Effect of audit and feedback with peer review on general practitioners' prescribing and test ordering performance: a cluster-randomized controlled trial.

BACKGROUND: Much research worldwide is focussed on cost containment and better adherence to guidelines in healthcare. The research focussing on professional behaviour is often performed in a well-controlled research setting. In this study a large-scale implementation of a peer review strategy was tested on both test ordering and prescribing behaviour in primary care in the normal quality improvement setting. METHODS: We planned a cluster-RCT in existing local quality improvement collaboratives (LQICs) in primary care. The study ran from January 2008 to January 2011. LQICs were randomly assigned to one of two trial arms, with each arm receiving the same intervention of audit and feedback combined with peer review. Both arms were offered five different clinical topics and acted as blind controls for the other arm. The differences in test ordering rates and prescribing rates between both arms were analysed in an intention-to-treat pre-post analysis and a per-protocol analysis. RESULTS: Twenty-one LQIC groups, including 197 GPs working in 88 practices, entered the trial. The intention-to-treat analysis did not show a difference in the changes in test ordering or prescribing performance between intervention and control groups. The per-protocol analysis showed positive results for half of the clinical topics. The increase in total tests ordered was 3% in the intervention arm and 15% in the control arm. For prescribing the increase in prescriptions was 20% in the intervention arm and 66% in the control group. It was observed that the groups with the highest baseline test ordering and prescription volumes showed the largest improvements. CONCLUSIONS: Our study shows that the results from earlier work could not be confirmed by our attempt to implement the strategy in the field. We did not see a decrease in the volumes of tests ordered or of the drugs prescribed but were able to show a lesser increase instead. Implementing the peer review with audit and feedback proved to be not feasible in primary care in the Netherlands. TRIAL REGISTRATION: This trial was registered at the Dutch trial register under number ISRCTN40008171 on August 7th 2007.

Evaluation of an effective multifaceted implementation strategy for elective single-embryo transfer after in vitro fertilization.

STUDY QUESTION: What is the relationship between the rate of elective single-embryo transfer (eSET) and couples' exposure to different elements of a multifaceted implementation strategy? SUMMARY ANSWER: Additional elements in a multifaceted implementation strategy do not result in an increased eSET rate. WHAT IS KNOWN ALREADY: A multifaceted eSET implementation strategy with four different elements is effective in increasing the eSET rate by 11%. It is unclear whether every strategy element contributes equally to the strategy's effectiveness. STUDY DESIGN AND SIZE: An observational study was performed among 222 subfertile couples included in a previously performed randomized controlled trial. PARTICIPANTS, SETTINGS AND METHODS: Of the 222 subfertile couples included, 109 couples received the implementation strategy and 113 couples received standard IVF care. A multivariate regression analysis assessed the effectiveness of four different strategy elements on the decision about the number embryos to be transferred. Questionnaires evaluated the experiences of couples with the different elements. MAIN RESULTS AND ROLE OF CHANCE: Of the couples who received the implementation strategy, almost 50% (52/109) were exposed to all the four elements of the strategy. The remaining 57 couples who received two or three elements of the strategy could be divided into two further classes of exposure. Our analysis demonstrated that additional elements do not result in an increased eSET rate. In addition to the physician's advice, couples rated a decision aid and a counselling session as more important for their decision to transfer one or two embryos, compared with a phone call and a reimbursement offer (P < 0.001). LIMITATIONS AND REASONS FOR CAUTION: The differences in eSET rate between exposure groups failed to reach significance, probably because of the small numbers of couples in each exposure group. WIDER IMPLICATIONS OF THE FINDINGS: Adding more elements to an implementation strategy does not always result in an increased effectiveness, which is in concordance with recent literature. This in-depth evaluation of a multifaceted intervention strategy could therefore help to modify strategies, by making them more effective and less expensive.

Guideline adherence is worth the effort: a cost-effectiveness analysis in intrauterine insemination care.

