The influence of government policies on the nurse practitioner and physician assistant workforce in the Netherlands, 2000-2022: a multimethod approach study.

BACKGROUND: Many countries are looking for ways to increase nurse practitioner (NP) and physician assistant/associate (PA) deployment. Countries are seeking to tackle the pressing issues of increasing healthcare demand, healthcare costs, and medical doctor shortages. This article provides insights into the potential impact of various policy measures on NP/PA workforce development in the Netherlands. METHODS: We applied a multimethod approach study using three methods: 1) a review of government policies, 2) surveys on NP/PA workforce characteristics, and 3) surveys on intake in NP/PA training programs. RESULTS: Until 2012, the annual intake into NP and PA training programs was comparable to the number of subsidized training places. In 2012, a 131% increase in intake coincided with extending the legal scope of practice of NPs and PAs and substantially increasing subsidized NP/PA training places. However, in 2013, the intake of NP and PA trainees decreased by 23% and 24%, respectively. The intake decreased in hospitals, (nursing) home care, and mental healthcare, coinciding with fiscal austerity in these sectors. We found that other policies, such as legal acknowledgment, reimbursement, and funding platforms and research, do not consistently coincide with NP/PA training and employment trends. The ratios of NPs and PAs to medical doctors increased substantially in all healthcare sectors from 3.5 and 1.0 per 100 full-time equivalents in medical doctors in 2012 to 11.0 and 3.9 in 2022, respectively. For NPs, the ratios vary between 2.5 per 100 full-time equivalents in medical doctors in primary care and 41.9 in mental healthcare. PA-medical doctor ratios range from 1.6 per 100 full-time equivalents in medical doctors in primary care to 5.8 in hospital care. CONCLUSIONS: This study reveals that specific policies coincided with NP and PA workforce growth. Sudden and severe fiscal austerity coincided with declining NP/PA training intake. Furthermore, governmental training subsidies coincided and were likely associated with NP/PA workforce growth. Other policy measures did not consistently coincide with trends in intake in NP/PA training or employment. The role of extending the scope of practice remains to be determined. The skill mix is shifting toward an increasing share of medical care provided by NPs and PAs in all healthcare sectors.

Facilitators for developing an interprofessional learning culture in nursing homes: a scoping review.

BACKGROUND: Healthcare professionals in nursing homes face complex care demands and nursing staff shortages. As a result, nursing homes are transforming into home-like personalised facilities that deliver person-centred care. These challenges and changes require an interprofessional learning culture in nursing homes, but there is little understanding of the facilitators that contribute to developing such a culture. This scoping review aims to identify those facilitators. METHODS: A scoping review was performed in accordance with the JBI Manual for Evidence Synthesis (2020). The search was carried out in 2020-2021 in seven international databases (PubMed, Cochrane Library, CINAHL, Medline, Embase, PsycINFO and Web of Science). Two researchers independently extracted reported facilitators that contribute to an interprofessional learning culture in nursing homes. Then the researchers inductively clustered the extracted facilitators into categories. RESULTS: In total, 5,747 studies were identified. After removing duplicates and screening titles, abstracts and full texts, 13 studies that matched the inclusion criteria were included in this scoping review. We identified 40 facilitators and clustered them into eight categories: (1) shared language, (2) shared goals, (3) clear tasks and responsibilities, (4) learning and sharing knowledge, (5) work approaches, (6) facilitating and supporting change and creativity by the frontline manager, (7) an open attitude, and (8) a safe, respectful and transparent environment. CONCLUSION: We found facilitators that could be used to discuss the current interprofessional learning culture in nursing homes and identify where improvements are required. Further research is needed to discover how to operationalise facilitators that develop an interprofessional learning culture in nursing homes and to gain insights into what works, for whom, to what extent and in what context.

Perceptions of interprofessional collaboration in education of dentists and dental hygienists and the impact on dental practice in the Netherlands: A qualitative study.

