Barriers to optimal antibiotic use for community-acquired pneumonia at hospitals: a qualitative study.

Background: Physician adherence to key recommendations of guidelines for community-acquired pneumonia (CAP) is often not optimal. A better understanding of factors influencing optimal performance is needed to plan effective change.

Methods: The authors used semistructured interviews with care providers in three Dutch medium-sized hospitals to qualitatively study and understand barriers to appropriate antibiotic use in patients with CAP.

Antibiotic prescribing in primary care: first choice and restrictive prescribing are two different traits.

Objective: To investigate the quality of antibiotic prescribing in primary care using quality indicators and the relatedness of these indicators. To determine the influence of general practice and practice population characteristics on the indicator scores.

Methods: Data on performance were collected during the Second National Survey of General Practice over 1 year between May 2000 and April 2002 in The Netherlands.

Tailoring quality improvement interventions to identified barriers: a multiple case analysis.

Rationale, Aims And Objectives: The prevailing view on implementation interventions to improve the organization and management of health care is that the interventions should be tailored to potential barriers. Ideally, possible barriers are analysed before the quality improvement interventions are developed to influence both type and content of the implementation intervention. While tailoring educational improvement interventions generally requires the assessment of professional knowledge and skills, less is known about methods to tailor organizational interventions.

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

Background: Optimal clinical management of childhood urinary tract infections (UTI) potentiates long-term positive health effects. Insight into the quality of care in Dutch family practices for UTIs was limited, particularly regarding observation periods of more than a year. Our aim was to describe the clinical management of young children's UTIs in Dutch primary care and to compare this to the national guideline recommendations.

Tailored interventions to improve antibiotic use for lower respiratory tract infections in hospitals: a cluster-randomized, controlled trial.

Background: Limited data exist on the most effective approach to increase the quality of antibiotic use for lower respiratory tract infections at hospitals.

Methods: One thousand nine hundred six patients with community-acquired pneumonia or an exacerbation of chronic obstructive pulmonary disease (acute exacerbation of chronic bronchitis) were included in a cluster-randomized, controlled trial at 6 medium-to-large Dutch hospitals. A multifaceted guideline-implementation strategy that was tailored to baseline performance and considered the barriers in the target group was used.

Planning and studying improvement in patient care: the use of theoretical perspectives.

A consistent finding in articles on quality improvement in health care is that change is difficult to achieve. According to the research literature, the majority of interventions are targeted at health care professionals. But success in achieving change may be influenced by factors other than those relating to individual professionals, and theories may help explain whether change is possible.

Improving cardiovascular risk management: a randomized, controlled trial on the effect of a decision support tool for patients and physicians.

Background: There is nonoptimal adherence of general practitioners (GPs) and patients to cardiovascular risk reducing interventions. GPs find it difficult to assimilate multiple risk factors into an accurate assessment of cardiovascular risk. In addition, communicating cardiovascular risk to patients has proved to be difficult.

General practice cooperatives: long waiting times for home visits due to long distances?

Background: The introduction of large-scale out-of-hours GP cooperatives has led to questions about increased distances between the GP cooperatives and the homes of patients and the increasing waiting times for home visits in urgent cases. We studied the relationship between the patient's waiting time for a home visit and the distance to the GP cooperative. Further, we investigated if other factors (traffic intensity, home visit intensity, time of day, and degree of urgency) influenced waiting times.

Clinical indicators: development and applications.

Clinical indicators give an indication of the quality of the patient care delivered. They must comply with highquality standards and should be constructed in a careful and transparent manner. Indicators must be relevant to the important aspects of quality of care.

Reasons for ordering spinal x-ray investigations: how they influence general practitioners' management.

Objective: To explore whether general practitioners who request spinal x-ray investigations are less likely to refer, prescribe medication, or order additional tests when they intend only to reassure patients rather than to exclude or confirm disease.

Design: Cross-sectional survey. Physicians recorded reasons for requesting x-ray examinations and differential diagnoses on the request form.

Much variety and little evidence: a description of guidelines for doctor-patient communication.

Aim: To explore the quality of the content of communication skills training programmes, we analysed and assessed guidelines for doctor-patient communication used in communication programmes for general practitioner (GP) trainees.

Method: Guidelines for doctor-patient communication were extracted from educational materials supplied by the 8 Dutch university centres for vocational training in general practice. Four themes guided the analysis of the guidelines: content, type of contact, format and structure and status.

Guideline implementation results in a decrease of pressure ulcer incidence in critically ill patients.

Objective: To describe the short-term and long-term effects of a hospital-wide pressure ulcer prevention and treatment guideline on both the incidence and the time to the onset of pressure ulcers in critically ill patients.

Design: Prospective cohort study.

Setting: Adult intensive care department of a university medical center.

Interventions for improving older patients' involvement in primary care episodes.

Background: There is a growing expectation among patients that they should be involved in the delivery of medical care. Accumulating evidence from empirical studies shows that patients of average age who are encouraged to participate more actively in treatment decisions have more favourable health outcomes, in terms of both physiological and functional status, than those who do not. Interventions to encourage more active participation may be focused on different stages, including: the use of health care; preparation for contact with a care provider; contact with the care provider; or feedback about care.