STUDY QUESTION: Is optimal adherence to guideline recommendations in intrauterine insemination (IUI) care cost-effective from a societal perspective when compared with suboptimal adherence to guideline recommendations? SUMMARY ANSWER: Optimal guideline adherence in IUI care has substantial economic benefits when compared with suboptimal guideline adherence. WHAT IS KNOWN ALREADY: Fertility guidelines are tools to help health-care professionals, and patients make better decisions about clinically effective, safe and cost-effective care. Up to now, there has been limited published evidence about the association between guideline adherence and cost-effectiveness in fertility care. STUDY DESIGN, SIZE, DURATION: In a retrospective cohort study involving medical record analysis and a patient survey (n = 415), interviews with staff members (n = 13) and a review of hospitals' financial department reports and literature, data were obtained about patient characteristics, process aspects and clinical outcomes of IUI care and resources consumed. In the cost-effectiveness analyses, restricted to four relevant guideline recommendations, the ongoing pregnancy rate per couple (effectiveness), the average medical and non-medical costs of IUI care, possible additional IVF treatment, pregnancy, delivery and period from birth up to 6 weeks after birth for both mother and offspring per couple (costs) and the incremental net monetary benefits were calculated to investigate if optimal guideline adherence is cost-effective from a societal perspective when compared with suboptimal guideline adherence. PARTICIPANTS/MATERIALS, SETTING, METHODS: Seven hundred and sixty five of 1100 randomly selected infertile couples from the databases of the fertility laboratories of 10 Dutch hospitals, including 1 large university hospital providing tertiary care and 9 public hospitals providing secondary care, were willing to participate, but 350 couples were excluded because of ovulatory disorders or the use of donated spermatozoa (n = 184), still ongoing IUI treatment (n = 143) or no access to their medical records (n = 23). As a result, 415 infertile couples who started a total of 1803 IUI cycles were eligible for the cost-effectiveness analyses. MAIN RESULTS AND THE ROLE OF CHANCE: Optimal adherence to the guideline recommendations about sperm quality, the total number of IUI cycles and dose of human chorionic gonadotrophin was cost-effective with an incremental net monetary benefit between € 645 and over € 7500 per couple, depending on the recommendation and assuming a willingness to pay € 20 000 for an ongoing pregnancy. LIMITATIONS, REASONS FOR CAUTION: Because not all recommendations applied to all 415 included couples, smaller groups were left for some of the cost-effectiveness analyses, and one integrated analysis with all recommendations within one model was impossible. WIDER IMPLICATIONS OF THE FINDINGS: Optimal guideline adherence in IUI care has substantial economic benefits when compared with suboptimal guideline adherence. For Europe, where over 144,000 IUI cycles are initiated each year to treat ≈ 32 000 infertile couples, this could mean a possible cost saving of at least 20 million euro yearly. Therefore, it is valuable to make an effort to improve guideline development and implementation.

A review of strategies to stimulate dental professionals to integrate smoking cessation interventions into primary care.

OBJECTIVE: To summarise evidence regarding the effectiveness of various implementation strategies to stimulate the delivery of smoking cessation advice and support during daily dental care. BASIC RESEARCH DESIGN: Search of online medical and psychological databases, correspondence with authors and checking of reference lists. Only studies were selected which examined a support strategy to promote tobacco use cessation having a component to be delivered by a dentist, dental hygienist or dental assistant in the daily practice setting. Furthermore only controlled studies and systematic reviews were included. Methodological quality and outcomes were independently summarised and checked by two reviewers. RESULTS: Eight studies met the inclusion criteria: 4 addressed strategies aimed at the dental professional and 4 addressed strategies aimed at both professional and patient. Only 4 of the studies were of a good quality. The 8 studies used combinations of implementation strategies, which made it difficult to evaluate the effectiveness of distinct components. Professional education appeared to enhance motivation for smoking cessation activities and advice giving. Organisational interventions (e.g., protocols, involvement of the whole team, referral possibilities) and incorporation of patient-oriented tools also contributed to the delivery of smoking cessation interventions. CONCLUSIONS: Multifaceted support strategies positively influence dental professionals' knowledge of smoking and smoking cessation, their motivation to give advice and their performance. As only 4 studies were of good methodological quality, it was not possible to draw firm conclusions about specific components. Additional research is needed to unravel which strategies best stimulate the provision of smoking cessation advice and support during daily dental practice.

