Development of a tailored strategy to improve postpartum hemorrhage guideline adherence.

BACKGROUND: Despite the introduction of evidence based guidelines and practical courses, the incidence of postpartum hemorrhage shows an increasing trend in developed countries. Substandard care is often found, which implies an inadequate implementation in high resource countries. We aimed to reduce the gap between evidence-based guidelines and clinical application, by developing a strategy, tailored to current barriers for implementation. METHODS: The development of the implementation strategy consisted of three phases, supervised by a multidisciplinary expert panel. In the first phase a framework of the strategy was created, based on barriers to optimal adherence identified among professionals and patients together with evidence on effectiveness of strategies found in literature. In the second phase, the tools within the framework were developed, leading to a first draft. In the third phase the strategy was evaluated among professionals and patients. The professionals were asked to give written feedback on tool contents, clinical usability and inconsistencies with current evidence care. Patients evaluated the tools on content and usability. Based on the feedback of both professionals and patients the tools were adjusted. RESULTS: We developed a tailored strategy to improve guideline adherence, covering the trajectory of the third trimester of pregnancy till the end of the delivery. The strategy, directed at professionals, comprehending three stop moments includes a risk assessment checklist, care bundle and time-out procedure. As patient empowerment tools, a patient passport and a website with patient information was developed. The evaluation among the expert panel showed all professionals to be satisfied with the content and usability and no discrepancies or inconsistencies with current evidence was found. Patients' evaluation revealed that the information they received through the tools was incomplete. The tools were adjusted accordingly to the missing information. CONCLUSION: A usable, tailored strategy to implement PPH guidelines and practical courses was developed. The next step is the evaluation of the strategy in a feasibility trial. TRIAL REGISTRATION: Clinical trial registration: The Fluxim study, registration number: NCT00928863 .

From Postpartum Haemorrhage Guideline to Local Protocol: A Study of Protocol Quality.

Objective Postpartum hemorrhage (PPH) has a continuously rising incidence worldwide, suggesting suboptimal care. An important step in optimizing care is the translation of evidence-based guidelines into comprehensive hospital protocols. However, knowledge about the quality of these protocols is lacking. The objective of this study was to evaluate the quality of PPH-protocols on structure and content in the Netherlands. Methods We performed an observational multicenter study. Eighteen PPH-protocols from 3 University Hospitals (UH), 8 Teaching Hospitals (TH) and 7 Non-Teaching hospitals (NTH) throughout the Netherlands were acquired. The structure of the PPH-protocols was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE-II) Instrument. The content was appraised using previously developed quality indicators, based on international guidelines and Advance-Trauma-Life-Support (ATLS)-based course instructions. Results The quality of the protocols for postpartum hemorrhage for both structure and content varied widely between different hospitals, but all of them showed room for improvement. The protocols scored mainly below average on the different items of the AGREE-II instrument (8 of the 10 items scored <4 on a 1-7 scale). Regarding the content, adoption of guideline recommendations in protocols was 46 %. In addition, a timely indication of 'when to perform' a recommendation was lacking in three-fourths of the items. Conclusion This study shows that the quality of the PPH-protocols for both structure and content in the Netherlands is suboptimal. This makes adherence to the guideline and ATLS-based course instructions difficult.

Influencing factors for high quality care on postpartum haemorrhage in the Netherlands: patient and professional perspectives.

BACKGROUND: Postpartum haemorrhage (PPH) remains a major contributor to maternal morbidity even in high resource settings, despite the development and dissemination of evidence-based guidelines and Advance-Trauma-Life-Support (ATLS) based courses for optimal management of PPH. We aimed to assess current influencing factors (obstacles and facilitators) for the delivery of high quality PPH-care from both patient and professional perspective. METHODS: We qualitatively explored influencing factors for delivering high quality PPH-care, by having individual interviews with PPH-patients and focus group interviews with the different types of professionals working in the delivery room. For both perspectives, the theoretical frameworks of Grol and Cabana were used to classify the influencing factors for optimal PPH-care (factors of the guidelines, of professionals, of patients, of the social setting and of the organisation). In order to assess the importance of the influencing factors found among the professionals, we quantified these factors in a web-based questionnaire. RESULTS: A total of 12 patients and 41 professionals participated in the interviews, and 315 complete surveys were analyzed. The main obstacle for high quality PPH-care identified by patients was the lack of information given by the professionals to the patient and partner before, during and after the PPH event. An informative patient website, a patient leaflet and a follow-up consultation were mentioned as facilitators. The main obstacles according to the professionals were: lack of clarity of the guidelines, lack of knowledge and failing team-communication. Team training and checklists/ flowcharts were considered facilitators. CONCLUSIONS: Different obstacles to the delivery of high quality PPH-care were identified by both patients and professionals. These data can be used to develop a focused strategy to improve PPH-care. TRIAL REGISTRATION: NCT 00928863.

