with MUS and MES. Patients presenting with either MUS or MES rated their experiences for task‐related and affect‐oriented communication of their GP higher than their expectations. GPs met patients’ expectations less often on task‐oriented communication in MUS patients compared to MES patients (70.2% vs 80.9%; P = ˂0.001). Affect‐oriented communication seems to be most important in reducing the anxiety level of MUS patients (β −0.63, 95% Cl = −1.07 to −0.19).

Discussion

Although the expectations of MUS patients are less often met compared to those of MES patients, GPs often communicate according to patients’ expectations. Experiencing affect‐oriented communication is associated with a stronger reduction in anxiety in patients with MUS than in those with MES.

Conclusion

GPs communicate according to patients’ expectations. However, GPs met patients’ expectations on task‐oriented communication less often in patients with MUS compared to patients with MES. Experiencing affect‐oriented communication had a stronger association with the post‐consultation anxiety for patients with MUS than MES.

Alpha-glucosidase inhibitors for prevention or delay of type 2 diabetes mellitus and its associated complications in people at increased risk of developing type 2 diabetes mellitus

BACKGROUND

Alpha-glucosidase inhibitors (AGI) reduce blood glucose levels and may thus prevent or delay type 2 diabetes mellitus (T2DM) and its associated complications in people at risk of developing of T2DM.

OBJECTIVES

To assess the effects of AGI in people with impaired glucose tolerance (IGT), impaired fasting blood glucose (IFG), moderately elevated glycosylated haemoglobin A1c (HbA1c) or any combination of these.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform, and the reference lists of systematic reviews, articles and health technology assessment reports. The date of the last search of all databases was December 2017.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), with a duration of one year or more, comparing AGI with any pharmacological glucose-lowering intervention, behaviour-changing intervention, placebo or no intervention in people with IFG, IGT, moderately elevated HbA1c or combinations of these.

DATA COLLECTION AND ANALYSIS

Two review authors read all abstracts and full-text articles or records, assessed quality and extracted outcome data independently. One review author extracted data, which were checked by a second review author. We resolved discrepancies by consensus or involvement of a third review author. For meta-analyses we used a random-effects model with assessment of risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, using 95% confidence intervals (CIs) for effect estimates. We assessed the overall quality of the evidence by using the GRADE instrument.

MAIN RESULTS

For this update of the Cochrane Review (first published 2006, Issue 4) we included 10 RCTs (11,814 participants), eight investigating acarbose and two investigating voglibose, that included people with IGT or people "at increased risk for diabetes". The trial duration ranged from one to six years. Most trials compared AGI with placebo (N = 4) or no intervention (N = 4).Acarbose reduced the incidence of T2DM compared to placebo: 670 out of 4014 people (16.7%) in the acarbose groups developed T2DM, compared to 812 out of 3994 people (20.3%) in the placebo groups (RR 0.82, 95% CI 0.75 to 0.89; P < 0.0001; 3 trials; 8008 participants; moderate-certainty evidence). One trial including participants with coronary heart disease and IGT contributed 64% of cases for this outcome. Acarbose reduced the risk of T2DM compared to no intervention: 7 out 75 people (9.3%) in the acarbose groups developed T2DM, compared to 18 out of 65 people (27.7%) in the no-intervention groups (RR 0.31, 95% CI 0.14 to 0.69; P = 0.004; 2 trials; 140 participants; very low-certainty evidence).Acarbose compared to placebo did not reduce or increase the risk of all-cause mortality (RR 0.98, 95% CI 0.82 to 1.18; P = 0.86; 3 trials; 8069 participants; very low-certainty evidence), cardiovascular mortality (RR 0.88; 95% CI 0.71 to 1.10; P = 0.26; 3 trials; 8069 participants; very low-certainty evidence), serious adverse events (RR 1.12, 95% CI 0.97 to 1.29; P = 0.13; 2 trials; 6625 participants; low-certainty evidence), non-fatal stroke (RR 0.50, 95% CI 0.09 to 2.74; P = 0.43; 1 trial; 1368 participants; very low-certainty evidence) or congestive heart failure (RR of 0.87; 95% CI 0.63 to 1.12; P = 0.40; 2 trials; 7890 participants; low-certainty evidence). Acarbose compared to placebo reduced non-fatal myocardial infarction: one out of 742 participants (0.1%) in the acarbose groups had a non-fatal myocardial infarction compared to 15 out of 744 participants (2%) in the placebo groups (RR 0.10, 95% CI 0.02 to 0.53; P = 0.007; 2 trials; 1486 participants; very low-certainty evidence). Acarbose treatment showed an increased risk of non-serious adverse events (mainly gastro-intestinal events), compared to placebo: 751 of 775 people (96.9%) in the acarbose groups experienced an event, compared to 723 of 775 people (93.3%) in the placebo groups (RR 1.04; 95% CI 1.01 to 1.06; P = 0.0008; 2 trials; 1550 participants). Acarbose compared to no intervention showed no advantage or disadvantage for any of these outcome measures (very low-certainty evidence).One trial each compared voglibose with placebo (1780 participants) or diet and exercise (870 participants). Voglibose compared to placebo reduced the incidence of T2DM: 50 out of 897 participants (5.6%) developed T2DM, compared to 106 out of 881 participants (12%) in the placebo group (RR 0.46, 95% CI 0.34 to 0.64; P < 0.0001; 1 trial; 1778 participants; low-certainty evidence). For all other reported outcome measures there were no clear differences between voglibose and comparator groups. One trial with 90 participants compared acarbose with diet and exercise and another trial with 98 participants reported data on acarbose versus metformin. There were no clear differences for any outcome measure between these two acarbose interventions and the associated comparator groups.None of the trials reported amputation of lower extremity, blindness or severe vision loss, end-stage renal disease, health-related quality of life, time to progression to T2DM, or socioeconomic effects.