Nurse telephone triage: good quality associated with appropriate decisions.

BACKGROUND: Triage at out-of-hours GP cooperatives (GPCs) is aimed at determining medical urgency and guiding decisions. Both medical knowledge and communication skills are required for this complex task. OBJECTIVE: To explore the impact of quality of consultation and estimated urgency on the appropriateness of decisions. METHODS: We performed a secondary analysis of telephone triage consultations by nurses at 29 Dutch GPCs. Consultations were taped and assessed by trained observers, using a validated instrument. Measures concerned quality of consultation, nurse-estimated urgency (four levels) and appropriateness of decisions (urgency, follow-up advice and timing). Bivariate analyses and logistic multilevel regression analyses were used to explore the impact of quality of consultation (controlling for urgency) on appropriateness of decisions. RESULTS: The sample included 6739 telephone contacts, most of which (90%) were non-urgent. The majority of decisions were appropriate (91% for urgency, 96% for follow-up advice and 95% for timing). In bivariate analyses, appropriateness of decisions was positively related to higher quality of consultation. Estimated urgency was negatively associated with quality of consultation. Logistic multilevel analysis showed that higher quality of consultation was related to a more appropriate estimation of urgency [odds ratio (OR) = 1.82; 95% confidence interval (CI): 1.69-1.95], follow-up advice (OR = 2.69; 95% CI: 2.41-3.01) and timing of decisions (OR = 2.41; 95% CI: 2.20-2.63). CONCLUSIONS: High quality of consultation has a positive, but small, impact on the appropriateness of decisions. Quality of consultation needs to be targeted in training and support of triage nurses, especially when it concerns highly urgent contacts.

Experienced barriers and facilitators for integrating smoking cessation advice and support into daily dental practice. A short report.

In a controlled study, primary care dental professionals in the intervention group were encouraged to provide smoking cessation advice and support for all smoking patients with the help of a stage-based motivational protocol. The barriers and facilitators reported by the dental professionals on two occasions for their efforts to incorporate smoking cessation advice and counselling into daily patient care are summarised here. Lack of practice time and anticipated resistance on the part of the patient were cited as barriers by over 50% of the dental professionals in the first interviews. Periodontal treatment and the presence of smoking-related diseases were mentioned as the most important stimuli. The experience-based interviews revealed key points for the implementation of smoking cessation advice and support in daily dental care. Education on the associations between smoking and oral health, vocational training on motivational interviewing and the offering of structured advice protocols were identified as promising components for an implementation strategy to promote the involvement of dental professionals in the primary and secondary prevention of tobacco addiction.

In-training assessment using direct observation of single-patient encounters: a literature review.

We reviewed the literature on instruments for work-based assessment in single clinical encounters, such as the mini-clinical evaluation exercise (mini-CEX), and examined differences between these instruments in characteristics and feasibility, reliability, validity and educational effect. A PubMed search of the literature published before 8 January 2009 yielded 39 articles dealing with 18 different assessment instruments. One researcher extracted data on the characteristics of the instruments and two researchers extracted data on feasibility, reliability, validity and educational effect. Instruments are predominantly formative. Feasibility is generally deemed good and assessor training occurs sparsely but is considered crucial for successful implementation. Acceptable reliability can be achieved with 10 encounters. The validity of many instruments is not investigated, but the validity of the mini-CEX and the 'clinical evaluation exercise' is supported by strong and significant correlations with other valid assessment instruments. The evidence from the few studies on educational effects is not very convincing. The reports on clinical assessment instruments for single work-based encounters are generally positive, but supporting evidence is sparse. Feasibility of instruments seems to be good and reliability requires a minimum of 10 encounters, but no clear conclusions emerge on other aspects. Studies on assessor and learner training and studies examining effects beyond 'happiness data' are badly needed.

Are oral health complaints related to smoking cessation intentions?