Guideline-based development of quality indicators for prevention and management of postpartum hemorrhage.

INTRODUCTION: To systematically develop a set of guideline-based quality indicators for postpartum hemorrhage (PPH) as a tool to measure guideline adherence in actual PPH care. MATERIAL AND METHODS: A Rand-modified Delphi procedure was used to systematically achieve consensus among a panel of 22 experts on PPH care on recommendations extracted from evidence-based guidelines, Managing-Obstetrics-Emergencies-Trauma (MOET) instructions and international literature. The selected recommendations were individually rated on health gain (prevention of maternal mortality and morbidity) and overall efficiency by the expert panel. Subsequently, consensus about the most important recommendations to measure quality of PPH care among the panel members was reached, followed by a final approval. Last, definition of the final set by critical appraisal of the recommendations regarding measurability took place. The main outcome measure was a set of valid quality indicators for prevention and management of PPH. RESULTS: From the 69 extracted recommendations, 50 were selected and translated into 22 quality indicators on professional performance (n = 17) and organization of PPH care (n = 5). The professional performance indicators covered all fields of PPH care, such as prevention (n = 2) and management of PPH, including communication and documentation (n = 4), monitoring and prevention of shock (n = 3), use of blood products (n = 3) and treatment of PPH (n = 5). Organizational indicators (n = 5) were clustered into protocols and agreements, audit, accessibility and documentation. CONCLUSIONS: This study describes a stepwise systematic development of 22 performance and organizational indicators to use for measuring the whole care process of prevention and management of PPH.

Implementing guidelines for depression on antidepressant prescribing in general practice: a quasi-experimental evaluation.

BACKGROUND: Internationally, guidelines for depression recommend a stepped care approach, implying that antidepressant medication should not be offered as a first step treatment to patients with sub-threshold or mild depression. In the Netherlands, antidepressant prescribing rates in general practice as a first treatment step are considered to be high. The aim of this study was to evaluate the implementation of guideline recommendations on antidepressant prescribing. METHODS: A quasi-experimental study with a non-equivalent naturalistic control group and three years follow-up was performed in the general practice setting in the Netherlands. General Practitioners (GPs) participated in a national Quality Improvement Collaborative (QIC), focusing on the implementation of a guideline based model for a stepped care approach to depression. The model consisted of self-help and psychological treatment options for patients with milder symptoms as an alternative to antidepressants in general practice. Changes in antidepressant prescription rates of GPs were documented for a three-year period and compared to those in a control group of GPs, selected from an ongoing national registration network. RESULTS: A decrease of 23.3% (49.4%-26.1%) in antidepressant prescription rates for newly diagnosed patients with depressive symptoms was found within the intervention group, whereas no difference occurred in the reference group (50.3%-52.6%). The decrease over time was significant, compared to the usual care group (OR 0.44, 95% CI: 0.21-0.92). CONCLUSIONS: An implementation program using stepped care principles for the allocation of depression interventions resulted in reduced antidepressant prescription rates in general practice. GPs can change prescribing behaviour within the context of a QIC.

Retrospective evaluation of control measures for contacts of patient with Marburg hemorrhagic fever.

