The most efficient and effective BRCA1/2 testing strategy in epithelial ovarian cancer: Tumor-First or Germline-First?

OBJECTIVE: Genetic testing in epithelial ovarian cancer (OC) is essential to identify a hereditary cause like a germline BRCA1/2 pathogenic variant (PV). An efficient strategy for genetic testing in OC is highly desired. We evaluated costs and effects of two strategies; (i) Tumor-First strategy, using a tumor DNA test as prescreen to germline testing, and (ii) Germline-First strategy, referring all patients to the clinical geneticist for germline testing. METHODS: Tumor-First and Germline-First were compared in two scenarios; using real-world uptake of testing and setting implementation to 100%. Decision analytic models were built to analyze genetic testing costs (including counseling) per OC patient and per family as well as BRCA1/2 detection probabilities. With a Markov model, the life years gained among female relatives with a germline BRCA1/2 PV was investigated. RESULTS: Focusing on real-world uptake, with the Tumor-First strategy more OC patients and relatives with a germline BRCA1/2 PV are detected (70% versus 49%), at lower genetic testing costs (€1898 versus €2502 per patient, and €2511 versus €2930 per family). Thereby, female relatives with a germline BRCA1/2 PV can live on average 0.54 life years longer with Tumor-First compared to Germline-First. Focusing on 100% uptake, the genetic testing costs per OC patient are substantially lower in the Tumor-First strategy (€2257 versus €4986). CONCLUSIONS: The Tumor-First strategy in OC patients is more effective in identifying germline BRCA1/2 PV at lower genetic testing costs per patient and per family. Optimal implementation of Tumor-First can further improve detection of heredity in OC patients.

Minimally Invasive Intervention for Primary Caries Lesions: Are Dentists Implementing This Concept?

Contemporary minimally invasive treatment concepts for restorative treatment of primary caries lesions include both delayed intervention and smaller-sized preparations restricted to removal of carious tissue. The aim of this study was to investigate whether these concepts have resulted in a trend towards a more conservative choice made by dentists regarding treatment thresholds and restorative techniques. The results from previously conducted, precoded questionnaires developed by Espelid and Tveit, as well as from a recent Dutch questionnaire, were collected and analysed. A worldwide trend towards more minimally invasive strategies in the operative treatment of caries lesions could not be observed, neither for the initiation of operative treatment nor for the preparation techniques. However, in some countries, changes over time could be assessed, especially in Norway, where a reduction in the proportion of interventions is visible for both occlusal and approximal lesions, indicating that more dentists are postponing interventions until the lesions have progressed to a deeper level. From the Dutch national survey, it could be concluded that operators that intervene at an earlier stage of approximal lesioning (stage ≤4) also intervene at an earlier stage of occlusal caries (stage ≤3) (p = 0.012; OR = 2.52; 95% CI: 1.22-5.22). Generally, it can be concluded that dentists worldwide still tend to operatively intervene at a too early stage of caries, although variations exist between countries. A worldwide shift could be observed in the restorative material applied, since composite resin has almost completely replaced amalgam for restoring primary caries lesions.

Variation in Integrated Head and Neck Cancer Care: Impact of Patient and Hospital Characteristics.

Background: Monitoring and effectively improving oncologic integrated care requires dashboard information based on quality registrations. The dashboard includes evidence-based quality indicators (QIs) that measure quality of care. This study aimed to assess the quality of current integrated head and neck cancer care with QIs, the variation between Dutch hospitals, and the influence of patient and hospital characteristics. Methods: Previously, 39 QIs were developed with input from medical specialists, allied health professionals, and patients' perspectives. QI scores were calculated with data from 1,667 curatively treated patients in 8 hospitals. QIs with a sample size of >400 patients were included to calculate reliable QI scores. We used multilevel analysis to explain the variation. Results: Current care varied from 29% for the QI about a case manager being present to discuss the treatment plan to 100% for the QI about the availability of a treatment plan. Variation between hospitals was small for the QI about patients discussed in multidisciplinary team meetings (adherence: 95%, range 88%-98%), but large for the QI about malnutrition screening (adherence: 50%, range 2%-100%). Higher QI scores were associated with lower performance status, advanced tumor stage, and tumor in the oral cavity or oropharynx at the patient level, and with more curatively treated patients (volume) at hospital level. Conclusions: Although the quality registration was only recently launched, it already visualizes hospital variation in current care. Four determinants were found to be influential: tumor stage, performance status, tumor site, and volume. More data are needed to assure stable results for use in quality improvement.

