[Chronic low back pain-user types of ambulatory care : Cluster analysis of the utilization of ambulatory health care resources with administrative data of the AOK Baden-Württemberg]. / Chronische Kreuzschmerzen ­ Nutzertypen ambulanter Versorgung : Eine Clusteranalyse der Inanspruchnahme ambulanter Regelversorgung anhand von Routinedaten der AOK Baden-Württemberg.

BACKGROUND: Chronic low back pain (CLBP) is one of the most common musculoskeletal disorders. Ambulatory care currently does not provide a structured multimodal approach, even though multimodal therapy is recommended. OBJECTIVES: The goal was to explore utilization of ambulatory health care resources concerning a multimodal therapy approach in the first year of CLBP and determine user types. MATERIALS AND METHODS: A two-step cluster analysis was executed with administrative data of 11,182 incident cases. The age was between 18 and 65 years and data of four consecutively quarters per patient were analyzed. With the administrative data from orthopedics, pain therapy, psychotherapy, exercise therapy, analgesics and opioids, clusters were determined. Further results were provided by variables of patients and the structure of care. RESULTS: The analysis reveals four user types: 39.7% used no specialist care and less exercise therapy; 37.3% used orthopedics; 15.6% used orthopedics and pain therapy; and 7.4% used orthopedics, pain therapy and/or psychotherapy. Characteristics for multimodal utilization were the following: female, high use of analgesics (m = 143.94 DDD), high use of opioids (m = 37.12 DDD), high costs of exercise therapy (m = 631.79 €), acupuncture, antidepressants, hospitalization, interdisciplinary case conference, and consult neurologists. In all, 60.4% of the study population received analgesics. CONCLUSIONS: The cluster analysis indicated differential user types. Approximately 23% of the study population receives the recommended multimodal therapy.

Converting habits of antibiotic use for respiratory tract infections in German primary care (CHANGE-3) - process evaluation of a complex intervention.

BACKGROUND: Antimicrobial resistance remains a global challenge. In Germany, the national health agenda supports measures that enhance the appropriate, guideline-oriented use of antibiotics. The study "Converting Habits of Antibiotic Use for Respiratory Tract Infections in German Primary Care (CHANGE-3)" aimed at a sustainable reduction of antimicrobial resistance through converting patterns of prescribing practice and use of antibiotics and an increase in health literacy in primary care patients, practice teams, and in the general public. Embedded in a cluster-randomized trial of a multifaceted implementation program, a process evaluation focused on the uptake of program components to assess the fidelity of the implementation program in the CHANGE-3 study and to understand utilization of its educational components. METHODS: A mix of qualitative and quantitative methods was used. Semi-structured telephone interviews were conducted with General Practitioners, Medical Assistants, patients treated for respiratory tract infection and outreach visitors who had carried out individual outreach visits. A two-wave written survey (T1: 5 months after start, T2: 16 months after start) was conducted in general practitioners and medical assistants. Qualitative data were analyzed using thematic framework analysis. Descriptive statistics were used to analyze survey data. RESULTS: Uptake of intervention components was heterogenous. Across all components, the uptake reported by General Practitioners varied from 20 to 88% at T1 and 31 to 63% at T2. Medical Assistants reported uptake from 22 to 70% at T1 and 6 to 69% at T2. Paper-based components could by and large be integrated in daily practice (64 to 90% in T1; 41 to 93% in T2), but uptake of digital components was low. A one-time outreach visit provided thematic information and feedback regarding actual prescribing, but due to time constraints were received with reluctance by practice teams. Patients were largely unaware of program components, but assumed that information and education could promote health literacy regarding antibiotics use. CONCLUSIONS: The process evaluation contributed to understanding the applicability of the delivered educational components with regards to the appropriate use of antibiotics. Future research efforts need to identify the best mode of delivery to reach the targeted population. TRIAL REGISTRATION: ISRCTN, ISRCTN15061174 . Registered 13 July 2018 - Retrospectively registered.

Study protocol of a multicenter randomized controlled trial of mindfulness-based cognitive therapy and treatment as usual in bipolar disorder.