AUTHORS' CONCLUSIONS

AGI may prevent or delay the development of T2DM in people with IGT. There is no firm evidence that AGI have a beneficial effect on cardiovascular mortality or cardiovascular events.

The association between implementation and outcome of a complex care program for frail elderly people

BACKGROUND

Over the last 20 years, the effectiveness of complex care programs aiming to prevent adverse outcomes in frail elderly people has been disappointing. Recently, we found no effectiveness of the CareWell primary care program. It is largely unknown to what extent incomplete implementation of these complex interventions influences their outcomes.

OBJECTIVE

To examine the association between the degree of implementation of the CareWell program and the prevention of functional decline in frail elderly people.

METHODS

Quantitative process evaluation conducted alongside a cluster-controlled trial. Two hundred and four frail elderly participants from six general practitioner practices in the Netherlands received care according to the CareWell program, consisting of four key components: multidisciplinary team meetings, proactive care planning, case management and medication reviews. We measured time registrations of team meetings, case management and medication reviews and care plan data as stored in a digital information portal. These data were aggregated into a total implementation score (TIS) representing the program's overall implementation. We measured functional decline with the Katz-15 change score (follow-up score at 12 months minus the baseline score). The association between TIS and functional decline was analyzed with linear mixed model analyses.

RESULTS

We found no statistically significant differences in functional decline between TIS groups (F = 1.350, P = 0.245). In the groups with the highest TISs, we found more functional decline.

CONCLUSION

A higher degree of implementation of the CareWell program did not lead to the prevention of functional decline in frail elderly people.

Rheumatologists' guideline adherence in rheumatoid arthritis: a randomised controlled study on electronic decision support, education and feedback

OBJECTIVES

To assess the effects of education, feedback and a computerised decision support system (CDSS) versus education and feedback alone on rheumatologists' rheumatoid arthritis (RA) guideline adherence.

METHODS

A single-centre, randomised controlled pilot study was performed among clinicians (rheumatologists, residents and physician assistants; n=20) working at the study centre, with a 1:1 randomisation of included clinicians. A standardized sum score (SSS) on guideline adherence was used as the primary outcome (patient level). The SSS was calculated from 13 dichotomous indicators on quality of RA monitoring, treatment and follow-up. The randomised controlled design was combined with a before-after design in the control group to assess the effect education and feedback alone.

RESULTS

Twenty clinicians (mean age 44.3±10.9 years; 55% female) and 990 patients (mean age 62 ± 13 years; 69% female; 72% rheumatoid factor and/or anti-CCP positive) were included. Addition of CDSS to education and feedback did not result in significant better quality of RA care than education and feedback alone (SSS difference 0.02; 95%-CI -0.04 to 0.08; p=0.60). However, before/after comparison showed that education and feedback alone resulted in a significant increase in the SSS from 0.58 to 0.64 (difference 0.06; 95%-CI 0.02 to 0.11; p<0.01).

CONCLUSIONS

Our results suggest that CDSS did not have added value with regard to guideline adherence, whereas education and feedback can lead to a small but significant improvement of guideline adherence.

Appropriate antibiotic use reduces length of hospital stay

Objectives

To define appropriate antibiotic use in hospitalized adults treated for a bacterial infection, we previously developed and validated a set of six generic quality indicators (QIs) covering all steps in the process of antibiotic use. We assessed the association between appropriate antibiotic use, defined by these QIs, and length of hospital stay (LOS).

Methods

An observational multicentre study in 22 hospitals in the Netherlands included 1890 adult, non-ICU patients using antibiotics for a suspected bacterial infection. Performance scores were calculated for all QIs separately (appropriate or not), and a sum score described performance on the total set of QIs. We divided the sum scores into two groups: low (0%-49%) versus high (50%-100%). Multilevel analyses, correcting for confounders, were used to correlate QI performance (single and combined) with (log-transformed) LOS and in-hospital mortality.

Results

The only single QI associated with shorter LOS was appropriate intravenous-oral switch (geometric means 6.5 versus 11.2 days; P  < 0.001). A high sum score was associated with a shorter LOS in the total group (10.1 versus 11.2 days; P  = 0.002) and in the subgroup of community-acquired infections (9.7 versus 10.9 days; P  =   0.007), but not in the subgroup of hospital-acquired infections. We found no association between performance on QIs and in-hospital mortality or readmission rate.

Conclusions

Appropriate antibiotic use, defined by validated process QIs, in hospitalized adult patients with a suspected bacterial infection appears to be associated with a shorter LOS and therefore positively contributes to patient outcome and healthcare costs.

Web-based consultation between general practitioners and nephrologists: a cluster randomized controlled trial

BACKGROUND

Consultation of a nephrologist is important in aligning care for patients with chronic kidney disease (CKD) at the primary-secondary care interface. However, current consultation methods come with practical difficulties that can lead to postponed consultation or patient referral instead.