INTRODUCTION: The purpose of this study was to evaluate the perceptions of dentists and dental hygienists regarding their own and each other's roles in interprofessional collaboration following a clinical interprofessional educational programme (CIEP) as part of their graduate programme at Radboud university medical center (Radboudumc) and HAN University of Applied Sciences (HAN UAS), Nijmegen, the Netherlands, respectively. Perceptions were obtained at the end of their study (2014) and two years after their graduation (2016). METHODS: A qualitative study was conducted using a questionnaire with open-ended questions. Sixty-two dentists and thirty-eight dental hygienists were invited. Theory-based analyses were applied in combination with principles of Grounded Theory to analyse and synthesise the collected data from the open-ended questions. RESULTS: At baseline, 100% responded. At follow-up, thirty-two dentists (51.6%) and twenty-six dental hygienists (68.4%) responded; twenty-seven dentists (43.5%) and eighteen dental hygienists (47.4%) were included. Many similarities were found between baseline and follow-up regarding perceptions of each other's expertise and responsibility, learning from and with each other, and the behaviour of students and the "novice" professionals in interprofessional collaboration. Both dentists and dental hygienists experienced the CIEP as useful for interprofessional collaboration. The "novice" dentists and dental hygienists indicated that in dental practices interprofessional collaboration was less common. CONCLUSION: The CIEP resulted in more understanding amongst dentists and dental hygienists with regard to interprofessional roles, but in practice the "novice" dentists and dental hygienists face difficulties in applying the interprofessional roles.

Skill mix change between physicians, nurse practitioners, physician assistants, and nurses in nursing homes: A qualitative study.

Nursing home physicians face heavy workloads, because of the aging population and rising number of older adults with one or more chronic diseases. Skill mix change, in which professionals perform tasks previously reserved for physicians independently or under supervision, could be an answer to this challenge. The aim of this study was to describe how skill mix change in nursing homes is organized from four monodisciplinary perspectives and the interdisciplinary perspective, what influences it, and what its effects are. The study focused particularly on skill mix change through the substitution of nurse practitioners, physician assistants, or registered nurses for nursing home physicians. Five focus group interviews were conducted in the Netherlands. Variation in tasks and responsibilities was found. Despite this variation, stakeholders reported increased quality of health care, patient centeredness, and support for care teams. A clear vision on skill mix change, acceptance of nurse practitioners, physician assistants, and registered nurses, and a reduction of legal insecurity are needed that might maximize the added value of nurse practitioners, physician assistants, and registered nurses.

Skill mix change between general practitioners, nurse practitioners, physician assistants and nurses in primary healthcare for older people: a qualitative study.

BACKGROUND: More and more older adults desire to and are enabled to grow old in their own home, regardless of their physical and mental capabilities. This change, together with the growing number of older adults, increases the demand for general practitioners (GPs). However, care for older people lacks prestige among medical students and few medical students are interested in a career in care for older people. Innovative solutions are needed to reduce the demand for GPs, to guarantee quality of healthcare and to contain costs. A solution might be found in skill mix change by introducing nurse practitioners (NPs), physician assistants (PAs) or registered nurses (RNs). The aim of this study was to describe how skill mix change is organised in daily practice, what influences it and what the effects are of introducing NPs, PAs or RNs into primary healthcare for older people. METHODS: In total, 34 care providers working in primary healthcare in the Netherlands were interviewed: GPs (n = 9), NPs (n = 10), PAs (n = 5) and RNs (n = 10). Five focus groups and 14 individual interviews were conducted. Analysis consisted of open coding, creating categories and abstraction. RESULTS: In most cases, healthcare for older people was only a small part of the tasks of NPs, PAs and RNs; they did not solely focus on older people. The tasks they performed and their responsibilities in healthcare for older people differed between, as well as within, professions. Although the interviewees debated the usefulness of proactive structural screening on frailty in the older population, when implemented, it was also unclear who should perform the geriatric assessment. Interviewees considered NPs, PAs and RNs an added value, and it was stated that the role of the GP changed with the introduction of NPs, PAs or RNs. CONCLUSIONS: The roles and responsibilities of NPs, PAs and RNs for the care of older people living at home are still not established. Nonetheless, these examples show the potential of these professionals. The establishment of a clear vision on primary healthcare for older people, including the organisation of proactive healthcare, is necessary to optimise the impact of skill mix change.

Effects of substituting nurse practitioners, physician assistants or nurses for physicians concerning healthcare for the ageing population: a systematic literature review.