BACKGROUND: Despite multiple pharmacological interventions, many people with bipolar disorder (BD) experience substantial residual mood symptoms, even in the absence of severe mood episodes, which have a negative impact on the course of illness and quality of life. Limited data are available on how to optimize treatment for BD, especially for those who suffer from persistent and residual depressive symptoms. Preliminary evidence suggests Mindfulness-Based Cognitive Therapy (MBCT) as a psychological treatment option for BD. This study aims to investigate whether adding MBCT to treatment as usual (TAU) will result in symptomatic and functional improvements in adults with BD compared to TAU alone. METHODS/DESIGN: This study is a prospective, evaluator blinded, multicenter, randomized controlled trial of MBCT + TAU and TAU alone in 160 adults with bipolar type I and type II. Assessments will be conducted at baseline (T0), mid-treatment (Tmid), and at 3 (T1), 6 (T2), 9 (T3), 12 (T4), and 15 (T5) months follow-up. Primary outcome is post-treatment severity of depressive symptoms (Inventory of Depressive Symptomatology- Clinician administered). Secondary outcomes are severity of (hypo) manic symptoms, anxiety, relapse rates, overall functioning, positive mental health, and cost-effectiveness. As possible mediators will be assessed rumination of negative affect, dampening and rumination of positive affect, mindfulness skills, and self-compassion. DISCUSSION: This study will provide valuable insight into the (cost-)effectiveness of MBCT on clinician- and self-rated symptoms of BD, relapse rates, positive mental health, and overall functioning. TRIAL REGISTRATION: NCT03507647 . Registered 25th of April 2018.

The multi-spectral imaging diagnostic.

The Multi-Spectral Imaging system is a new diagnostic that captures simultaneous spectrally filtered images from a common line of sight while maintaining a large étendue and high throughput. Imaging several atomic line intensities simultaneously may enable numerous measurement techniques. By making a novel modification of a polychromator layout, the MSI sequentially filters and focuses images onto commercial CMOS cameras while exhibiting minimal vignetting and aberrations. A four-wavelength system was initially installed and tested on Alcator C-Mod and subsequently moved to TCV. The images are absolutely calibrated and spatially registered enabling 2D mappings of atomic line ratios and absolute line intensities. The spectral transmission of the optical system was calibrated using an integrating sphere of known radiance. The images are inverted by cross-referencing points on TCV with a computer-aided design (CAD) model.

A longitudinal communication approach in advanced lung cancer: A qualitative study of patients', relatives' and staff's perspectives.

Communication and the care of patients with advanced cancer are a dynamic, interactive and challenging process, often characterised in every day practice by discontinuity and lack of coordination. The objective of this study was to explore the patients' and family-caregivers' needs and preferences regarding communication, quality of life and care over the trajectory of disease. The second aim was to assess health professionals' views on a longitudinally structured, forward-thinking communication approach based on defined milestones. A qualitative approach was chosen incorporating semi-structured interviews with nine patients with metastatic lung cancer and nine relatives, and focus groups with 15 healthcare providers from different professions involved in the care of these patients. Patients and relatives described a situation of shock and coping deficits with moments of insufficient communication and lack of continuity in care. Healthcare providers reported the strong need for improvement in communication within the team and between patients and professionals and welcomed the implementation of a longitudinal communication approach. Requirements for the implementation of a longitudinal communication approach include specific communication training with focus on the process that patients and relatives are involved in. Team-building measures and the necessary flexibility to respect individuality in life should be incorporated.

Impact of primary care on hospital admission rates for diabetes patients: A systematic review.

High-quality primary care for diabetes patients may be related to lowered hospital admissions. A systematic search was performed to assess the impact of structure, process, and outcome of primary diabetes care on hospital admission rates, considering patient characteristics. Studies on diabetes patients in primary care with hospitalisation rates as outcomes published between January 1996 and December 2015 were included. Indicators of quality of care (access, continuity and structure of care, process, and outcome indicators) and patient characteristics (age, gender, ethnicity, insurance, socio-economic status, diabetes characteristics, co-morbidity, and health-related lifestyle) were extracted. After assessment of the strength of evidence, characteristics of care and diabetes patients were presented in relation to the likelihood of hospitalisation. Thirty-one studies were identified. A regular source of primary care and a well-controlled HbA1c level decreased the likelihood of hospitalisation. Other aspects of care were less consistent. Patients' age, co-morbidity, and socio-economic status were related to higher hospitalisation. Gender and health-related lifestyle showed no relationship. Studies were heterogeneous in design, sample, and healthcare system. Different definitions of diabetes and unscheduled admissions limited comparisons. In healthcare systems where diabetes patients have a regular source of primary care, hospital admission rates cannot be meaningfully related to primary care characteristics.