OBJECTIVE

This study aimed to investigate whether a web-based consultation platform, telenephrology, led to a lower referral rate of indicated patients. Furthermore, we assessed consultation rate, quality of care, costs and general practitioner (GPs') experiences with telenephrology.

METHODS

Cluster randomized controlled trial with 47 general practices in the Netherlands was randomized to access to telenephrology or to enhanced usual care. A total of 3004 CKD patients aged 18 years or older who were under primary care were included (intervention group n = 1277, control group n = 1727) and 2693 completed the trial. All practices participated in a CKD management course and were given an overview of their CKD patients.

RESULTS

The referral rates amounted to 2.3% (n = 29) in the intervention group and 3.0% (n = 52) in the control group, which was a non-significant difference, OR 0.61; 95% CI 0.31 to 1.23. The intervention group's consultation rate was 6.3% (n = 81) against 5.0% (n = 87) (OR 2.00; 95% CI 0.75-5.33). We found no difference in quality of care or costs. The majority of GPs had a positive opinion about telenephrology.

CONCLUSION

The data in our study do not allow for conclusions on the effect of telenephrology on the rate of patient referrals and provider-to-provider consultations, compared to conventional methods. It was positively evaluated by GPs and was non-inferior in terms of quality of care and costs.

Adherence to chronic kidney disease guidelines in primary care patients is associated with comorbidity

BACKGROUND

GPs insufficiently follow guidelines regarding consultation and referral for chronic kidney disease (CKD).

OBJECTIVE

To identify patient characteristics and quality of care (QoC) in CKD patients with whom consultation and referral recommendations were not followed.

METHOD

A 14 month prospective observational cohort study of primary care patients with CKD stage 3-5. 47 practices participated, serving 207469 people. 2547 CKD patients fulfilled consultation criteria, 225 fulfilled referral criteria. We compared characteristics of patients managed by GPs with patients receiving nephrologist co-management. We assessed QoC as adherence to monitoring criteria, CKD recognition and achievement of blood pressure (BP) targets.

RESULTS

Patients treated in primary care despite a consultation recommendation (94%) had higher eGFR values (OR 1.07; 95% CI: 1.05-1.09), were less often monitored for renal function (OR 0.42; 95% CI: 0.24-0.74) and potassium (OR 0.56; 95% CI: 0.35-0.92) and CKD was less frequently recognised (OR 0.46; 95% CI: 0.31-0.68) than in patients with nephrologist co-management. Patients treated in primary care despite referral recommendation (70%) were older (OR 1.03; 95% CI:1.01-1.06) and had less cardiovascular disease (OR 0.37; 95% CI: 0.19-0.73). Overall, in patients solely managed by GPs, CKD recognition was 50%, monitoring disease progression in 36% and metabolic parameters in 3%, BP targets were achieved in 51%. Monitoring of renal function and BP was positively associated with diabetes (OR 3.10; 95% CI: 2.47-3.88 and OR 7.78; 95% CI: 3.21-18.87) and hypertension (OR 3.19; 95% CI: 2.67-3.82 and OR 3.35; 95% CI: 1.45-7.77).

CONCLUSION

Patients remaining in primary care despite nephrologists' co-management recommendations were inadequately monitored, and BP targets were insufficiently met. CKD patients without cardiovascular comorbidity or diabetes require extra attention to guarantee adequate monitoring of renal function and BP.

Effects of Mindfulness-Based Stress Reduction on the Mental Health of Clinical Clerkship Students: A Cluster-Randomized Controlled Trial

PURPOSE

To examine the effect of mindfulness-based stress reduction training (MBSR) on the mental health of medical students during clinical clerkships.

METHOD

Between February 2011 and May 2014, the authors conducted a cluster-randomized controlled trial of clerkships as usual (CAU) and clerkships with additional MBSR in medical students during their first year of clinical clerkships at a Dutch university medical center. MBSR consisted of eight weekly two-hour sessions, comprising didactic teaching, meditation exercises, and group dialogues. Students completed online assessments at baseline and after 3, 7, 12, 15, and 20 months. Outcome measures were psychological distress, positive mental health, life satisfaction, physician empathy, mindfulness skills, and dysfunctional cognitions as measured by validated tools.

RESULTS

Of 232 eligible students, 167 students (72%) participated and were randomized by clerkship group into MBSR (n = 83) or CAU (n = 84). The MBSR group reported a small reduction of psychological distress (P = .03, Cohen's d = 0.20) and dysfunctional cognitions (P = .05, Cohen's d = 0.18) and a moderate increase of positive mental health (P = .002, Cohen's d = 0.44), life satisfaction (P = .01, Cohen's d = 0.51), and mindfulness skills (P = .05, Cohen's d = 0.35) compared with CAU during the 20-month follow-up. The authors detected no significant effect on physician empathy (P = .18, Cohen's d = 0.27).

CONCLUSIONS

MBSR appeared feasible and acceptable to medical clerkship students and resulted in a small to moderate improvement of mental health compared with CAU over the 20-month follow-up.

The Influence of Muscle Weakness on the Association Between Obesity and Inpatient Recovery From Total Hip Arthroplasty

BACKGROUND

There is ongoing discussion about whether preoperative obesity is negatively associated with inpatient outcomes of total hip arthroplasty (THA). The aim was to investigate the interaction between obesity and muscle strength and the association with postoperative inpatient recovery after THA.