After an imported case of Marburg hemorrhagic fever was reported in 2008 in the Netherlands, control measures to prevent transmission were implemented. To evaluate consequences of these measures, we administered a structured questionnaire to 130 contacts classified as either having high-risk or low-risk exposure to body fluids of the case-patient; 77 (59.2%) of 130 contacts responded. A total of 67 (87.0%) of 77 respondents agreed that temperature monitoring and reporting was necessary, significantly more often among high-risk than low-risk contacts (p<0.001). Strict compliance with daily temperature monitoring decreased from 80.5% (62/77) during week 1 to 66.2% (51/77) during week 3. Contacts expressed concern about development of Marburg hemorrhagic fever (58.4%, 45/77) and infecting a family member (40.2%, 31/77). High-risk contacts had significantly higher scores on psychological impact scales (p<0.001) during and after the monitoring period. Public health authorities should specifically address consequences of control measures on the daily life of contacts.

Evaluation of physicians' professional performance: an iterative development and validation study of multisource feedback instruments.

BACKGROUND: There is a global need to assess physicians' professional performance in actual clinical practice. Valid and reliable instruments are necessary to support these efforts. This study focuses on the reliability and validity, the influences of some sociodemographic biasing factors, associations between self and other evaluations, and the number of evaluations needed for reliable assessment of a physician based on the three instruments used for the multisource assessment of physicians' professional performance in the Netherlands. METHODS: This observational validation study of three instruments underlying multisource feedback (MSF) was set in 26 non-academic hospitals in the Netherlands. In total, 146 hospital-based physicians took part in the study. Each physician's professional performance was assessed by peers (physician colleagues), co-workers (including nurses, secretary assistants and other healthcare professionals) and patients. Physicians also completed a self-evaluation. Ratings of 864 peers, 894 co-workers and 1960 patients on MSF were available. We used principal components analysis and methods of classical test theory to evaluate the factor structure, reliability and validity of instruments. We used Pearson's correlation coefficient and linear mixed models to address other objectives. RESULTS: The peer, co-worker and patient instruments respectively had six factors, three factors and one factor with high internal consistencies (Cronbach's alpha 0.95 - 0.96). It appeared that only 2 percent of variance in the mean ratings could be attributed to biasing factors. Self-ratings were not correlated with peer, co-worker or patient ratings. However, ratings of peers, co-workers and patients were correlated. Five peer evaluations, five co-worker evaluations and 11 patient evaluations are required to achieve reliable results (reliability coefficient ≥ 0.70). CONCLUSIONS: The study demonstrated that the three MSF instruments produced reliable and valid data for evaluating physicians' professional performance in the Netherlands. Scores from peers, co-workers and patients were not correlated with self-evaluations. Future research should examine improvement of performance when using MSF.

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.

Patient and hospital characteristics associated with variation in guideline adherence in intrauterine insemination care.

OBJECTIVE: To assess the association of patient and hospital characteristics with adherence to guidelines for intrauterine insemination (IUI) care. DESIGN: Retrospective cohort study using multilevel regression analysis. Characteristics studied at the patient level were female age, type and duration of subfertility, diagnosis and number of started IUI cycles. At the hospital level, the characteristics studied were hospital size, teaching hospital, in vitro fertilization (IVF) licence and number of physicians involved in the IUI programme. Data were obtained from medical records and questionnaires for gynaecologists. SETTING AND PARTICIPANTS: Five hundred and fifty-eight subfertile couples who underwent IUI treatment at 10 Dutch hospitals. MAIN OUTCOME MEASURES: Adherence to systematically developed guideline-based performance indicators describing 20 processes of IUI care. RESULTS: A total of 558 couples who started 2,334 IUI cycles participated. Guideline adherence in IUI care was often substandard and varied considerably between hospitals. Variation in guideline adherence in IUI care was associated with the patient characteristics 'diagnosis' and 'female age'. Only adherence to the guideline recommendation regarding 'screening for tubal occlusion' was associated with hospital characteristics ('hospital size' and 'IVF licence'). Large explained variances up to 39% were found for the different models. CONCLUSIONS: A number of patient and hospital characteristics were associated with variation in guideline adherence in IUI care, particularly the patient characteristics 'diagnosis' and 'female age'. The identification of different subgroups in the patient population and different types of hospitals with regard to the extent of guideline adherence in IUI care is important for the tailoring of interventions to improve IUI care.

Antibiotic use: how to improve it?