Illness behaviour of general practitioners-a cross-sectional survey.

BACKGROUND: International guidelines recommend that physicians should be registered with a general practitioner (GP) and should avoid self-treatment. Adherence to these recommendations is mixed. AIMS: To describe illness behaviour and chronic medical conditions of GPs in Germany. METHODS: Cross-sectional, observational questionnaire study. We contacted 1000 GPs by mail in April 2014. We asked about registration with a GP, chronic conditions and self-treatment. We undertook descriptive statistical analysis and analysed associations using t-tests and chi-square test. RESULTS: Two hundred and eighty-five responses (29%) were eligible for analysis. Nineteen per cent of GPs were registered as patients of a GP, 58% reported at least one chronic condition, 68% disclosed self-diagnosis and 60% self-treatment. Self-therapy for chronic conditions was inversely correlated with subjective severity of the disease (r = -0.159; P < 0.05). CONCLUSIONS: The high rates of self-treatment and the low rate of registration with a GP of German GPs are in contrast to international guideline recommendations. Further research is needed to analyse specific reasons.

Process evaluation of a tailored intervention programme of cardiovascular risk management in general practices.

BACKGROUND: A tailored implementation programme to improve cardiovascular risk management (CVRM) in general practice had little impact on outcomes. The questions in this process evaluation concerned (1) impact on counselling skills and CVRM knowledge of practice nurses, (2) their use of the various components of the intervention programme and adoption of recommended practices and (3) patients' perceptions of counselling for CVRM. METHODS: A mixed-methods process evaluation was conducted. We assessed practice nurses' motivational interviewing skills on audio-taped consultations using Motivational Interviewing Treatment Integrity (MITI). They also completed a clinical knowledge test. Both practice nurses and patients reported on their experiences in a written questionnaire and interviews. A multilevel regression analysis and an independent sample t test were used to examine motivational interviewing skills and CVRM knowledge. Framework analysis was applied to analyse qualitative data. RESULTS: Data from 34 general practices were available, 19 intervention practices and 14 control practices. No improvements were measured on motivational interviewing skills in both groups. There appeared to be better knowledge of CVRM in the control group. On average half of the practice nurses indicated that they adopted the recommended interventions, but stated that they did not necessarily record this in patients' medical files. The tailored programme was perceived as too large. Time, follow-up support and reminders were felt to be lacking. About 20% of patients in the intervention group visited the general practice during the intervention period, yet only a small number of these patients were referred to recommended options. CONCLUSIONS: The tailored programme was only partly used by practice nurses and had little impact on either their clinical knowledge and communication skills or on patient reported healthcare. If the assumed logical model of change is valid, a more intensive programme is needed to have an impact on CVRM in general practice at all.

[Supporting patients in self-management: moving to a personalised approach]. / Ondersteuning van patiënten bij zelfmanagement.

OBJECTIVE: The aim of this research was to assess the effect of providing personalised self-management support on patient activation (knowledge, skills, self-efficacy) and self-management behaviour. DESIGN: Cluster randomised trial in 15 general practices (Dutch Trial Register No.: NTR 3960). METHOD: Patients aged 18 years or older with a chronic condition were invited to participate in the study. The Self-Management Screening (SeMaS) questionnaire - which illustrates barriers to self-management - was used as a tool for personalised self-management support. Nurse practitioners in the intervention practices were trained for 2 hours in using SeMaS and personalising self-management support on the basis of the SeMaS profile. At baseline and after 6 months, patients filled in questionnaires on patient activation (PAM-13) and lifestyle. Using data from the questionnaires and medical records, the use of individual care plans, referrals to self-management interventions, self-monitoring and healthcare use were assessed. We used a multiple multilevel regression model for data analysis. RESULTS: After 6 months, no difference was found in patient activation between the control group (n = 348) and the intervention group (n = 296). 29.4% of the patients in the intervention group performed self-monitoring, versus 15.2% in the control group (regression coefficient r = 0.9, p = 0.01). In the per-protocol analysis (control n = 348; intervention n = 136), the number of individual care plans (r = 1.3, p = 0.04) and the number of patients performing self-monitoring (r = 1.0; p = 0.01) were higher in the intervention group. CONCLUSION: Personalised self-management support with the use of the SeMaS method stimulates self-monitoring and the use of individual care plans. The intervention had no effect on patient activation or lifestyle. Given the positive secondary outcomes, the further potential of the tool should be researched.