METHODS

Preoperative obesity (body mass index [BMI] >30 kg/m²) and muscle weakness (hand grip strength <20 kg for woman and <30 kg for men) were measured about 6 weeks before THA. Patients with a BMI <18.5 kg/m² were excluded. Outcomes were delayed inpatient recovery of activities (>2 days to reach independence of walking) and prolonged length of hospital stay (LOS, >4 days and/or discharge to extended rehabilitation). Univariate and multivariable regression analyses with the independent variables muscle weakness and obesity, and the interaction between obesity and muscle weakness, were performed and corrected for possible confounders.

RESULTS

Two hundred and ninety-seven patients were included, 54 (18%) of whom were obese and 21 (7%) who also had muscle weakness. Obesity was not significantly associated with prolonged LOS (odds ratio [OR] 1.36, 95% confidence interval [CI] 0.75-2.47) or prolonged recovery of activities (OR 1.77, 95% CI 0.98-3.22), but the combination of obesity and weakness was significantly associated with prolonged LOS (OR 3.59, 95% CI 1.09-11.89) and prolonged recovery of activities (OR 6.21, 95% CI 1.64-23.65).

CONCLUSION

Obesity is associated with inpatient recovery after THA only in patients with muscle weakness. The results of this study suggest that we should measure muscle strength in addition to BMI (or body composition) to identify patients at risk of prolonged LOS.

Pre-operative functional mobility as an independent determinant of inpatient functional recovery after total knee arthroplasty during three periods that coincided with changes in clinical pathways

AIMS

To investigate whether pre-operative functional mobility is a determinant of delayed inpatient recovery of activities (IRoA) after total knee arthroplasty (TKA) in three periods that coincided with changes in the clinical pathway.

PATIENTS AND METHODS

All patients (n = 682, 73% women, mean age 70 years, standard deviation 9) scheduled for TKA between 2009 and 2015 were pre-operatively screened for functional mobility by the Timed-up-and-Go test (TUG) and De Morton mobility index (DEMMI). The cut-off point for delayed IRoA was set on the day that 70% of the patients were recovered, according to the Modified Iowa Levels of Assistance Scale (mILAS) (a 5-item activity scale). In a multivariable logistic regression analysis, we added either the TUG or the DEMMI to a reference model including established determinants.

RESULTS

Both the TUG (Odds Ratio (OR) 1.10 per second, 95% confidence intervals (CI) 1.06 to 1.15) and the DEMMI (OR 0.96 per point on the 100-point scale, 95% CI 0.95 to 0.98) were statistically significant determinants of delayed IRoA in a model that also included age, BMI, ASA score and ISAR score. These associations did not depend on the time period during which the TKA took place, as assessed by tests for interaction.

CONCLUSION

Functional mobility, as assessed pre-operatively by the TUG and DEMMI, is an independent and stable determinant of delayed inpatient recovery of activities after TKA. Future research, focusing on improvement of pre-operative functional mobility through tailored physiotherapy intervention, should indicate whether such intervention enhances post-operative recovery among high-risk patients. Cite this article: Bone Joint J 2017;99-B:211-17.

High variability of individual longitudinal motor performance over five years in very preterm infants

AIM

To determine longitudinal motor performance in very preterm (VPT) infants from 6 months to 5 years of age for the entire cohort of infants, according to gender and gestational age and at the individual level.

METHOD

Single-center, prospective longitudinal study of 201 VPT infants (106 boys) without severe impairments.

OUTCOMES

Motor performance was assessed with the Bayley Scales of Infant Development (BSID-II-MS: 6, 12, 24 months) and the Movement Assessment Battery for Children (MABC-2-NL: 5 years).

RESULTS

At 6, 12, and 24 months and then at 5 years, 77%, 80%, 48%, and 22% of the infants, respectively, showed delayed motor performance (<-1SD). At 5 years, girls performed significantly better than boys in manual dexterity and balance. MIXED MODEL ANALYSES: that examined interactions between time and gender and time and gestational age, revealed no significant interactions. The variance at child level was 29%. Linear mixed model analysis revealed that mean z-scores of -1.46 at 6 months of age declined significantly to -0.52 at 5 years. Individual longitudinal motor performance showed high variability.

IMPLICATIONS

Longitudinal motor performance improved almost 1 SD over five years. However, the variability of individual longitudinal motor performance hampers evaluation in clinical care and research.

Determinants of students' willingness to accept a measles-mumps-rubella booster vaccination during a mumps outbreak: a cross-sectional study

Background

Despite high vaccination coverage, a mumps outbreak that affected mainly vaccinated university students and their contacts took place in the Netherlands in the period 2009–2012. We presented university students with a hypothetical case in which we offered them a measles, mumps, and rubella (MMR) booster vaccination to control the mumps outbreak. The aim of this study was to get insight into the determinants of university students' willingness to accept this vaccination.

Methods

A questionnaire containing 38 items was developed for the purpose of assessing students' willingness and the psychosocial and social demographic determinants influencing their willingness to accept an MMR booster vaccination. In addition, we explored how organisational characteristics influenced the willingness to be vaccinated. Data were collected at six Dutch universities; a total of 790 students from various faculties were invited to participate. This was a convenience sampling procedure.