Antibiotics are an extremely important weapon in the fight against infections. However, antimicrobial resistance is a growing problem. That is why the appropriate use of antibiotics is of great importance. A proper analysis of factors influencing appropriate antibiotic use is at the heart of an effective improvement programme, as interventions can only result in improved medical behaviour if they are well attuned to the problems, the target group, and the setting in which the change is to take place. Determinants of appropriate and inappropriate prescribing are not only found in patient knowledge and behaviour, in the way medical professionals think and act, and in the way in which patient care is organised, but also in the wider, socio-cultural environment of doctors and their patients. We present several relevant factors at each of these 4 levels and various possible measures that could be an effective response to them. The reasons why antibiotic use is inappropriate are complex. This means that any programme to rationalise antibiotic use - if it is to be effective - will have to include activities at all 4 levels discussed above. A national programme for 'appropriate antibiotic use' could be considered, including patient, professional and organisational-oriented activities. In addition, close international cooperation is required involving international guidelines, agreements, monitoring and feedback of information, and implementation programmes.

Cost-effectiveness of a quality improvement collaborative focusing on patients with diabetes.

OBJECTIVE: To investigate the lifelong health effects, costs, and cost-effectiveness of a quality improvement collaborative focusing on improving diabetes management in an integrated care setting. STUDY DESIGN AND METHODS: Economic evaluation from a healthcare perspective with lifetime horizon alongside a nonrandomized, controlled, before-after study in the Netherlands. Analyses were based on 1861 diabetes patients in 6 intervention and 9 control regions, representing 37 general practices and 13 out-patient clinics. Change in the United Kingdom Prospective Diabetes Study score, remaining lifetime, and costs per quality-adjusted life year gained were calculated. Probabilistic life tables were constructed using the United Kingdom Prospective Diabetes Study risk engine, a validated diabetes model, and nonparametric bootstrapping of individual patient data. RESULTS: Annual United Kingdom Prospective Diabetes Study risk scores reduced for cardiovascular events (hazard ratio: 0.83 and 0.98) and cardiovascular mortality (hazard ratio: 0.78 and 0.88) for men and women, respectively. Life expectancy improved by 0.97 and 0.76 years for men and women, and quality-adjusted life years by 0.44 and 0.37, respectively. Higher life expectancy in the intervention group increased lifelong costs by &OV0556;860 for men and &OV0556;645 for women. Initial program costs were about &OV0556;22 per patient. The incremental costs per quality-adjusted life year were &OV0556;1937 for men and &OV0556;1751 for women compared with usual care costs. There is a probability >95% that the collaborative is cost-effective, using a threshold of &OV0556;20,000 per quality-adjusted life year. CONCLUSION: Optimizing integrated and patient-centered diabetes care through a quality-improvement collaborative is cost-effective compared with usual care.

Variation in guideline adherence in intrauterine insemination care.

Health-care delivery according to clinical practice guidelines is thought to be critical in achieving optimal outcomes. This study aimed to assess the extent to which practice performance in intrauterine insemination (IUI) care is consistent with guideline recommendations and to evaluate the association between guideline adherence and outcome of IUI care. In a retrospective cohort study, 1100 infertile couples who underwent IUI treatment at 10 Dutch hospitals were asked to grant access to their medical record for assessment of guideline adherence using 25 systematically developed guideline-based performance indicators. A total of 558 couples who started 2334 IUI cycles participated. Guideline adherence regarding 20 process and five structure aspects of IUI care was often substandard and varied considerably between hospitals. Out of 10 possible associations investigated, guideline adherence regarding sperm quality and guideline adherence regarding the total number of IUI cycles were associated with improved ongoing pregnancy rates after IUI. Thus, guideline adherence in IUI care is far from optimal and varies substantially between hospitals. As associations between guideline adherence and ongoing pregnancy after IUI were mainly non-significant, further research is needed to evaluate associations between guideline adherence and other outcomes of IUI care besides ongoing pregnancy, such as patient safety and cost effectiveness.

Haemorrhagia post partum; an implementation study on the evidence-based guideline of the Dutch Society of Obstetrics and Gynaecology (NVOG) and the MOET (Managing Obstetric Emergencies and Trauma-course) instructions; the Fluxim study.