Process evaluation of five tailored programs to improve the implementation of evidence-based recommendations for chronic conditions in primary care.

BACKGROUND: Although there is evidence that tailored implementation strategies can be effective, there is little evidence on which methods of tailoring improve the effect. We designed and evaluated five tailored programs (TPs) each consisting of various strategies. The aim of this study was to examine (a) how determinants of practice prioritized in the design phase of the TPs were perceived by health care professionals who had been exposed to the TPs and whether they suggested other important determinants of practice and (b) how professionals used the offered strategies and whether they suggested other strategies that might have been more effective. METHODS: We conducted a mixed-method process evaluation linked to five cluster-randomized trials carried out in five European countries to implement recommendations for five chronic conditions in primary care settings. The five TPs used a total of 28 strategies which aimed to address 38 determinants of practice. Interviews of professionals in the intervention groups and a survey of professionals in the intervention and control groups were performed. Data collection was conducted by each research team in the respective national language. The interview data were first analyzed inductively by each research team, and subsequently, a meta-synthesis was conducted. The survey was analyzed descriptively. RESULTS: We conducted 71 interviews; 125 professionals completed the survey. The survey showed that 76 % (n = 29) of targeted determinants of practice were perceived as relevant and 95 % (n = 36) as being modified by the implementation interventions by 66 to 100 % of professionals. On average, 47 % of professionals reported using the strategies and 51 % considered them helpful, albeit with substantial variance between countries and strategies. In the interviews, 89 determinants of practice were identified, of which 70 % (n = 62) had been identified and 45 % (n = 40) had been prioritized in the design phase. The interviewees suggested 65 additional strategies, of which 54 % (n = 35) had been identified and 20 % (n = 13) had been prioritized, but not selected in the final programs. CONCLUSIONS: This study largely confirmed the perceived relevance of the targeted determinants of practice. This contrasts with the fact that no impact of the trials on the implementation of the recommendations could be observed. The findings suggest that better methods for prioritization of determinants and strategies are needed. TRIAL REGISTRATION: Each of the five trials was registered separately in recognized trial registries. Details are given in the respective trial outcome papers.

Impact of primary healthcare providers' initial role security and therapeutic commitment on implementing brief interventions in managing risky alcohol consumption: a cluster randomised factorial trial.

BACKGROUND: Brief interventions in primary healthcare are cost-effective in reducing drinking problems but poorly implemented in routine practice. Although evidence about implementing brief interventions is growing, knowledge is limited with regard to impact of initial role security and therapeutic commitment on brief intervention implementation. METHODS: In a cluster randomised factorial trial, 120 primary healthcare units (PHCUs) were randomised to eight groups: care as usual, training and support, financial reimbursement, and the opportunity to refer patients to an internet-based brief intervention (e-BI); paired combinations of these three strategies, and all three strategies combined. To explore the impact of initial role security and therapeutic commitment on implementing brief interventions, we performed multilevel linear regression analyses adapted to the factorial design. RESULTS: Data from 746 providers from 120 PHCUs were included in the analyses. Baseline role security and therapeutic commitment were found not to influence implementation of brief interventions. Furthermore, there were no significant interactions between these characteristics and allocated implementation groups. CONCLUSIONS: The extent to which providers changed their brief intervention delivery following experience of different implementation strategies was not determined by their initial attitudes towards alcohol problems. In future research, more attention is needed to unravel the causal relation between practitioners' attitudes, their actual behaviour and care improvement strategies to enhance implementation science. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01501552.

Strategies in primary healthcare to implement early identification of risky alcohol consumption: why do they work or not? A qualitative evaluation of the ODHIN study.