Feedback preferences of patients, professionals and health insurers in integrated head and neck cancer care.

BACKGROUND: Audit and feedback on professional practice and health care outcomes are the most often used interventions to change behaviour of professionals and improve quality of health care. However, limited information is available regarding preferred feedback for patients, professionals and health insurers. OBJECTIVE: Investigate the (differences in) preferences of receiving feedback between stakeholders, using the Dutch Head and Neck Audit as an example. METHODS: A total of 37 patients, medical specialists, allied health professionals and health insurers were interviewed using semi-structured interviews. Questions focussed on: "Why," "On what aspects" and "How" do you prefer to receive feedback on professional practice and health care outcomes? RESULTS: All stakeholders mentioned that feedback can improve health care by creating awareness, enabling self-reflection and reflection on peers or colleagues, and by benchmarking to others. Patients prefer feedback on the actual professional practice that matches the health care received, whereas medical specialists and health insurers are interested mainly in health care outcomes. All stakeholders largely prefer a bar graph. Patients prefer a pie chart for patient-reported outcomes and experiences, while Kaplan-Meier survival curves are preferred by medical specialists. Feedback should be simple with firstly an overview, and 1-4 times a year sent by e-mail. Finally, patients and health professionals are cautious with regard to transparency of audit data. CONCLUSIONS: This exploratory study shows how feedback preferences differ between stakeholders. Therefore, tailored reports are recommended. Using this information, effects of audit and feedback can be improved by adapting the feedback format and contents to the preferences of stakeholders.

Inter-practice variation in polypharmacy prevalence amongst older patients in primary care.

PURPOSE: Complex medication management in older people with multiple chronic conditions can introduce practice variation in polypharmacy prevalence. This study aimed to determine the inter-practice variation in polypharmacy prevalence and examine how this variation was influenced by patient and practice characteristics. METHODS: This cohort study included 45,731 patients aged 55 years and older with at least one prescribed medication from 126 general practices that participated in NIVEL Primary Care Database in the Netherlands. Medication dispensing data of the year 2012 were used to determine polypharmacy. Polypharmacy was defined as the chronic and simultaneous use of at least five different medications. Multilevel logistic regression models were constructed to quantify the polypharmacy prevalence variation between practices. Patient characteristics (age, gender, socioeconomic status, number, and type of chronic conditions) and practice characteristics (practice location and practice population) were added to the models. RESULTS: After accounting for differences in patient and practice characteristics, polypharmacy rates varied with a factor of 2.4 between practices (from 12.4% to 30.1%) and an overall mean of 19.8%. Age and type of conditions were highly positively associated with polypharmacy, and to a lesser extent a lower socioeconomic status. CONCLUSIONS: Considerable variation in polypharmacy rates existed between general practices, even after accounting for patient and practice characteristics, which suggests that there is not much agreement concerning medication management in this complex patient group. Initiatives that could reduce inappropriate heterogeneity in medication management can add value to the care delivered to these patients. Copyright © 2016 John Wiley & Sons, Ltd.

Quality of chronic kidney disease management in primary care: a retrospective study.