Results

687 university students participated (response rate 87.0 %) and 60.4 % of the participants said they would be willing accept the hypothetical MMR booster vaccination. The perceived seriousness of mumps (OR 6.1) was the most important predictor of willingness to accept vaccination. Students who expected the MMR vaccination to be effective and to prevent individual illness and who believed their own vaccination would help stop the epidemic were more likely to be willing than others. The students were more willing to accept vaccination when they perceived that the social norms of significant others and the government favoured vaccination. Organisational characteristics, such as offering vaccination cost free and offering it at the university site, increased students’ willingness.

Conclusion

During a mumps outbreak, university students were generally willing to accept a hypothetical MMR booster vaccination. Risk perception, outcome expectations, perceived social norms, and organisational characteristics should be taken into account in the planning of any vaccination campaign for university students during an outbreak of an infectious disease.

Work participation in Q-fever patients and patients with Legionnaires' disease: a 12-month cohort study

AIMS

The aim of the study was to assess long-term work participation of Q-fever patients and patients with Legionnaires' disease, and to identify which factors are associated with a reduced work participation in Q-fever patients.

METHODS

Q-fever patients participated at four time points until 12 months after onset of illness, patients with Legionnaires' disease only at 12 months. Data were self-reported using questionnaires on the amount of hours that patients worked, and on socio-demographic, medical, psychosocial and lifestyle aspects.

RESULTS

Our study included 336 Q-fever patients and 190 patients with Legionnaires' disease. There was a decrease in the proportion of Q-fever patients with reduced work participation over time, from 45% at 3 months to 19% at 12 months (versus 15% of patients with Legionnaires' disease at 12 months). Factors associated with reduced work participation of Q-fever patients in a multivariate model were having symptoms, a higher level of sorrow, being a former smoker (compared to never smoking), not consuming any alcohol and following additional treatment for the long-term health effects of Q-fever.

CONCLUSIONS

Despite an increase in work participation of Q-fever patients over time, almost one in five Q-fever patients and one in six patients with Legionnaires' disease still suffer from reduced work participation at 12 months. Occupational and insurance physicians need to be aware of the long-term impact of these diseases on work participation.

COPD prognosis in relation to diagnostic criteria for airflow obstruction in smokers

The aim of this study was to establish which cut-off point for the forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) ratio (i.e. fixed 0.70 or lower limit of normal (LLN) cut-off point) best predicts accelerated lung function decline and exacerbations in middle-aged smokers. We performed secondary analyses on the Lung Health Study dataset. 4045 smokers aged 35-60 years with mild-to-moderate obstructive pulmonary disease were subdivided into categories based on presence or absence of obstruction according to both FEV1/FVC cut-off points. Post-bronchodilator FEV1 decline served as the primary outcome to compare subjects between the categories. 583 (14.4%) subjects were nonobstructed and 3230 (79.8%) subjects were obstructed according to both FEV1/FVC cut-off points. 173 (4.3%) subjects were obstructed according to the fixed cut-off point, but not according to the LLN cut-off point ("discordant" subjects). Mean±SE post-bronchodilator FEV1 decline was 41.8±2.0 mL·year(-1) in nonobstructed subjects, 43.8±3.8 mL·year(-1) in discordant subjects and 53.5±0.9 mL·year(-1) in obstructed subjects (p<0.001). Our study showed that FEV1 decline in subjects deemed obstructed according to a fixed criterion (FEV1/FVC <0.70), but non-obstructed by a sex- and age-specific criterion (LLN) closely resembles FEV1 decline in subjects designated as non-obstructed by both criteria. Sex and age should be taken into account when assessing airflow obstruction in middle-aged smokers.

Assessment of a pay-for-performance program in primary care designed by target users

BACKGROUND

Evidence for pay-for-performance (P4P) has been searched for in the last decade as financial incentives increased to influence behaviour of health care professionals to improve quality of care. The effectiveness of P4P is inconclusive, though some reviews reported significant effects.

OBJECTIVE

To assess changes in performance after introducing a participatory P4P program.

DESIGN

An observational study with a pre- and post-measurement. Setting and subjects. Sixty-five general practices in the south of the Netherlands. Intervention. A P4P program designed by target users containing indicators for chronic care, prevention, practice management and patient experience (general practitioner's [GP] functioning and organization of care). Quality indicators were calculated for each practice. A bonus with a maximum of 6890 Euros per 1000 patients was determined by comparing practice performance with a benchmark.

MAIN OUTCOME MEASURES

Quality indicators for clinical care (process and outcome) and patient experience.

RESULTS

We included 60 practices. After 1 year, significant improvement was shown for the process indicators for all chronic conditions ranging from +7.9% improvement for cardiovascular risk management to +11.5% for asthma. Five outcome indicators significantly improved as well as patients' experiences with GP's functioning and organization of care. No significant improvements were seen for influenza vaccination rate and the cervical cancer screening uptake. The clinical process and outcome indicators, as well as patient experience indicators were affected by baseline measures. Smaller practices showed more improvement.

CONCLUSIONS

A participatory P4P program might stimulate quality improvement in clinical care and improve patient experiences with GP's functioning and the organization of care.

Vascular outcomes in patients with screen-detected or clinically diagnosed type 2 diabetes: Diabscreen study follow-up

PURPOSE

Screening guidelines for type 2 diabetes recommend targeting high-risk individuals. Our objective was to assess whether diagnosis of type 2 diabetes based on opportunistic targeted screening results in lower vascular event rates compared with diagnosis on the basis of clinical signs or symptoms.