BACKGROUND: Screening and brief interventions (SBI) in primary healthcare are cost-effective in risky drinkers, yet they are not offered to all eligible patients. This qualitative study aimed to provide more insight into the factors and mechanisms of why, how, for whom and under what circumstances implementation strategies work or do not work in increasing SBI. METHODS: Semi-structured interviews were conducted between February and July 2014 with 40 GPs and 28 nurses in Catalonia, the Netherlands, Poland, and Sweden. Participants were purposefully selected from the European Optimising Delivery of Healthcare Interventions (ODHIN) trial. This randomised controlled trial evaluated the influence of training and support, financial reimbursement and an internet-based method of delivering advice on SBI. Amongst them were 38 providers with a high screening performance and 30 with a low screening performance from different allocation groups. Realist evaluation was combined with the Tailored Implementation for Chronic Diseases framework for identification of implementation determinants to guide the interviews and analysis. Transcripts were analysed thematically with the diagram affinity method. RESULTS: Training and support motivated SBI by improved knowledge, skills and prioritisation. Continuous provision, sufficient time to learn intervention techniques and to tailor to individual experienced barriers, seemed important T&S conditions. Catalan and Polish professionals perceived financial reimbursement to be an additional stimulating factor as well, as effects on SBI were smoothened by personnel levels and salary levels. Structural payment for preventive services rather than a temporary project based payment, might have increased the effects of financial reimbursement. Implementing e-BI seem to require more guidance than was delivered in ODHIN. Despite the allocation, important preconditions for SBI routine seemed frequent exposure of this topic in media and guidelines, SBI facilitating information systems, and having SBI in protocol-led care. Hence, the second order analysis revealed that the applied implementation strategies have high potential on the micro professional level and meso-organisational level, however due to influences from the macro- level such as societal and political culture the effects risks to get nullified. CONCLUSIONS: Essential determinants perceived for the implementation of SBI routines were identified, in particular for training and support and financial reimbursement. However, focusing only on the primary healthcare setting seems insufficient and a more integrated SBI culture, together with meso- and macro-focused implementation process is requested. TRIAL REGISTRATION: ClinicalTrials.gov. Trial identifier: NCT01501552 .

Perceived determinants of cardiovascular risk management in primary care: disconnections between patient behaviours, practice organisation and healthcare system.

BACKGROUND: Although conditions for high quality cardiovascular risk management in primary care in the Netherlands are favourable, there still remains a gap between practice guideline recommendations and practice. The aim of the current study was to identify determinants of cardiovascular primary care in the Netherlands. METHODS: We performed a qualitative study, using semi-structured interviews with healthcare professionals and patients with established cardiovascular diseases or at high cardiovascular risk. A framework analysis was used to cluster the determinants into seven domains: 1) guideline factors, 2) individual healthcare professional factors, 3) patient factors, 4) professional interaction, 5) incentives and recourses, 6) mandate, authority and accountability, and 7) social, political and legal factors. RESULTS: Twelve healthcare professionals and 16 patients were interviewed. Healthcare professionals and patients mentioned a variety of factors concerning all seven domains. Determinants of practice according to the health care professionals were related to communication between healthcare professionals, patients' lack of knowledge and self-management, time management, market mechanisms in the Dutch healthcare system and motivational interviewing skills of healthcare professionals. Patients mentioned determinants related to their knowledge of risk factors for cardiovascular diseases, medication adherence and self-management as key determinants. A key finding is the mismatch between healthcare professionals' and patients' views on patient's knowledge and self-management. CONCLUSIONS: Perceived determinants of cardiovascular risk management were mainly related to patient behaviors and (but only for health professionals) to the healthcare system. Though health care professionals and patients agree upon the importance of patients' knowledge and self-management, their judgment of the current state of knowledge and self-management is entirely different.

[Evidence-based clinical oral healthcare guidelines 4. Adherence requires an implementation strategy]. / Evidencebased klinische praktijkrichtlijnen in de mondzorg 4. Toepassing vergt een implementatiestrategie.

Adherence to clinical guidelines requires support in practice. However, systematic implementation of evidence-based guidelines is not common practice in oral healthcare. The Knowledge Institute Oral Care (KiMo) offers the opportunity to take into account potential barriers and facilitators during the development of evidence-based clinical practice guidelines. These factors which are relevant to the guideline and the oral healthcare practice provide the ingredients for a tailor-made programme of implementation that has a scientific basis. Elements of any implementation programme are the quality indicators derived from the oral healthcare guidelines. These indicators should fit, on the one hand, the specific goals of the guidelines (patient safety, effectiveness, efficiency, patient-centred, timeliness, accessibility) and, onthe other hand, the various perspectives of the different stakeholders, such as patients, caregivers, health insurers and inspectorate. These quality indicators provide information on adherence to the guidelines, the results of a certain treatment and the success of the implementation strategy, all with the aim to improve the quality of oral healthcare.