BACKGROUND: Early detection and appropriate management of chronic kidney disease (CKD) in primary care are essential to reduce morbidity and mortality. AIM: To assess the quality of care (QoC) of CKD in primary healthcare in relation to patient and practice characteristics in order to tailor improvement strategies. DESIGN AND SETTING: Retrospective study using data between 2008 and 2011 from 47 general practices (207 469 patients of whom 162 562 were adults). METHOD: CKD management of patients under the care of their general practitioner (GP) was qualified using indicators derived from the Dutch interdisciplinary CKD guideline for primary care and nephrology and included (1) monitoring of renal function, albuminuria, blood pressure, and glucose, (2) monitoring of metabolic parameters, and alongside the guideline: (3) recognition of CKD. The outcome indicator was (4) achieving blood pressure targets. Multilevel logistic regression analysis was applied to identify associated patient and practice characteristics. RESULTS: Kidney function or albuminuria data were available for 59 728 adult patients; 9288 patients had CKD, of whom 8794 were under GP care. Monitoring of disease progression was complete in 42% of CKD patients, monitoring of metabolic parameters in 2%, and blood pressure target was reached in 43.1%. GPs documented CKD in 31.4% of CKD patients. High QoC was strongly associated with diabetes, and to a lesser extent with hypertension and male sex. CONCLUSION: Room for improvement was found in all aspects of CKD management. As QoC was higher in patients who received structured diabetes care, future CKD care may profit from more structured primary care management, e.g. according to the chronic care model. KEY POINTS: Quality of care for chronic kidney disease patients in primary care can be improved. In comparison with guideline advice, adequate monitoring of disease progression was observed in 42%, of metabolic parameters in 2%, correct recognition of impaired renal function in 31%, and reaching blood pressure targets in 43% of chronic kidney disease patients. Quality of care was higher in patients with diabetes. Chronic kidney disease management may be improved by developing strategies similar to diabetes care.

Multimorbidity patterns in a primary care population aged 55 years and over.

BACKGROUND: To support the management of multimorbid patients in primary care, evidence is needed on prevalent multimorbidity patterns. OBJECTIVE: To identify the common and distinctive multimorbidity patterns. METHODS: Clinical data of 120480 patients (≥55 years) were extracted from 158 general practices in 2002-11. Prevalence rates of multimorbidity were analyzed (overall, and for 24 chronic diseases), adjusted for practice, number of diseases and patients' registration period; differentiated between patients 55-69 and ≥70 years. To investigate multimorbidity patterns, prevalence ratios (prevalence rate index-disease group divided by that in the non-index-disease group) were calculated for patients with heart failure, diabetes mellitus, migraine or dementia. RESULTS: Multiple membership multilevel models showed that the overall adjusted multimorbidity rate was 86% in patients with ≥1 chronic condition, varying from 70% (migraine) to 98% (heart failure), 38% had ≥4 chronic diseases. In patients 55-69 years, 83% had multimorbidity. Numerous significant prevalence ratios were found for disease patterns in heart failure patients, ranging from 1.2 to 7.7, highest ratio for chronic obstructive pulmonary disease-cardiac dysrhythmia. For diabetes mellitus, dementia or migraine patients highest ratios were for heart failure-visual disorder (2.1), heart failure-depression (3.9) and depression-back/neck disorder (2.1), respectively (all P-values<0.001). CONCLUSIONS: Multimorbidity management in general practice can be reinforced by knowledge on the clinical implications of the presence of the comprehensive disease patterns among the elderly patients, and those between 55 and 69 years. Guideline developers should be aware of the complexity of multimorbidity. As a consequence of this complexity, it is even more important to focus on what matters to a patient with multimorbidity in general practice.

Patients' expectations of variation in quality of care relates to their search for comparative performance information.

BACKGROUND: Choice of hospital based on comparative performance information (CPI) was introduced for Dutch healthcare consumers at least 5 years ago, but CPI use has not yet become commonplace. Our aim was to assess the role of patients' expectations regarding variation in the quality of hospital care in determining whether they search for CPI. METHODS: A questionnaire (for a cross-sectional survey) was distributed to 475 orthopaedic patients in a consecutive sample, who underwent primary hip or knee replacement in a university, teaching, or community hospital between September 2009 and July 2010. RESULTS: Of the 302 patients (63%) who responded, 13% reported searching for CPI to help them choose a hospital. People who expected quality differences between hospitals (67%) were more likely to search for CPI (OR =3.18 [95% CI: 1.02-9.89]; p <0.04) than those who did not. Quality differences were most often expected in hospital reputation, distance, and accessibility. Patients who did not search for CPI stated that they felt no need for this type of information. CONCLUSION: Patients' expectations regarding variation in quality of care are positively related to their reported search for CPI. To increase the relevance of CPI for patients, future studies should explore the underlying reasoning of patients about meaningful quality-of-care variation between hospitals.