METHODS

In a prospective, nonrandomized, observational study, we enrolled patients aged 45 to 75 years from 10 family practices in the Netherlands with a new diagnosis of type 2 diabetes, detected either by (1) opportunistic targeted screening (n = 359) or (2) clinical signs or symptoms (n = 206). Patients in both groups received the same guideline-concordant diabetes care. The main group outcome measure was a composite of death from cardiovascular disease (CVD), nonfatal myocardial infarction, and nonfatal stroke.

RESULTS

Baseline vascular disease was more prevalent in the opportunistic targeted screening group, mainly ischemic heart disease (12.3% vs 3.9%, P = .001) and nephropathy (16.9% vs 7.1%, P = .002). After a mean follow-up of 7.7 years (SD = 2.4 years) and 7.1 years (SD = 2.7 years) for the opportunistic targeted screening and clinical diagnosis groups, respectively, composite primary event rates did not differ significantly between the 2 groups (9.5% vs 10.2%, P = .78; adjusted hazard ratio 0.67, 95% confidence interval, 0.36-1.25; P = .21). There were also no significant differences in the separate event rates of deaths from CVD, nonfatal myocardial infarction, and nonfatal strokes.

CONCLUSIONS

Opportunistic targeted screening for type 2 diabetes detected patients with higher CVD morbidity at baseline when compared with clinical diagnosis but showed similar CVD mortality and major CVD morbidity after 7.7 years. Opportunistic targeted screening and guided care appears to improve vascular outcomes in type 2 diabetes in primary care.

The CareWell-primary care program: design of a cluster controlled trial and process evaluation of a complex intervention targeting community-dwelling frail elderly

Background

With increasing age and longevity, the rising number of frail elders with complex and numerous health-related needs demands a coordinated health care delivery system integrating cure, care and welfare. Studies on the effectiveness of such comprehensive chronic care models targeting frail elders show inconclusive results. The CareWell-primary care program is a complex intervention targeting community-dwelling frail elderly people, that aims to prevent functional decline, improve quality of life, and reduce or postpone hospital and nursing home admissions of community dwelling frail elderly.

Methods/design

The CareWell-primary care study includes a (cost-) effectiveness study and a comprehensive process evaluation. In a one-year pragmatic, cluster controlled trial, six general practices are non-randomly recruited to adopt the CareWell-primary care program and six control practices will deliver ‘care as usual’. Each practice includes a random sample of fifty frail elders aged 70 years or above in the cost-effectiveness study. A sample of patients and informal caregivers and all health care professionals participating in the CareWell-primary care program are included in the process evaluation. In the cost-effectiveness study, the primary outcome is the level of functional abilities as measured with the Katz-15 index. Hierarchical mixed-effects regression models / multilevel modeling approach will be used, since the study participants are nested within the general practices. Furthermore, incremental cost-effectiveness ratios will be calculated as costs per QALY gained and as costs weighed against functional abilities. In the process evaluation, mixed methods will be used to provide insight in the implementation degree of the program, patients’ and professionals’ approval of the program, and the barriers and facilitators to implementation.

Discussion

The CareWell-primary care study will provide new insights into the (cost-) effectiveness, feasibility, and barriers and facilitators for implementation of this complex intervention in primary care.

Trial registration

The CareWell-primary care study is registered in the ClinicalTrials.gov Protocol Registration System: NCT01499797

Involvement of general practitioners in managing alcohol problems: a randomized controlled trial of a tailored improvement programme

AIMS

To assess the effect of a tailored multi-faceted improvement programme on general practitioners' (GPs') behaviour towards prevention of hazardous and harmful alcohol consumption. The improvement programme consisted of activities aimed at the GP, organization and patient. Educational training sessions and visits by a facilitator were tailored to the GPs' needs and attitudes.

DESIGN

Cluster randomized controlled trial.

SETTING

General practices in the Netherlands.

PARTICIPANTS

Seventy-seven general practices; 119 GPs participated. Data from 6318 patients were available, of whom 765 (12.1%) were at risk. A total of 1502 patients' electronic medical records were reviewed.

MEASUREMENTS

The primary outcome was the number of eligible patients who received screening and advice.

FINDINGS

Difficulties in recruiting GPs and in motivating GPs for participation in the tailored parts of the programme impeded optimal implementation of the programme. Although GPs in both groups became more involved after enrolment, this improvement waned during the trial. The quality improvement programme enhanced the initial improvement in behaviour and it tempered waning (intervention group), compared to our control condition, resulting in average improvement rates of 5% (screening) and 2% (advice-giving) at 12-month follow-up (not significant).

CONCLUSIONS

A tailored, multi-faceted programme aimed at improving general practitioner management of alcohol consumption in their patients failed to show an effect and proved difficult to implement. There remains little evidence to support the use of such an intensive implementation programme to improve the management of harmful and hazardous alcohol consumption in primary care.

Lung function decline in relation to diagnostic criteria for airflow obstruction in respiratory symptomatic subjects

Background

Current COPD guidelines advocate a fixed < 0.70 FEV1/FVC cutpoint to define airflow obstruction. We compared rate of lung function decline in respiratory symptomatic 40+ subjects who were 'obstructive' or 'non-obstructive' according to the fixed and/or age and gender specific lower limit of normal (LLN) FEV1/FVC cutpoints.