A multifaceted intervention: no increase in general practitioners' competence to diagnose skin cancer (minSKIN) - randomized controlled trial.

BACKGROUND: General practitioners (GPs) play crucial roles in early detection of skin cancer. A pilot-study found a positive short-term effect of a 1-day dermatologic education programme on GPs' diagnostic competence. OBJECTIVE: To determine effects of a multifaceted intervention, including technical equipment and continuing feedback by a dermatologist, on GPs' diagnostic skills regarding skin cancer. METHODS: Randomized controlled trial with 78 GPs of the Canton of Zurich, Switzerland. INTERVENTION: GPs in intervention group received a 1-day training, a Lumio (magnifying glass with polarized light, 3Gen), a Nikon digital camera and - during 1 year - feedback on skin lesion pictures sent to the dermatologist. GPs in control group only received the 1-day training. PRIMARY OUTCOME: structured assessment of GP's diagnostic skills in correctly diagnosing images of skin lesions regarding skin cancer. At baseline prior to intervention (T0), after the full-day training course in both groups (T1), and after 1 year of continuing feedback (T2) to the intervention group. MEASURES: Non-parametric unpaired (Wilcoxon-Mann-Whitney) tests were used to compare numbers of correctly classified skin lesions between both groups at T2 and for the change between T1 and T2. RESULTS: At T0, both groups classified a median of 23 skin lesions of the 36 images correctly. This value rose to 28 for both groups at T1 and fell to 24 for both groups at T2. No difference between control and intervention group at T2. Furthermore, we compared differences in the sum scores per GP between T1 and T2 for each group. Also in this comparison, no difference between control and intervention group was found. CONCLUSION AND RELEVANCE: No long-term effect of the multifaceted intervention was found on the competence to diagnose skin cancer by GPs. The positive short-term effect of the 1-day dermatologic education programme did not persist over 12 months.

The impact on emergency department utilization and patient flows after integrating with a general practitioner cooperative: an observational study.

Introduction. A new model, an emergency care access point (ECAP) for after-hours emergency care, is emerging in The Netherlands. This study assessed the effect on emergency department (ED) utilization and patient flows. Methods. Routinely recorded clinical ED patient data, covering a six-year period, was collected. Segmented regression analysis was used to analyze after-hours changes over time. Results. 59.182 patients attended the ED before the start of the ECAP and 51.513 patients after, a decrease of 13%. Self-referred ED patients decreased 99.5% (OR 0.003; 95% CI 0.002-0.004). Referred patients increased by 213.4% and ED hospital admissions increased by 20.2%. A planned outpatient follow-up increased by 5.8% (OR 1.968 95% CI 1.870-2.071). The latter changed from fewer contacts to more contacts (OR 1.015 95% CI 1.013-1.017). Consultations at the regional genereral practitioner cooperative (GPC) increased by 26.0% (183.782 versus 232.246). Conclusion. ECAP implementation resulted in a decrease in ED utilization, a near absence of self-referring patients, and a higher probability of hospital admission and clinical follow-up. This suggests either an increase of ED patients with a higher acuity or a lower threshold of admitting referred patients compared to self-referred patients. Overall, increased collaboration with after-hours primary care and emergency care seemed to optimize ED utilization.

[Adjustment and alteration of the quality indicators in the Basic Set (GGZ) for use in child and adolescent psychiatry]. / Aanpassing en aanvulling van kwaliteitsindicatoren uit de basisset ggz voor gebruik in de kinder- en jeugdpsychiatrie.