Effect of accreditation on the quality of chronic disease management: a comparative observational study.

BACKGROUND: Practice accreditation is widely used to assess and improve quality of healthcare providers. Little is known about its effectiveness, particularly in primary care. In this study we examined the effect of accreditation on quality of care regarding diabetes, chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD). METHODS: A comparative observational study with two cohorts was performed. We included 138 Dutch family practices that participated in the national accreditation program for primary care. A first cohort of 69 practices was measured at start and completion of a 3-year accreditation program. A second cohort of 69 practices was included and measured simultaneously with the final measurement of the first cohort. In separate multilevel regression analyses, we compared both within-group changes in the first cohort and between-groups differences at follow-up (first cohort) and start (second cohort). Outcome measures consisted of 24 systematically developed indicators of quality of care in targeted chronic diseases. RESULTS: In the within-group comparison, we found improvements on 6 indicators related to diabetes (feet examination, cholesterol measurement, lipid lowering medication prescription) and COPD (spirometry performance, stop smoking advice). In the between-groups comparison we found that first cohort practices performed better on 4 indicators related to diabetes (cholesterol outcome) and CVD (blood pressure outcome, smoke status registration, glucose measurement). CONCLUSIONS: Improvements of the quality of primary care for patients with chronic diseases were found, but few could be attributed to the accreditation program. Further development of accreditation is needed to enhance its effectiveness on chronic disease management.

Comparative performance information plays no role in the referral behaviour of GPs.

BACKGROUND: Comparative performance information (CPI) about the quality of hospital care is information used to identify high-quality hospitals and providers. As the gatekeeper to secondary care, the general practitioner (GP) can use CPI to reflect on the pros and cons of the available options with the patient and choose a provider best fitted to the patient's needs. We investigated how GPs view their role in using CPI to choose providers and support patients. METHOD: We used a mixed-method, sequential, exploratory design to conduct explorative interviews with 15 GPs about their referral routines, methods of referral consideration, patient involvement, and the role of CPI. Then we quantified the qualitative results by sending a survey questionnaire to 81 GPs affiliated with a representative national research network. RESULTS: Seventy GPs (86% response rate) filled out the questionnaire. Most GPs did not know where to find CPI (87%) and had never searched for it (94%). The GPs reported that they were not motivated to use CPI due to doubts about its role as support information, uncertainty about the effect of using CPI, lack of faith in better outcomes, and uncertainty about CPI content and validity. Nonetheless, most GPs believed that patients would like to be informed about quality-of-care differences (62%), and about half the GPs discussed quality-of-care differences with their patients (46%), though these discussions were not based on CPI. CONCLUSION: Decisions about referrals to hospital care are not based on CPI exchanges during GP consultations. As a gatekeeper, the GP is in a good position to guide patients through the enormous amount of quality information that is available. Nevertheless, it is unclear how and whether the GP's role in using information about quality of care in the referral process can grow, as patients hardly ever initiate a discussion based on CPI, though they seem to be increasingly more critical about differences in quality of care. Future research should address the conditions needed to support GPs' ability and willingness to use CPI to guide their patients in the referral process.

Organizational determinants of high-quality routine diabetes care.

OBJECTIVE: Randomized trials showed that changes in healthcare organization improved diabetes care. This study aimed to identify which organizational determinants were associated with patient outcomes in routine diabetes care. DESIGN: Observational study, in which multilevel regression analyses were applied to examine the impact of 12 organizational determinants on diabetes care as separate measures and as a composite score. SETTING: Primary care practices in the Netherlands. SUBJECTS: 11,751 patients with diabetes in 354 practices. MAIN OUTCOME MEASURES: Patients' recorded glycated hemoglobin (HbA1c), systolic blood pressure, and serum cholesterol levels. RESULTS: A higher score on the composite measure of organizational determinants was associated with better control of systolic blood pressure (p = 0.017). No effects on HbA1C or cholesterol levels were found. Exploration of specific organizational factors found significant impact of use of an electronic patient registry on HbA1c (OR = 1.80, 95% CI 1.12-2.88), availability of patient leaflets on systolic blood pressure control (OR = 2.59, 95% CI 1.06-6.35), and number of hours' nurse education on cholesterol control (OR = 2.51, 95% CI 1.02-6.15). CONCLUSION: In routine primary care, it was found that favorable healthcare organization was associated with a number of intermediate outcomes in diabetes care. This finding lends support to the findings of trials on organizational changes in diabetes care. Notably, the composite measure of organizational determinants had most impact.