Methods

We studied 3,324 respiratory symptomatic subjects referred to primary care diagnostic centres for spirometry. The cohort was subdivided into four categories based on presence or absence of obstruction according to the fixed and LLN FEV1/FVC cutpoints. Postbronchodilator FEV1 decline served as primary outcome to compare subjects between the respective categories.

Results

918 subjects were obstructive according to the fixed FEV1/FVC cutpoint; 389 (42%) of them were non-obstructive according to the LLN cutpoint. In smokers, postbronchodilator FEV1 decline was 21 (SE 3) ml/year in those non-obstructive according to both cutpoints, 21 (7) ml/year in those obstructive according to the fixed but not according to the LLN cutpoint, and 50 (5) ml/year in those obstructive according to both cutpoints (p = 0.004).

Conclusion

This study showed that respiratory symptomatic 40+ smokers and non-smokers who show FEV1/FVC values below the fixed 0.70 cutpoint but above their age/gender specific LLN value did not show accelerated FEV1 decline, in contrast with those showing FEV1/FVC values below their LLN cutpoint.

Unstable longitudinal motor performance in preterm infants from 6 to 24 months on the Bayley Scales of Infant Development--Second edition

Preterm birth increases the risk for neurologic and developmental disabilities and therefore long-term follow-up is important. This prospective follow-up study aims to describe longitudinal motor performance in preterm infants from 6 to 24 months and to detect the influence of risk factors on motor performance trajectories. We included preterm infants (n=348) with a gestational age of ≤32 weeks. The Bayley Scales of Infant Development, 2nd edition (BSID-II) Motor Scale and the Behaviour Rating Scale were recorded at the corrected ages of 6, 12 and 24 months. The Motor Scale raw score was the dependent variable in random coefficient analysis for risk factors in the cohort if infants with cerebral damage were in- and excluded. The raw score increased, showed the highest correlation (rp=0.48-0.67) and was more stable than the PDI and its classification. Fifteen percent of the infants had a stable classification, while 45% changed one class. Male sex and intra-ventricular haemorrhage (IVH) lowered the raw scores. Higher motor quality scores and height increased the raw scores, while the influence of maternal education varied at different time points. Removal of infants with cerebral damage from the cohort did not change the risk factors. The results showed that the raw score trajectories were more stable, but after corrections for norm data, the measurements became highly unstable. This is clinically important when reporting results to parents, guiding intervention and in randomised trials. The risk factors predominantly influenced the level of motor performance raw scores. Maternal education additionally influenced the trajectory and should be included in randomisation procedures.

The role of schools in the spread of mumps among unvaccinated children: a retrospective cohort study

BACKGROUND

In the Netherlands, epidemics of vaccine preventable diseases are largely confined to an orthodox protestant minority with religious objections to vaccination. The clustering of unvaccinated children in orthodox protestant schools can foster the spread of epidemics. School closure has nevertheless not been practiced up until now. A mumps epidemic in 2007-2008 gave us an opportunity to study the role of schools in the spread of a vaccine preventable disease in a village with low vaccination coverage.

METHODS

A retrospective cohort study was conducted among the students in four elementary schools and their siblings. The following information was collected for each child: having had the mumps or not and when, school, age, MMR vaccination status, household size, presence of high school students in the household, religious denomination, and home village. The spread of mumps among unvaccinated children was compared for the four schools in a Kaplan-Meier analysis using a log-rank test. Cox proportional hazard analyses were performed to test for the influence of other factors. To correct for confounding, a univariate Cox regression model with only school included as a determinant was compared to a multivariate regression model containing all possible confounders.

RESULTS

Out of 650 households with children at the schools, 54% completed a questionnaire, which provided information on 1191 children. For the unvaccinated children (N = 769), the Kaplan-Meier curves showed significant differences among the schools in their cumulative attack rates. After correction for confounding, the Cox regression analysis showed the hazard of mumps to be higher in one orthodox protestant school compared to the other (hazard ratio 1.43, p < 0.001). Household size independently influenced the hazard of mumps (hazard ratio 1.44, p < 0.005) with children in larger households running a greater risk.

CONCLUSION

If and when unvaccinated children got mumps was determined by the particular school the children and their siblings attended, and by the household size. This finding suggests that school closure can influence the spread of an epidemic among orthodox protestant populations, provided that social distancing is adhered to as well. Further research on the effects of school closure on the final attack rate is nevertheless recommended.

Effect of e-learning and repeated performance feedback on spirometry test quality in family practice: a cluster trial

PURPOSE

Spirometry has become an indispensable tool in primary care to exclude, diagnose, and monitor chronic respiratory conditions, but the quality of spirometry tests in family practices is a reason for concern. Aim of this study was to investigate whether a combination of e-learning and bimonthly performance feedback would improve spirometry test quality in family practices in the course of 1 year.

METHODS

Our study was a cluster trial with 19 family practices allocated to intervention or control conditions through minimization. Intervention consisted of e-learning and bimonthly feedback reports to practice nurses. Control practices received only the joint baseline workshop. Spirometry quality was assessed by independent lung function technicians. Two outcomes were defined, with the difference between rates of tests with 2 acceptable and repeatable blows being the primary outcome and the difference between rates of tests with 2 acceptable blows being the secondary outcome. We used multilevel logistic regression analysis to calculate odds ratios (ORs) for an adequate test in intervention group practices.