OBJECTIVE: Smoking influences oral health in several ways (such as the occurrence of periodontitis, teeth discolouration and oral cancer); therefore, smoking behaviour should be addressed in dental care. Dentists can play a role in primary and secondary prevention of tobacco dependence. They see their patients repeatedly over time. This study investigates whether oral health complaints can be seized as an opportunity to start smoking cessation counselling. METHODS: A structured patient questionnaire in a sample of 1101 smokers (52.1% women, mean age 40.4 years) in a convenience sample of 87 primary care dental practices. The I-change model was used to describe factors influencing behavioural change. Dependent factors such as intention to quit smoking and related factors (attitude, social support and self-efficacy) were analysed in relation to independent factors such as oral health complaints (gingiva problems, gingiva inflammation, oral cancer and discoloured teeth) using a general linear model (univariate analysis), multinomial logistic regression analysis and multiple linear regression analysis. RESULTS: A total of 56.3% had discoloured teeth, 27% of the smokers had a problem with their gums and 15.7% had gingiva inflammation. We found no direct relation between oral health complaints and the intention to quit smoking. However, teeth discolouration was positively related to attitudes towards smoking cessation [ß, Confidential interval (95%); 1.92 (1.45-2.40 for advantages and -0.86(-1.18 to -0.53) for disadvantages] and negatively to self-efficacy regarding quitting [-2.69 (-3.49 to 1.88)]. CONCLUSIONS: We found no direct relation between oral health complaints and the intention to quit smoking, but oral health complaints and especially teeth discolouration were related to factors influencing the quit intention. Patients with discoloured teeth are more likely to have a positive attitude towards smoking cessation but are uncertain to persist smoking cessation. It is suggested that teeth discolouration can be a good entrance for addressing smoking cessation in daily dental practice.

Improving access to primary care: the impact of a quality-improvement strategy.

PROBLEM: Many patients are not satisfied with the accessibility and availability of general practice, and they would like to see improvement. DESIGN: Quality-improvement study with pre-intervention and post-intervention data collection in 36 general practices. SETTING: General practices located in the south of The Netherlands. KEY MEASURES FOR IMPROVEMENT: Patient satisfaction, experiences and awareness; practice information; and experiences of a mystery patient. STRATEGY FOR CHANGE: The practices received feedback about their accessibility and availability compared with data from practices of colleagues. The practices developed practice-based improvement plans using these feedback results. EFFECTS OF CHANGE: Eighty per cent of the improvement plans were completed or almost completed in 5 months. After the intervention, the accessibility by phone within 2 min increased significantly (10% improvement). The practices that designed an improvement plan showed a larger increase (25% improvement) than practices that did not. Patient awareness of an information leaflet and a separate telephone number for emergency calls also significantly increased (29% improvement and 12% improvement) in practices that designed improvement plans. LESSONS LEARNED: Feedback and practice-based improvement plans were a stimulus to work on and to improve accessibility and availability. All practices started improvement plans, but the overall effect of the changes was modest. This may be due to acceptable accessibility and availability before the intervention was introduced and to the time period of 5 months, which seemed to be too short to complete all practice-based improvement plans. The mystery patient was more satisfied with the accessibility than the real patients. This may be related to our concept of accessibility. We learned that adding a mystery patient for data collection can contribute to more objective measurements of practice accessibility than patient questionnaires alone.

Three methods of multi-source feedback compared: a plea for narrative comments and coworkers' perspectives.