Exploring consumer values of comparative performance information for hospital choice.

BACKGROUND: In many countries, market orientation in healthcare has resulted in the publication of comparative performance information (CPI). Most of the research in this field is oriented towards the content and the presentation format of CPI while little is known about how consumers value CPI and the use of this information. AIM: The aim of this study was to clarify the perceived value that CPI brings for consumers of healthcare. Methods Qualitative research using six focus group interviews. Twenty-seven healthcare consumers were recruited using a mailing list and by personal invitation. Data from focus group interviews were transcribed and thematic analysis undertaken. RESULTS: Most participants were unaware of CPI, and valued alternative sources of information more than CPI. Through discussion with other consumers and by means of examples of CPI, respondents were able to express the values and perceived effects of CPI. Numerous underlying values hindered consumers' use of CPI, and therefore clarification of consumer values gave insights into the current non-usage of CPI. CONCLUSIONS: CPI is marginally valued, partly because of conflicting values expressed by consumers and, as such, it does not yet provide a useful information source on hospital choice beyond consumers' current selection routines in healthcare. Future research should be more focused on the values of consumers and their impact on the use of CPI.

Precision of individual and composite performance scores: the ideal number of indicators in an indicator set.

BACKGROUND: In many countries, quality indicators are used to assess the quality of care of family practice. Such assessments need to have an adequate precision, so that the results can be interpreted correctly. However, a small sample size per practitioner can lead to inadequate precision. A possible solution could be to create composite performance scores. OBJECTIVES: To evaluate the relationship between sample size and precision. We examine whether a composite performance score has an increased precision and how many indicators are needed minimally to achieve this level of precision. RESEARCH DESIGN: We performed a descriptive statistical study on data from the medical records of 455 Dutch practices. We included 3 different conditions: diabetes (12 indicators), chronic obstructive pulmonary disease (4 indicators), and Cardiovascular Disease and Risk Management (9 indicators). RESULTS: For individual quality indicators, patient samples close to 100 are required to achieve even moderate precision (10 percentage points) on the performance scores. This number decreases substantially when a composite score is used. A composite derived from combining 5 to 7 indicators can provide much the same precision of measurement as one made up from a much larger number of indicators. CONCLUSIONS: The added value of a composite score depends on the a priori reasons for measuring quality. Our results indicate that especially for formative quality improvement a small number of carefully selected indicators can provide a sufficiently precise composite measure.

Healthcare professionals' perspectives on implementation of universal tumor DNA testing in ovarian cancer patients: multidisciplinary focus groups.

Universal tumor DNA testing in epithelial ovarian cancer patients can function not only as an efficient prescreen for hereditary cancer testing, but may also guide treatment choices. This innovation, introduced as Tumor-First workflow, offers great opportunities, but ensuring optimal multidisciplinary collaboration is a challenge. We investigated factors that were relevant and important for large-scale implementation. In three multidisciplinary online focus groups, healthcare professionals (gynecologic oncologists, pathologists, clinical geneticists, and clinical laboratory specialists) were interviewed on factors critical for the implementation of the Tumor-First workflow. Recordings were transcribed for analysis in Atlas.ti according to the framework of Flottorp that categorizes seven implementation domains. Healthcare professionals from all disciplines endorse implementation of the Tumor-First workflow, but more detailed standardization and advice regarding the logistics of the workflow were needed. Healthcare professionals explored ways to stay informed about the different phases of the workflow and the results. They emphasized the importance of including all epithelial ovarian cancer patients in the workflow and monitoring this inclusion. Overall, healthcare professionals would appreciate supporting material for the implementation of the Tumor-First workflow in the daily work routine. Focus group discussions have revealed factors for developing a tailored implementation strategy for the Tumor-First workflow in order to optimize care for epithelial ovarian cancer patients. Future innovations affecting multidisciplinary oncology teams including clinical geneticists can benefit from the lessons learned.