BACKGROUND: One of the most important causes of maternal mortality and severe morbidity worldwide is post partum haemorrhage (PPH). Factors as substandard care are frequently reported in the international literature and there are similar reports in the Netherlands. The incidence of PPH in the Dutch population is 5% containing 10.000 women a year. The introduction of an evidence-based guideline on PPH by the Dutch society of Obstetrics and Gynaecology (NVOG) and the initiation of the MOET course (Managing Obstetrics Emergencies and Trauma) did not lead to a reduction of PPH. This implies the possibility of an incomplete implementation of both the NVOG guideline and MOET-instructions. Therefore, the aim of this study is to develop and test a tailored strategy to implement both the NVOG guideline and MOET-instructions METHODS/DESIGN: One step in the development procedure is to evaluate the implementation of the guideline and MOET-instructions in the current care. Therefore measurement of the actual care will be performed in a representative sample of 20 hospitals. This will be done by prospective observation of the third stage of labour of 320 women with a high risk of PPH using quality indicators extracted from the NVOG guideline and MOET instructions. In the next step barriers and facilitators for guideline adherence will be analyzed by performance of semi structured interviews with 30 professionals and 10 patients, followed by a questionnaire study among all Dutch gynaecologists and midwives to quantify the barriers mentioned. Based on the outcomes, a tailored strategy to implement the NVOG guideline and MOET-instructions will be developed and tested in a feasibility study in 4 hospitals, including effect-, process- and cost evaluation. DISCUSSION: This study will provide insight into current Dutch practice, in particular to what extent the PPH guidelines of the NVOG and the MOET-instructions have been implemented in the actual care, and into the barriers and facilitators regarding guideline adherence. The knowledge of the feasibility study regarding the effects and costs of the tailored strategy and the experiences of the users can be used in countries with a relatively high incidence of PPH. TRIAL REGISTRATION: ClinicTrials.gov NCT00928863.

Peer mentoring in doctor performance assessment: strategies, obstacles and benefits.

CONTEXT: Mentors are increasingly involved in doctor performance assessments. Mentoring seems to be a key determinant in achieving the ultimate goal of those assessments, namely, improving doctor performance. Little is known, however, about how mentors perceive and fulfil this role. OBJECTIVE: The aim of this paper is to expand understanding of the role of mentors in performance assessment. METHODS: Thirty-eight mentors undertook formative performance assessments of their peers in a pilot study. A mixed-methods design was used, consisting of a postal survey (n = 28) and qualitative interviews with a subset of mentors (n = 11). Individual semi-structured interviews were completed and transcripts were analysed by two researchers using a grounded theory approach. RESULTS: The results of the survey showed that 89% of mentors intended to continue in their mentorship role. Interviews revealed that mentors used several strategies in the assessments, including: contrasting and collating information; posing reflective questions, and goal setting. Mentors experienced difficulty in disregarding their views of the doctors evaluated. Some mentors noticed obstacles with specific interview skills such as 'paying attention to their colleagues' strengths' and 'enabling doctors to find their own solutions'. Mentors reported that they and their organisations benefited from the assessments. The perceived benefits included: improved interview skills; increased solidarity, and increased mutual respect. CONCLUSIONS: The study provides insights into what mentors can do to increase the chance that externally derived information is integrated into doctors' self-assessments. Mainly, mentors used strategies aimed at effectively delivering feedback and encouraging reflection. However, we found that mentors who took part in our study appeared to struggle with a number of obstacles related to: time investment; familiarity with the doctor assessed, and the acquiring of specific interview skills.

Pretest expectations strongly influence interpretation of abnormal laboratory results and further management.