Why do patients want to have their blood tested? A qualitative study of patient expectations in general practice.

Background: General practitioners often take their impression of patients' expectations into account in their decision to have blood tests done. It is commonly recommended to involve patients in decision-making during consultations. The study aimed to obtain detailed information on patients' expectations about blood tests.

The impact of home parenteral nutrition on daily life-a review.

Background: Total parenteral nutrition (TPN) is a lifesaving therapy in patients with severe intestinal failure that can be administered at home. However, patients have to face complex technological nutritional support issues at home, which will influence their personal life.

Objectives: This review aims to describe the implications of home parenteral nutrition (HPN) on the quality of life, as experienced by patients, as well as to describe the caregiver's reactions regarding these notions.

Living on borrowed time: experiences in palliative care.

Objective: To gain insight into the experiences of a palliative care patient and her husband who were living on borrowed time.

Methods: A qualitative single case design was used. Systematic content analysis of the interview data, obtained in an in-depth semi-structured interview, from the husband and wife was conducted to extract themes relating to living on borrowed time.

Quality of integrated care for patients with head and neck cancer: Development and measurement of clinical indicators.

Background: To improve the quality of integrated care, we developed indicators for assessing current practice in a large reference center for head and neck oncology.

Methods: We defined a set of indicators based on integrated care literature, national evidence-based guidelines for patients with head and neck cancer, and the opinions of professionals and patients. We tested this set regarding assessment of current practice and clinimetric characteristics.

Consultation in palliative care: the relevance of clarification of problems.

This study aims to determine the extent and nature of problems in palliative care that are newly identified in the consultation process and the factors influencing their identification. The consultation process includes clarification of problems mentioned by professionals requesting advice. Data are derived from the standard registration forms of Palliative Care Consultation teams.

After-hours care in the United Kingdom, Denmark, and the Netherlands: new models.

There are indications that after-hours care in some countries is of poor quality. European after-hours care is shifting away from individual and group practices with local after-hours call schedules toward large-scale after-hours care services. Experiences with primary care cooperatives in three countries show that this model can lighten physicians' workloads, reduce the number of face-to-face contacts, reduce use of emergency services and hospital admissions, and lower costs.

Logistic support service improves processes and outcomes of diabetes care in general practice.

Background: Guidelines for type 2 diabetes care in general practice are well known and accepted, but the implementation falls short.

Objective: To implement these guidelines by introducing a diabetes support service (DSS) to support the care delivered by the GP.

Methods: A controlled, non-randomised study with delayed intervention in the control group; 78 GPs (n=51 for the intervention and n=21 for the control group) in the south of the Netherlands and 613 of their type 2 diabetic patients participated.

The feasibility of a primary care model for the management of COPD.

Aims: To investigate the feasibility of a primary care model to improve the management of COPD.

Methods: An intervention study on 1,497 patients with documented COPD from 22 general practices, involving 11 practice nurses and a COPD Support Service (CSS). Outcome measures included the successful delegation of tasks from general practitioners (GPs) to the CSS and practice nurse, and performance in daily practice according to the model components -- keeping a patient register with a recall system, periodical history taking and lung function measurements, asking diagnostic and therapeutic advice, and performing regular follow-up visits with education and counselling.

The effects of a team-based continuous quality improvement intervention on the management of primary care: a randomised controlled trial.

Aim: To study the effects of a team-based model for continuous quality improvement (CQI) on primary care practice management.

Design Of Study: Randomised controlled trial.

Setting: Twenty-six intervention and 23 control primary care practices in the Netherlands.

Problems experienced by the informal caregivers of cancer patients and their needs for support.

Informal caregivers experience problems of their own for which they need support, but despite the efforts of the World Health Organization to include the well-being of family members and caregivers in the concept of palliative care, their needs are rarely assessed systematically. This report explores caregivers' problems and their needs for professional support. Seventy-six caregivers of cancer patients with advanced disease completed a comprehensive needs assessment questionnaire, the Problems and Needs in Palliative Care questionnaire-caregiver form, listing 67 potential problems in their quality of life and their role of caregiver and 9 items concerning informational needs.

Measuring physiotherapists' guideline adherence by means of clinical vignettes: a validation study.

Rationale, Aims And Objectives: To assess the criterion validity of paper-and-pencil vignettes to assess guideline adherence by physiotherapists in the Netherlands. The evidence-based physiotherapy practice guideline for low back pain was used as an example.

Methods: Four vignettes were constructed and pre-tested.

Patients evaluate accessibility and nurse telephone consultations in out-of-hours GP care: determinants of a negative evaluation.

Objective: The shift towards large-scale organization of out-of-hours primary healthcare in different western countries has created an important role for the nurse telephone consultation. We explored the association between negative patient evaluation of nurse telephone consultations and characteristics of patients and GP cooperatives.

Methods: A cross-sectional study using postal patient questionnaires sent to patients receiving a nurse telephone consultation from one of 26 GP cooperatives in the Netherlands.