Uniform Registration Agreements on Cholesteatoma Care: A Nationwide Consensus Procedure.

BACKGROUND: To coordinate and align the content for registration of cholesteatoma care. METHODS: Systematic Delphi consensus procedure, consisting three rounds: two written sessions followed by a face-to-face meeting. Before this procedure, input on important patient outcomes was obtained. Consensus was defined as at least 80% agreement by participants. Hundred-thirty-six adult patients who had undergone cholesteatoma surgery and all ENT surgeons of the Dutch ENT Society were invited. The consensus rounds were attended by ENT surgeons with cholesteatoma surgery experience. Feasibility and acceptability of outcome measures and reporting agreements were assessed in round 1 by 150 ENT surgeons. In round 2 definitions were narrowed and context information to interpret outcome measure were questioned. In round 3, the results, amendments, and the open-ended points were discussed to reach agreement. RESULTS: Most important outcome measures are: 1) the presence or absence of a cholesteatoma in the first 5 years after surgical removal of cholesteatoma, 2) hearing level after surgical removal of cholesteatoma, and 3) the documented assessment of patient's complaints with a validated patient reported outcome measures questionnaire (PROM). Furthermore, consensus was reached on the registration of cholesteatoma type (residual/recurrent), localization of cholesteatoma, and reporting of the presence of cholesteatoma in the follow-up. CONCLUSION: Consensus was reached on the content and method of registration of cholesteatoma care based on patient's and ENT surgeons input. Three outcome measures were defined. National agreements on the method and content of registration will facilitate monitoring and feedback to the ENT surgeon about the cholesteatoma care.

Labour intensity of guidelines may have a greater effect on adherence than GPs' workload.

BACKGROUND: Physicians' heavy workload is often thought to jeopardise the quality of care and to be a barrier to improving quality. The relationship between these has, however, rarely been investigated. In this study quality of care is defined as care 'in accordance with professional guidelines'. In this study we investigated whether GPs with a higher workload adhere less to guidelines than those with a lower workload and whether guideline recommendations that require a greater time investment are less adhered to than those that can save time. METHODS: Data were used from the Second Dutch National survey of General Practice (DNSGP-2). This nationwide study was carried out between April 2000 and January 2002.A multilevel logistic-regression analysis was conducted of 170,677 decisions made by GPs, referring to 41 Guideline Adherence Indicators (GAIs), which were derived from 32 different guidelines. Data were used from 130 GPs, working in 83 practices with 98,577 patients. GP-characteristics as well as guideline characteristics were used as independent variables. Measures include workload (number of contacts), hours spent on continuing medical education, satisfaction with available time, practice characteristics and patient characteristics. Outcome measure is an indicator score, which is 1 when a decision is in accordance with professional guidelines or 0 when the decision deviates from guidelines. RESULTS: On average, 66% of the decisions GPs made were in accordance with guidelines. No relationship was found between the objective workload of GPs and their adherence to guidelines. Subjective workload (measured on a five point scale) was negatively related to guideline adherence (OR = 0.95). After controlling for all other variables, the variation between GPs in adherence to guideline recommendations showed a range of less than 10%.84% of the variation in guideline adherence was located at the GAI-level. Which means that the differences in adherence levels between guidelines are much larger than differences between GPs. Guideline recommendations that require an extra time investment during the same consultation are significantly less adhered to: (OR = 0.46), while those that can save time have much higher adherence levels: OR = 1.55). Recommendations that reduce the likelihood of a follow-up consultation for the same problem are also more often adhered to compared to those that have no influence on this (OR = 3.13). CONCLUSION: No significant relationship was found between the objective workload of GPs and adherence to guidelines. However, guideline recommendations that require an extra time investment are significantly less well adhered to while those that can save time are significantly more often adhered to.

The differences between three performance measures on dental restorations, clinical success, survival and failure: A matter of perspective.