RESULTS

We analyzed 1,135 tests. Rate of adequate tests was 33% in intervention and 30% in control group practices (OR = 1.3; P=.605). Adequacy of tests did not differ between groups but tended to increase with time: OR = 2.2 (P = .057) after 3 and OR = 2.0 (P = .086) in intervention group practices after 4 feedback reports. When ignoring test repeatability, these differences between the groups were slightly more pronounced: OR = 2.4 (P = .033) after 3 and OR=2.2 (P = .051) after 4 feedback reports.

CONCLUSIONS

In the course of 1 year, we observed a small and late effect of e-learning and repeated feedback on the quality of spirometry as performed by family practice nurses. This intervention does not seem to compensate the lack of rigorous training and experience in performing spirometry tests in most practices.

A multi-faceted strategy to improve the use of national fertility guidelines; a cluster-randomized controlled trial

BACKGROUND Proper use of clinical practice guidelines can decrease variation in care between settings. However, actual use of fertility guidelines is suboptimal and in need of improvement. Hence, a cluster-randomized controlled trial was designed to study the effects of two strategies to implement national Dutch guidelines on comprehensive fertility care. METHODS Sixteen fertility clinics participated in the trial. A minimal, professional-oriented implementation strategy of audit and feedback was tested versus a maximal multi-faceted strategy that was both professional and patient oriented. The extent of adherence to guideline recommendations, reflected in quality indicator scores, was the primary outcome measure. To gain an insight into unwanted side effects, patient anxiety and depression scores were gathered as secondary outcomes. Data collection encompassed medical record search, patient and professional questionnaires. RESULTS A total of 1499 couples were included at baseline and 1396 at the after-measurement. No overall significant improvement in indicator scores was found for either strategy [odds ratios ranging from 0.23 (95% confidence interval (CI): 0.06-0.95) to 6.66 (95% CI: 0.33-132.8]. Secondary outcomes did not differ significantly for both groups, although selected anxiety scores appeared lower in the maximal intervention group. Process evaluation of the trial revealed positive patient experiences with the intervention material [e.g. an increased understanding of their doctor's treatment policy (61%), an increased ability to ask questions about the treatment (61%)]. Professionals' appreciation of intervention elements varied, and execution of the multi-faceted strategy appeared incomplete. DISCUSSION Absence of an intervention effect may be due to the nature of the strategies, incomplete execution or flaws in study design. Process evaluation data raise the question of whether professionals should be the only stakeholder responsible for guideline implementation. This study therefore contributes to an increased understanding of fertility guideline implementation in general, and the role of patients in particular.

Barriers to implementing infection prevention and control guidelines during crises: experiences of health care professionals

Background

Communicable disease crises can endanger the health care system and often require special guidelines. Understanding reasons for nonadherence to crisis guidelines is needed to improve crisis management. We identified and measured barriers and conditions for optimal adherence as perceived by 4 categories of health care professionals.

Methods

In-depth interviews were performed (n = 26) to develop a questionnaire for a cross-sectional survey of microbiologists (100% response), infection preventionists (74% response), public health physicians (96% response), and public health nurses (82% response). The groups were asked to appraise barriers encountered during 4 outbreaks (severe acute respiratory syndrome [SARS], Clostridium difficile ribotype 027, rubella, and avian influenza) according to a 5-point Likert scale. When at least 33% of the participants responded “strongly agree,” “agree,” or “rather agree than disagree,” a barrier was defined as “often experienced.” The common (“generic”) barriers were included in a univariate and multivariate model. Barriers specific to the various groups were studied as well.

Results

Crisis guidelines were found to have 4 generic barriers to adherence: (1) lack of imperative or precise wording, (2) lack of easily identifiable instructions specific to each profession, (3) lack of concrete performance targets, and (4) lack of timely and adequate guidance on personal protective equipment and other safety measures. The cross-sectional study also yielded profession-specific sets of often-experienced barriers.

Conclusion

To improve adherence to crisis guidelines, the generic barriers should be addressed when developing guidelines, irrespective of the infectious agent. Profession-specific barriers require profession-specific strategies to change attitudes, ensure organizational facilities, and provide an adequate setting for crisis management.

Organizational determinants of patient-centered fertility care: a multilevel analysis

OBJECTIVE

To identify organizational determinants of positive patient experiences with fertility care, with the goal of improving patient centeredness of care.

DESIGN

Cross-sectional survey.

SETTING

One large university clinic and 12 medium-sized fertility clinics in the Netherlands.

PATIENT(S)

Three hundred and sixty-nine couples receiving medically assisted reproduction in one of the participating clinics between March and May 2008.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Organizational determinants of patients' experiences with patient centeredness in fertility care.

RESULT(S)

Of the patients during the relevant period, 78% of the women and 76% of their partners participated in the study. Infertile couples who have a lead physician, have access to an electronic personal health record, or see trained fertility nurses have more positive experiences with aspects of patient-centered care, like continuity of care and partner involvement. Moreover, receiving a treatment other than in vitro fertilization was negatively associated with the perceived patient centeredness of care. The identified determinants explained 5.1% to 22.4% of the total variance.

CONCLUSION(S)

This study provides organizational determinants of patients' experiences with fertility care on numerous facets of patient centeredness. These organizational determinants can be used as valuable tools to enable clinics to provide a more positive patient experience.