AIMS: To evaluate the effects of substituting nurse practitioners, physician assistants or nurses for physicians in long-term care facilities and primary healthcare for the ageing population (primary aim) and to describe what influences the implementation (secondary aim). BACKGROUND: Healthcare for the ageing population is undergoing major changes and physicians face heavy workloads. A solution to guarantee quality and contain costs might be to substitute nurse practitioners, physician assistants or nurses for physicians. DESIGN: A systematic literature review. DATA SOURCES: PubMed, EMBASE, CINAHL, PsycINFO, CENTRAL, Web of Science; searched January 1995-August 2015. REVIEW METHODS: Study selection, data extraction and quality appraisal were conducted independently by two reviewers. Outcomes collected: patient outcomes, care provider outcomes, process of care outcomes, resource use outcomes, costs and descriptions of the implementation. Data synthesis consisted of a narrative summary. RESULTS: Two studies used a randomized design and eight studies used other comparative designs. The evidence of the two randomized controlled trials showed no effect on approximately half of the outcomes and a positive effect on the other half of the outcomes. Results of eight other comparative study designs point towards the same direction. The implementation was influenced by factors on a social, organizational and individual level. CONCLUSION: Physician substitution in healthcare for the ageing population may achieve at least as good patient outcomes and process of care outcomes compared with care provided by physicians. Evidence about resource use and costs is too limited to draw conclusions.

Cost-effectiveness of a nurse-led intervention to optimise implementation of guideline-concordant continence care: Study protocol of the COCON study.

BACKGROUND: Guidelines on urinary incontinence recommend that absorbent products are only used as a coping strategy pending definitive treatment, as an adjunct to ongoing therapy, or for long-term management after all treatment options have been explored. However, these criteria are rarely met and a significant share of long-term product users could still benefit from therapeutic interventions recommended in guidelines for urinary incontinence. Better implementation of these guidelines can potentially result in both health benefits for women and long-term cost savings for society. The aim of the COCON study is to evaluate the (cost-)effectiveness of a nurse-led intervention to optimise implementation of guideline-concordant continence care in comparison with usual care for urinary incontinent women aged 55 years and over who use absorbent products. METHODS: This randomised clinical trial compares usual care with a nurse-led intervention to optimise implementation of guideline-concordant continence care. Women (anticipated N = 160) are recruited in 12 community pharmacies in three Dutch regions, and are eligible for trial entry when they are 55 years and over, community-dwelling and long-term users of absorbent products (≥4 months) reimbursed by health insurance. Measurements are administered at baseline, 3, 6 and 12 months. Primary outcome is severity of urinary incontinence (ICIQ-UI SF); other outcomes include health related quality of life (EQ-5D-5 L), use of absorbent products (in accordance with the recommended criteria in guidelines) (yes/no), and societal costs. Mixed model analysis will be performed to compare (the course) of outcomes between groups. The economic evaluation will be performed from a societal perspective. The implementation process is investigated using the Tailored Implementation for Chronic Diseases (TICD) framework. DISCUSSION: Results will add to current knowledge of the (cost-)effectiveness of nurse-led primary healthcare to improve guideline-concordant care for older women with urinary incontinence. In addition, the results will provide more insight into care needs and health service utilization of this group of women, as well as into use of absorbent products in accordance with the recommended criteria in guidelines. Finally, results will increase our understanding of the intervention's uptake and could provide useful insights for future dissemination and sustenance. TRIAL REGISTRATION: Dutch Trial Register NTR4396, registered 13-January-2014.

Are gynaecological and pregnancy-associated conditions in family practice indicators of intimate partner violence?

BACKGROUND: Some gynaecological and pregnancy-associated conditions are more common in abused women than in non-abused women, but this has not been examined in family practice. OBJECTIVE: We aimed to investigate intimate partner violence (IPV) prevalence in family practice and to investigate whether gynaecological and pregnancy-associated conditions are more common in abused women than in non-abused women. METHODS: We conducted a cross-sectional waiting room survey in 12 family practices in the Netherlands in 2012. Women were eligible if they were of 18 years or older. Questionnaires measured IPV and gynaecological and pregnancy-associated conditions. Chi-square tests were used to assess the differences in gynaecological and pregnancy-associated conditions between abused women and non-abused women. RESULTS: The response rate was 86% (262 of 306 women). The past-year prevalence of IPV in women who had had an intimate relationship in the past year and were not accompanied by their partner was 8.7% (n = 195). Lifetime prevalence of women who had ever had an intimate relationship, but not in the past year, was 17.6% (n = 51). Sexually transmitted infections (STIs) [odds ratio (OR) = 4.6, 95% confidence interval [CI] = 1.7-12.5, n = 240], menstrual disorders (OR = 3.7, 95% CI = 1.2-11.2, n = 143), sexual problems (OR = 3.3, 95% CI = 1.2-9.3, n = 229), miscarriages (OR = 2.5, 95% CI = 1.062-5.8, n = 202) and induced abortions (OR = 2.7, 95% CI = 1.028-7.3, n = 202) were significantly more common in abused women than in non-abused women. CONCLUSION: Family physicians should ask about IPV when women present with STIs, menstrual disorders, sexual problems, miscarriages or induced abortions. To improve the recognition of IPV, future research needs to investigate whether a combination of symptoms offers improved prediction of IPV.