OBJECTIVES: The aim of this retrospective methodology study was to investigate the influence of using different definitions for restoration failure and inclusion criteria on restoration longevity expressed in AFR. METHODS: EPF from fifteen general dental practices were used for collecting the data for this study. From the EPF, 321,749 composite restorations placed in 52,245 patients by forty-seven GDPs between January 2000 and December 2011 were included. Kaplan-Meier statistics were applied and mean AFRs over 2, 5 and 10 years were calculated. The effect on the AFR of using different levels of failure: based on Claims data (CD), Success (SUC), Survival (SUR) and different inclusion criteria of tooth/restoration variables were reported. RESULTS: Highest AFRs were found for level CD, in which every intervention was considered as failure, and the lowest AFRs for level SUR in which repairs and an endodontic treatments were not considered as a failure. AFRs increased when the observation period prolonged especially for SUR, followed by SUC and CD. An overview of long-term survival studies showed a wide variation in study design, performed clinical examination (USPHS criteria or GDP), number of restorations included, description of restoration failure and found AFRs for CD, SUC and SUR. SIGNIFICANCE: Using failure criteria, Success and Survival, in future clinical studies would enable a better comparison of studies as well as demonstrate the impact of more conservative restorative intervention protocols on patient care.

An overview of patients' preference for, and satisfaction with, care provided by general practitioners and nurse practitioners.

AIM AND OBJECTIVES: To assess patients' views on the care provided by nurse practitioners compared with that provided by general practitioners and to determine factors influencing these views. BACKGROUND: Many countries have sought to shift aspects of primary care provision from doctors to nurses. It is unclear how patients view these skill mix changes. DESIGN: Cross-sectional survey. METHOD: Patients (n = 235) who received care from both nurse and doctor were sent a self-administered questionnaire. The main outcome measures were patient preferences, satisfaction with the nurses and doctors and factors influencing patients' preference and satisfaction. RESULTS: Patients preferred the doctor for medical aspects of care, whereas for educational and routine aspects of care half of the patients preferred the nurse or had no preference for either the nurse or doctor. Patients were generally very satisfied with both nurse and doctor. Patients were significantly more satisfied with the nurse for those aspects of care related to the support provided to patients and families and to the time made available to patients. However, variations in preference and satisfaction were mostly attributable to variation in individual patient characteristics, not doctor, nurse or practice characteristics. CONCLUSION: Patient preference for nurse or doctor and patient satisfaction both vary with the type of care required and reflect usual work demarcations between nurses and doctors. In general, patients are very satisfied with the care they receive. RELEVANCE TO CLINICAL PRACTICE: In many countries, different aspects of primary care provision have shifted from doctors to nurses. Our study suggests that these skill mix changes meet the needs of patients and that patients are very satisfied with the care they receive. However, to implement skill mix change in general practice it is important to consider usual work demarcations between nurses and doctors.

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

BACKGROUND: Optimal clinical management of childhood urinary tract infections (UTI) potentiates long-term positive health effects. Insight into the quality of care in Dutch family practices for UTIs was limited, particularly regarding observation periods of more than a year. Our aim was to describe the clinical management of young children's UTIs in Dutch primary care and to compare this to the national guideline recommendations. METHODS: In this cohort study, all 0 to 6-year-old children with a diagnosed UTI in 2001 were identified within the Netherlands Information Network of General Practitioners (LINH), which comprises 120 practices. From the Dutch guideline on urinary tract infections, seven indicators were derived, on prescription, follow-up, and referral. RESULTS: Of the 284 children with UTI who could be followed for three years, 183 (64%) were registered to have had one cystitis episode, 52 (18%) had two episodes, and 43 (15%) had three or more episodes. Another six children were registered to have had one or two episodes of acute pyelonephritis. Overall, antibiotics were prescribed for 66% of the children having had < or = 3 cystitis episodes, two-thirds of whom received the antibiotics of first choice. About 30% of all episodes were followed up in general practice. Thirty-eight children were referred (14%), mostly to a paediatrician (76%). Less than one-third of the children who should have been referred was actually referred. CONCLUSION: Treatment of childhood UTIs in Dutch family practice should be improved with respect to prescription, follow-up, and referral. Quality improvement should address the low incidence of urinary tract infections in children in family practice.