BACKGROUND: Doctor performance assessments based on multi-source feedback (MSF) are increasingly central in professional self-regulation. Research has shown that simple MSF is often unproductive. It has been suggested that MSF should be delivered by a facilitator and combined with a portfolio. AIMS: To compare three methods of MSF for consultants in the Netherlands and evaluate the feasibility, topics addressed and perceived impact upon clinical practice. METHOD: In 2007, 38 facilitators and 109 consultants participated in the study. The performance assessment system was composed of (i) one of the three MSF methods, namely, Violato's Physician Achievement Review (PAR), the method developed by Ramsey et al. for the American Board of Internal Medicine (ABIM), or the Dutch Appraisal and Assessment Instrument (AAI), (ii) portfolio, (iii) assessment interview with a facilitator and (iv) personal development plan. The evaluation consisted of a postal survey for facilitators and consultants. Generalized estimating equations were used to assess the association between MSF method used and perceived impact. RESULTS: It takes on average 8 hours to conduct one assessment. The CanMEDS roles 'collaborator', 'communicator' and 'manager' were discussed in, respectively, 79, 74 and 71% of the assessment interviews. The 'health advocate role' was the subject of conversation in 35% of the interviews. Consultants are more satisfied with feedback that contains narrative comments. The perceived impact of MSF that includes coworkers' perspectives significantly exceeds the perceived impact of methods not including this perspective. CONCLUSIONS: Performance assessments based on MSF combined with a portfolio and a facilitator-led interview seem to be feasible in hospital settings. The perceived impact of MSF increases when it contains coworkers' perspectives.

The effect of communication skills training on patient outcomes in cancer care: a systematic review of the literature.

The objective of this review was to determine whether communication training for healthcare professionals (HCP), including nurses and medical doctors, in cancer care improves patient outcomes. Eligible studies with a focus on patient outcomes and a controlled or single group pretest-posttest design were identified according to Cochrane Collaboration Guidelines. Seven studies, encompassing 10 papers and involving five randomised controlled trials, were included. Studies involved 411 HCP, including a total of 1677 encounters with adult cancer patients. Forty-nine papers were excluded, primarily because no patient outcomes were reported. Regarding patient satisfaction outcomes, estimated effects in favour of communication training ranged from 0.07 (95% CI: -0.30 to 0.44) for satisfaction with information and support to 0.70 (95% CI: 0.16 to 1.24) for satisfaction with assessment of concerns. No evidence was found for the effectiveness of communication training on patient distress outcomes. We concluded that the current review reveals inconclusive evidence to prove the effectiveness of communication training on patient satisfaction and patient distress. More high-quality studies are needed.

Impact of guideline implementation on patient care: a cluster RCT.

In Western European countries, dentists use standardized procedures, rather than individualized risk assessment, for routine oral examinations. The predictive hypothesis was that guideline implementation strategies based on multifaceted interventions would be more effective in patient care than the dissemination of guidelines only. A cluster-randomized trial was conducted, with groups of general dental practitioners (GDPs) as the unit of randomization. Patients were clustered within practices and prospectively enrolled in the trial. Patient data were collected from registration forms. The primary outcome measure was guideline-adherent recall assignment, and a secondary outcome measure was guideline-adherent bitewing frequency. The interventions consisted of online training, guideline dissemination, and educational sessions. For low-risk patients, guideline-adherent recall increased in the intervention group (+8%), which differed from the control group (-6.1%) (p = 0.01). Guideline-adherent bitewings showed mixed results. We conclude that multifaceted intervention had a moderate but relevant effect on the performance of GDPs, which is consistent with other findings in primary care.

Development of quality indicators for monitoring of the disease course in rheumatoid arthritis.

OBJECTIVES: To suppress rheumatoid arthritis (RA) patients' disease activity, it should be periodically measured and patients should be treated on the basis of the disease activity outcomes. Insight into the actual care, by using quality indicators, is the first step in achieving optimal care. The objective of this study was to develop a set of quality indicators to evaluate RA disease course monitoring of rheumatologists in daily clinical practice. METHODS: A RAND-modified Delphi method in a five-step procedure was applied: a literature search for quality indicators and recommendations about disease course monitoring; a first questionnaire round; a consensus meeting; a second questionnaire round and drawing up the final set. RESULTS: The systematic procedure resulted in the development of 18 quality indicators: 10 process, five structure and three outcome indicators that describe seven domains of disease course monitoring: schedule follow-up visits; measure disease activity; functional impairment; structural damage; change medication; preconditions for measuring disease activity and outcome measures in terms of disease activity. CONCLUSIONS: This quality indicator set can be used to assess the quality of disease course monitoring of rheumatologists in daily clinical practice, and to determine for which aspects of disease course monitoring rheumatologists perform well, or where there is room for improvement. This information can be used to improve the quality of disease course monitoring.