Professional's Attitudes Do Not Influence Screening and Brief Interventions Rates for Hazardous and Harmful Drinkers: Results from ODHIN Study.

AIMS: To determine the relation between existing levels of alcohol screening and brief intervention rates in five European jurisdictions and role security and therapeutic commitment by the participating primary healthcare professionals. METHODS: Health care professionals consisting of, 409 GPs, 282 nurses and 55 other staff including psychologists, social workers and nurse aids from 120 primary health care centres participated in a cross-sectional 4-week survey. The participants registered all screening and brief intervention activities as part of their normal routine. The participants also completed the Shortened Alcohol and Alcohol Problems Perception Questionnaire (SAAPPQ), which measure role security and therapeutic commitment. RESULTS: The only significant but small relationship was found between role security and screening rate in a multilevel logistic regression analysis adjusted for occupation of the provider, number of eligible patients and the random effects of jurisdictions and primary health care units (PHCU). No significant relationship was found between role security and brief intervention rate nor between therapeutic commitment and screening rate/brief intervention rate. The proportion of patients screened varied across jurisdictions between 2 and 10%. CONCLUSION: The findings show that the studied factors (role security and therapeutic commitment) are not of great importance for alcohol screening and BI rates. Given the fact that screening and brief intervention implementation rate has not changed much in the last decade in spite of increased policy emphasis, training initiatives and more research being published, this raises a question about what else is needed to enhance implementation.

Pulling out all the stops: what motivates 65+ year olds with depressive symptoms to participate in an outreaching preference-led intervention programme?

OBJECTIVES: Many older adults have significant depressive symptoms but few people access care for these. This study explores which personal, clinical and need factors facilitate or hinder acceptance of a new outreaching preference-led intervention programme. METHODS: From a sample of 9661 community-dwelling 65+ year olds, 244 persons with depressive symptoms according to the Patient Health Questionnaire-9 were included. Data on programme effectiveness in terms of care utilisation were collected. Associations between programme acceptance and personal, clinical and need factors were studied using quantitative (logistic regression analyses) and qualitative methods (semi-structured interviews with 26 subjects, who accepted (n = 20) or declined (n = 6) the programme). RESULTS: Fifty-six per cent (n = 137) took part in the interventions. Quantitative logistic regression analyses showed that participants were more often female, suffered from more severe depressive symptoms and perceived more loneliness. Qualitative analyses revealed that people accepting the intervention programme felt that medical terms as having a depressed mood were applicable to their situation, more often perceived their symptoms as hindering, felt lonely and more often perceived a need for care. They were more often advised by their general practitioner to participate than individuals who refused the interventions. Many participating individuals did not see a match between the intervention programme and their needs, especially with respect to meeting new people. CONCLUSION: Many older persons with depressive symptoms did not feel the need to take part in the programme. Providing support in alleviating loneliness and further adaptation to older adults' illness representations and perceptions when discussing depressive symptoms might enhance care utilisation.

Physician substitution by mid-level providers in primary healthcare for older people and long-term care facilities: protocol for a systematic literature review.

AIM: This protocol describes a systematic review that evaluates the effects of physician substitution by mid-level providers (nurse practitioners, physician assistants or nurses) in primary healthcare for older people and long-term care facilities. The secondary aim is to describe facilitators and barriers to the implementation of physician substitution in these settings. BACKGROUND: Healthcare for older people is undergoing major changes, due to population ageing and reforms that shift care to the community. Besides, relatively few medical students are pursuing careers in healthcare for older people. Innovative solutions are needed to guarantee the quality of healthcare and to contain costs. A solution might be shifting care from physicians to mid-level providers. To date, no systematic review on this topic exits to guide policymaking. DESIGN: A quantitative systematic literature review using Cochrane methods. METHODS: The following databases will be searched for original research studies that quantitatively compare care provided by a physician to the same care provided by a mid-level provider: PubMed, EMBASE, CINAHL, PsycINFO, CENTRAL and Web of Science. Study selection, data extraction and quality appraisal will be conducted independently by two reviewers. Data synthesis will consist of a qualitative analysis of the data. Funding of the review was confirmed in August 2013 by the Ministry of Health, Welfare and Sport of the Netherlands. DISCUSSION: This review will contribute to the knowledge on effects of physician substitution in healthcare for older people and factors that influence the outcomes. This knowledge will guide professionals and policy administrators in their decisions to optimize healthcare for older people.