BACKGROUND: Abnormal results of diagnostic laboratory tests can be difficult to interpret when disease probability is very low. Although most physicians generally do not use Bayesian calculations to interpret abnormal results, their estimates of pretest disease probability and reasons for ordering diagnostic tests may--in a more implicit manner--influence test interpretation and further management. A better understanding of this influence may help to improve test interpretation and management. Therefore, the objective of this study was to examine the influence of physicians' pretest disease probability estimates, and their reasons for ordering diagnostic tests, on test result interpretation, posttest probability estimates and further management. METHODS: Prospective study among 87 primary care physicians in the Netherlands who each ordered laboratory tests for 25 patients. They recorded their reasons for ordering the tests (to exclude or confirm disease or to reassure patients) and their pretest disease probability estimates. Upon receiving the results they recorded how they interpreted the tests, their posttest probability estimates and further management. Logistic regression was used to analyse whether the pretest probability and the reasons for ordering tests influenced the interpretation, the posttest probability estimates and the decisions on further management. RESULTS: The physicians ordered tests for diagnostic purposes for 1253 patients; 742 patients had an abnormal result (64%). Physicians' pretest probability estimates and their reasons for ordering diagnostic tests influenced test interpretation, posttest probability estimates and further management. Abnormal results of tests ordered for reasons of reassurance were significantly more likely to be interpreted as normal (65.8%) compared to tests ordered to confirm a diagnosis or exclude a disease (27.7% and 50.9%, respectively). The odds for abnormal results to be interpreted as normal were much lower when the physician estimated a high pretest disease probability, compared to a low pretest probability estimate (OR = 0.18, 95% CI = 0.07-0.52, p < 0.001). CONCLUSIONS: Interpretation and management of abnormal test results were strongly influenced by physicians' estimation of pretest disease probability and by the reason for ordering the test. By relating abnormal laboratory results to their pretest expectations, physicians may seek a balance between over- and under-reacting to laboratory test results.

Reasons for ordering laboratory tests and relationship with frequency of abnormal results.

OBJECTIVE: Laboratory tests are ordered on a daily basis, even though disease probability is often very low. Abnormal results, especially mildly abnormal results, can be difficult to interpret in these circumstances. Further insights into the occurrence of abnormalities can help improve rational test ordering and test interpretation. The objective was therefore to examine the frequency of mildly and markedly abnormal results and their relationship with physicians' reasons for ordering tests. DESIGN: Prospective study. Participants. A total of 87 primary care physicians in the Netherlands collected data on 1775 patients. MAIN OUTCOME MEASURES: The physicians recorded the reason for ordering the tests, the most probable diagnosis and the pretest probability. The laboratories' reference values and specified "action limits" were used to assess the number of abnormal results and markedly abnormal results, respectively. RESULTS: Laboratory results were received for 1621 patients and 15,603 tests were reported (mean 9.6). The proportion of abnormal test results increased with increasing pretest probability (from 13.9% to 34.7%) and was 13.4% for tests ordered to reassure the patient and 13.3% for psychosocial diagnoses. The proportion of patients with at least one abnormal test result was high: 53.1% for tests ordered to reassure and 57.7% in patients with low pretest probability. Corresponding values for a marked abnormality were 11.1% and 12.4%, respectively. CONCLUSION: Abnormal laboratory test results were frequent, even when pretest probability was low. Physicians should therefore carefully consider when tests are necessary. Future research could explore physicians' interpretation of test results and its impact on diagnosis and management.

DOC questionnaire: measuring how GPs and medical specialists rate collaboration.

PURPOSE: This paper aims to assess the validity of a questionnaire aimed at assessing how general practitioners (GPs) and specialists rate collaboration. DESIGN/METHODOLOGY/APPROACH: Primary data were collected in The Netherlands during March to September 2006. A cross-sectional study was conducted among 259 GPs and 232 specialists. Participants were randomly selected from The Netherlands Medical Address Book. Specialists rarely contacting a GP were not invited to participate. FINDINGS: Exploratory factor analysis indicated that the questionnaire, consisting of 20 items, measured five domains: organisation; communication; professional expertise; image; and knowing each other. Cronbach's alpha coefficients ranged from 0.64 to 0.83 indicating sufficient internal consistency. Correlation coefficients between domains were all < 0.4. All but "communication" clearly produced distinguishing scores for different respondent groups. RESEARCH LIMITATIONS/IMPLICATIONS: This study shows that the doctors' opinions on collaboration (DOC) questionnaire is valid and that it may have the potential to give feedback to both medical professionals and policy makers. Such feedback creates an opportunity to improve collaboration. ORIGINALITY/VALUE: The DOC questionnaire is a useful instrument for assessing collaboration among GPs and specialists. It can provide feedback to both medical professionals and policy makers. Such feedback creates an opportunity to improve collaboration.

Management of childhood urinary tract infections: an economic modeling study.