Type 2 diabetes in primary care in belgium: need for structured shared care.

OBJECTIVE: To picture the profile of type 2 diabetic patients in Belgium and to study the quality of care in the primary care setting, with regard, to multi-factorial approach of the disease. METHODS: Observational study of all known DM2-patients registered by 120 volunteer general practitioners. Quality of care was evaluated by the achievement of three major treatment targets: HbA1c<7%; Systolic Blood Pressure

What determines the provision of smoking cessation advice and counselling by dental care teams?

OBJECTIVE: To investigate determinants of the provision of smoking cessation advice and counselling by various dental professionals in the dental team (dentists, dental hygienists and prevention auxiliaries). DESIGN: Cross-sectional design. SETTING: Sixty-two general dental practices in the Netherlands. METHODS: Multivariate logistic analyses of self-reported counselling behaviour collected from questionnaires for dentists (n = 72), dental hygienists (n = 31) and prevention auxiliaries (n = 50) in general dental practices. MAIN OUTCOME MEASURES: Stimuli and barriers for smoking cessation counselling and advice behaviour to patients with or without oral health problems. RESULTS: Dental hygienists provided more general cessation advice and counselling than dentists. However, when patients had oral complaints, dentists counselled more often compared to prevention auxiliaries. The support from experienced colleagues positively influenced the provision of advice and counselling as well as the perceived self-efficacy for all kinds of dental professionals. CONCLUSIONS: The provision of general smoking cessation advice to patients with no acute oral complaints can be improved by more involvement of the dentist and/or task delegation to prevention auxiliaries and dental hygienists. Social support is important in encouraging more smoking cessation advice and counselling. Implementation strategies for support of smoking cessation in dental care should focus on creating a positive advice culture among colleagues.

Information provision in fertility care: a call for improvement.

BACKGROUND: Adequate information provision is a crucial dimension of high-quality fertility care. Clinical practice guidelines containing consensus-based recommendations may standardize practice between settings. This study was designed for three purposes: (i) to assess actual adherence to recommendations on information provision, (ii) to measure patient satisfaction with current practice and (iii) to analyse how variation in adherence relates to the characteristics of patients and clinics. METHODS: All recommendations concerning patient information were extracted from 10 national fertility guidelines and edited into a patient questionnaire. Additional questions concerning patient satisfaction and potential determinants of information provision at patient level were included. A total of 2698 couples from 16 clinics were invited to participate. A professional's questionnaire was sent to all gynaecologists to gather potential determinants at clinic level. Multilevel regression analysis was performed to identify the determinants of information provision. RESULTS: A total of 1499 couples (56%) participated. The percentage of couples who reported to have received complete information varied between recommendations from 10 to 96% (mean 57%). Overall, 94% of couples were satisfied with fertility services. The use of checklists for information provision, the presence of obstetrics/gynaecology residents and specialized nursing personnel, and higher patient anxiety scores were significantly associated (P < 0.05) with higher levels of information received. CONCLUSIONS: Despite the possibility of recall bias in questionnaire studies and observed high patient satisfaction with fertility services, we conclude that information provision for infertile couples is currently poor and in need of improvement. This could easily be procured by, for example, the use of information checklists.

The Chronic Care Model: congruency and predictors among primary care patients with osteoarthritis.