BACKGROUND: Transparency by means of quality indicators is regarded as a method for monitoring and improving the quality of care. In the Dutch mental health service (GGZ) a generic basic set of indicators has been developed, but it is not clear whether the set is suitable for use in child and adolescent psychiatry. AIM: To assess whether the GGZ Basic Set of performance indicators for 2007-2008 was suitable for use in a child and adolescent psychiatric setting and to detect any omissions in that set. METHOD: A heterogeneous national group of eight health professionals and five 'stakeholders' in child and adolescent mental health judged the existing Basic Set by means of a Delphi procedure consisting of two written rounds and a panel discussion. The experts assessed potential indicators with regard to necessity, validity, clarity and applicability to child and adolescent psychiatry using a scale of 0 to 9. Indicators scoring more than 7 were considered to be appropriate. RESULTS: Only two of the 54 indicators were considered appropriate. A lower cut-off point would leave 16 indicators, of which 10 related to the outcome of treatment. One of the nine proposed innovative indicators was added. CONCLUSION: Very few of the indicators in the Basic Set were considered to be suitable for use in child and adolescent psychiatry. Respondents expressed a preference for a limited number of indicators that emphasised the opinion of the patient and of parents rather than the outcomes of treatment.

Trends and predictors of hospitalization, readmissions and length of stay in ambulatory patients with heart failure.

OBJECTIVES: Little is known on predictors of hospitalisation in ambulatory patients with chronic heart failure, and known predictors may not apply to Mediterranean countries. Our aim was to document longitudinal trends in hospitalisations and identify patient-related predictors of hospital admission, re-admission and length of stay in the targeted population. METHODS: Population-based retrospective cohort study in Catalonia (North-East Spain), including 7196 ambulatory patients (58.6% women; mean age 76 years). Eligible patients were selected from the electronic patient records of primary care practices, and followed for 3 years. RESULTS: At 3 years of follow up overall 645 (9.0%) patients had cardiovascular hospitalisation, 37% were readmitted, and median length of stay was 9 (interquartile range 5-17) days. Chronic kidney disease [odds ratio (OR)=1.98 (1.62-2.43)], IHD [OR=1.72 (1.45-2.04)], DM [OR=1.50 (1.27-1.78)] and chronic obstructive pulmonary disease [OR=1.43 (1.16-1.77)] increased the risk for hospitalisation. DM [OR=1.70 (1.22-2.38)], IHD [OR=1.85 (1.33-2.58)] and HTA [OR=1.66 (1.11-2.46)] increased the risk for readmissions. Chronic kidney disease [OR of 2.21 (1.70-2.90)], IHD [OR of 2.19 (1.73-2.77)], DM [OR=1.70 (1.34-2.15)], HTA [OR=1.51 (1.13-2.01)], chronic obstructive pulmonary disease [OR=1.37 (1.02-1.83)] increased the risk for long length of stay in hospital. CONCLUSIONS: Our study identified predictors of hospitalisation, readmissions and long length of stay which can help clinicians and managers to identify high risk patients which should be targeted on service planning and when designing preventive actions.

Comorbidity complicates cardiovascular treatment: is diabetes the exception?

BACKGROUND: Many patients with cardiovascular disease do not attain the targets for health-related lifestyle and preventive treatment recommended in practice guidelines. The aim of this study was to assess the impact of diabetes (DM) and chronic obstructive pulmonary disease (COPD) on the quality of cardiovascular risk management in patients with established cardiovascular diseases (CVD). METHODS AND RESULTS: Patients with established CVD were randomly selected in primary care practices using recorded diagnoses. Structured case forms were used to review data on 20 performance indicators concerning CVD from medical records. Descriptive and multilevel regression analyses were conducted. In 45 primary care practices with 106 physicians in the Netherlands, 1614 medical records of patients with CVD (37.9% women) were reviewed. A total of 1076 (66.7%) patients had recorded CVD only (reference group); 7.8% had CVD and COPD; 22.4% had CVD and DM; 3.1% patients had CVD, COPD and DM. Compared with the reference group, patients with CVD and DM yielded higher scores on 17 of 20 indicators; patients with CVD, DM and COPD on 14 indicators; and patients with CVD and COPD on three indicators. Of the patients with CVD and DM, fewer patients had LDL-cholesterol levels over 2.5 mmol/l (OR=0.36; 95% CI 0.26-0.50), more had antiplatelet drugs prescribed (OR=1.72; 95% CI 1.17-2.54), and more had systolic blood pressure measurement (OR=4.12; 95% CI 2.80-6.06). CONCLUSIONS: This study showed that DM but not COPD was associated with more comprehensive cardiovascular risk management. This finding adds to cumulating evidence that presence of DM is associated with better preventive treatment of cardiovascular risk.

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.