UNLABELLED: Childhood urinary tract infections (UTIs) can lead to renal scarring and ultimately to terminal renal failure, which has a high impact on quality of life, survival, and health-care costs. Variation in the treatment of UTIs between practices is high. OBJECTIVE: To assess the cost-effectiveness of a maximum care model for UTIs in children, implying more testing and antibiotic treatment, compared with current practice in primary care in The Netherlands. METHODS: We performed a probabilistic modeling study using Markov models. Figures used in the model were derived from a systematic review of the research literature. Multidimensional Monte Carlo simulation was used for the probabilistic analyses. RESULTS: Maximum care gained 0.00102 (males) and 0.00219 (girls) QALYs (quality-adjusted life-years) and saved 42.70 euro (boys) and 77.81 euro (girls) in 30 years compared with current care, and was thus dominant. Net monetary benefit of maximum care ranged from 20 euro to 200 euro for a willingness to pay for a QALY ranging from 0 euro to 80,000 euro, respectively. Maximum care was also dominant over improved current care, although less dominant than to current care. CONCLUSIONS: This study suggested that maximum care for childhood UTI was dominant in the long run to current care, meaning that it delivered more quality of life at lower costs. Nevertheless, making firm conclusions is not possible, given the limitations of the input data.

Influence of watchful waiting on satisfaction and anxiety among patients seeking care for unexplained complaints.

PURPOSE: We undertook a study to determine whether test-ordering strategy and other consultation-related factors influence satisfaction with and anxiety after a consultation among patients seeking care for unexplained complaints. METHODS: A cluster-randomized clinical trial was conducted in family medicine practices in the Netherlands. Participants were 498 patients with unexplained complaints seen by 63 primary care physicians. Physicians either immediately ordered a blood test for patients or followed a 4-week watchful waiting approach. Physicians and patients completed questionnaires asking about their characteristics, satisfaction with care, and anxiety, and aspects of the consultation. The main outcomes were patient satisfaction and anxiety. Data were analyzed by multilevel logistic regression analysis. RESULTS: Patients were generally satisfied with their consultation and had moderately low anxiety afterward (mean scores on 11-point scales, 7.3 and 3.1, respectively), with no difference between the immediate testing and watchful waiting groups (chi(2) = 2.4 and 0.3, respectively). The factors associated with higher odds of satisfaction were mainly related to physician-patient communication: patients' satisfaction with their physician generally, feeling taken seriously, and knowing the seriousness of complaints afterward; physicians' discussing testing and not considering complaints bearable; and older physician age. The same was true for factors associated with higher odds of anxiety: patients expecting testing or referral, patients not knowing the seriousness of their complaints afterward, and physicians not seeing a cause for alarm. CONCLUSIONS: Test-ordering strategy does not influence patients' satisfaction with and anxiety after a consultation. Instead, specific aspects of physician-patient communication are important. Apparently, primary care physicians underestimate how much they can contribute to the well-being of their patients by discussing their worries.

Factors that influence the stroke care team's effectiveness in reducing the length of hospital stay.

BACKGROUND AND PURPOSE: The purpose of this study was to explore the effects of a quality improvement program for improving stroke care and the determinants of success at the team and hospital levels. Method- For 16 months, 23 multidisciplinary stroke service teams participated in a quality improvement collaborative designed to set up stroke services and reduce the length of hospital stay (LOHS). We monitored the LOHS and the discharge delay during the project and measured indicators of well organized stroke services at baseline and after the intervention. A multiple and multilevel regression model was used to relate the outcome variables to the team and hospital characteristics. National LOHS figures served as reference data. RESULTS: Data regarding 4549 stroke patients were included in the analyses. The LOHS decreased significantly from 18.3 to 13.3 days. The mean LOHS varied substantially (9.2 to 20.9 days) after the intervention. Teams with higher team functioning scores showed lower LOHS scores and higher scores for the indicators of well organized stroke services. Team characteristics explain almost 40% of the variance in LOHS and 53% in the indicators of well organized stroke care. CONCLUSIONS: Participation in a national quality improvement collaborative effected a significant decrease of the LOHS and a significant increase in the presence of key features of stroke services. Variation in ability to reduce the LOHS and increase key features of stroke services were related to team functioning. The data suggest that the composite of team functioning is pivotal in quality-of-care improvement and may need specific attention in any quality improvement program.