OBJECTIVE: The Chronic Care Model (CCM) and the 5A approach have achieved widespread acceptance and reflect the core elements of patient-centred care in chronic diseases, including osteoarthritis (OA). The aim was to assess to what extent current care for patients with osteoarthritis accords with the CCM in Germany and to reveal possible predictors to assess whether certain patients are more likely to receive care complying with the CCM than others. METHODS: Cross-sectional observational study, addressing 1250 patients from 75 primary care practices in Germany. 1021 (81.7%) of the administered 1250 questionnaires were returned. The Patient Assessment of Chronic Illness Care (PACIC-5A) was used to assess accordance to the CCM and the 5A-approach. The impact of OA was assessed by means of the Arthritis Impact Measurement Scale (AIMS2-SF); the Patient Health Questionnaire (PHQ-9) was used to assess depression symptoms. Two stepwise multiple linear regression models with the PACIC sum score and the 5A score as dependents were performed to reveal predictors of a high accordance to the CCM and to the 5A approach, respectively. RESULTS: With a mean (SD) of 2.79 (0.83) in men and 2.67 (0.89) in women (p for difference = 0.89), the PACIC sum score was notably lower than in previous studies conducted in health maintenance organisation settings in the US. The PACIC score was associated with a higher educational level (beta = 0.421; p = 0.008) and younger age (beta = -0.319; p = 0.016); the 5A score was predicted by educational level (beta = 0.344; p = 0.002), age (beta = -0.386; p = 0.004) and the PHQ-9 score (beta = -0.288; p = 0.005). CONCLUSIONS: Younger and better educated patients achieve higher scores on the PACIC score, indicating that their care accords to a higher degree with the CCM. Whether this reflects differences in physician behaviour toward different patient groups or rather different demands of these patient groups cannot be concluded from the presented data. Further research is needed to confirm our results and assess possible implications for implementing the Chronic Care Model in primary care.

Patient-oriented intervention in addition to centrally organised checkups improves diabetic patient outcome in primary care.

BACKGROUND: Logistic support to general practitioners improves the care processes for patients with diabetes but is not sufficient to meet all criteria. AIM: To introduce patient-oriented interventions by a practice nurse in general practices which already use logistic support to improve the care processes for patients with diabetes. DESIGN OF STUDY: A controlled before-after study with delayed intervention in the control group. SETTING: 51 practices (n = 23 for the intervention and n = 28 for the control group) in the south of The Netherlands and 900 of their patients with type 2 diabetes. METHODS: Data were collected on the results of the checkups (fasting blood glucose, glycosylated haemoglobin (HbA1C), cholesterol, cholesterol/high-density lipoprotein ratio, triglycerides, creatinine, blood pressure, fundus photo, foot exam and body mass index), smoking status, physical activity and medication use. The effect of the patient-oriented intervention was analysed in a mixed model with repeated measurement covariance structure. RESULTS: The HbA1C improved in the intervention group (from 7.3 to 7.1), while that of the control group deteriorated (from 7.2 to 7.3). The percentage of patients with an HbA1C >or=8.5 was halved after the intervention (from 13 to 6). Patients in the intervention group started to exercise more besides their daily activities compared with the control group. The need for medication increased more in the control group than in the intervention group (more changes to insulin and more defined daily dose (DDD) oral medication). CONCLUSION: Patient-oriented interventions in addition to logistic support have a positive effect on diabetic patient outcomes.

Perceived barriers to elective single embryo transfer among IVF professionals: a national survey.

BACKGROUND: After initial years of improvement, the multiple pregnancy rate after in vitro fertilization (IVF) in Europe now remains stable at 23% with single embryo transfer (SET) constituting 19% of all IVF cycles. Although elective SET prevents multiple pregnancies after IVF, couples and professionals apparently often decide to transfer more embryos. Previous qualitative research has identified factors that impede the use of elective SET. The aim of this study was to quantify those barriers among IVF professionals and to identify predictors of professionals' willingness to perform elective SET. METHODS: A national survey among all Dutch IVF professionals quantified the barriers suggested by a previous qualitative study and assessed characteristics of the professionals and clinics. Multivariate analysis identified predictors related to the willingness of IVF professionals to perform elective SET. RESULTS: In total, 107 professionals participated. The most frequently mentioned barriers to elective SET use were suboptimal success rates associated with cryopreservation (96%), not seeing twin pregnancies as a complication (79%) and lack of a SET protocol (78%). Two variables seem to predict the professionals' willingness to perform elective SET: university hospital of the initial fertility training (P< 0.01) and high scores of perceived barriers, e.g. professionals' attitudes and skills (P < 0.01). The explained variance of these two variables was 25%. CONCLUSIONS: This study has identified the main barriers to elective SET use and predictors for willingness of professionals to perform elective SET. This insight into the decision-making process could be critical in terms of increasing the use of elective SET.