The effectiveness of substitution of hospital ward care from medical doctors to physician assistants: a study protocol.

BACKGROUND: Because of an expected shrinking supply of medical doctors for hospitalist posts, an increased emphasis on efficiency and continuity of care, and the standardization of many medical procedures, the role of hospitalist is increasingly allocated to physician assistants (PAs). PAs are nonphysician clinicians with medical tasks. This study aims to evaluate the effects of substitution of hospital ward care to PAs. METHODS/DESIGN: In a multicenter matched controlled study, the traditional model in which the role of hospitalist is taken solely by medical doctors (MD model) is compared with a mixed model in which a PA functions as a hospitalist, contingent with MDs (PA/MD model). Twenty intervention and twenty control wards are included across The Netherlands, from a range of medical specialisms. Primary outcome measure is patients' length of hospital stay. Secondary outcomes include indicators for quality of hospital ward care, patients experiences with medical ward care, patients health-related quality of life, and healthcare providers' experiences. An economic evaluation is conducted to assess the cost implications and potential efficiency of the PA/MD model. For most measures, data is collected from medical records or questionnaires in samples of 115 patients per hospital ward. Semi-structured interviews with healthcare professionals are conducted to identify determinants of efficiency, quality and continuity of care and barriers and facilitators for the implementation of PAs in the role of hospitalist. DISCUSSION: Findings from this study will help to further define the role of nonphysician clinicians and provides possible key components for the implementation of PAs in hospital ward care. Like in many studies of organizational change, random allocation to study arms is not feasible, which implies an increased risk for confounding. A major challenge is to deal with the heterogeneity of patients and hospital departments.

The psychiatric-mental health nurse practitioner as coordinating practitioner in the Netherlands: A multiple case study.

BACKGROUND: Psychiatric-mental health nurse practitioners (PMHNPs) in the Netherlands have been allowed to perform the role of coordinating practitioner (CP) since 2018. This role is reserved for mental health care specialists who are trained and qualified at the master's degree level. Earlier studies have not addressed how PMHNPs perform that role and what mechanisms and contextual factors determine their performance. This understanding could help optimize their performance in this role and promote effective deployment of PMHNPs in mental health care. PURPOSE: To understand how PMHNPs perform this role and what mechanisms and contextual factors underlie that performance. METHODOLOGY: A multiple case study involving PMHNPs who work in various settings as CPs. Data were collected and analyzed using the realistic evaluation approach. RESULTS: We identified four mechanisms related to the performance of PMHNPs in the role of CP: (1) autonomous performance; (2) unique expertise; (3) accessibility, availability, and professional involvement; and (4) additional roles. The extent to which these mechanisms are present is largely determined by organizational factors, team factors, and individual factors. CONCLUSIONS: Psychiatric-mental health nurse practitioners are seeking to identify and interpret the role of CP. This study helps to elucidate the mechanism of role performance by PMHNPs and what they should focus on to deliver effective and patient-centered mental health care. IMPLICATIONS: Policymakers, health care professionals, and educators should consider the mechanisms and contextual factors to facilitate and support PMHNPs' employment and training in the role of CP.

Developing an Evidence-Based Nursing Culture in Nursing Homes: An Action Research Study.

Background: Nursing homes face challenges caused by increasing numbers of older adults with multimorbidity and the demand for quality of care. Developing an evidence-based nursing (EBN) culture is a promising strategy to face these challenges. Therefore, the aim of this study was to develop an EBN culture in nursing homes and gain insight into the influencing factors. Methods: An action research study was conducted with 12 nursing teams in 4 Dutch nursing homes, using the Practice Development approach to develop an EBN culture. The teams (mostly certified nurse assistants) were coached by internal facilitators (bachelor's or master's degree nurses) and external facilitators (nursing teachers). Data were gathered at baseline and after 15 months using questionnaires and individual and focus group interviews. Results: With varying degrees, most nursing teams implemented elements (related to values, attitudes, and behaviors) of an EBN culture with appropriate leadership, advocacy, and training. The team members became open to new insights and asked critical questions. During the project, participants learned how EBN could be incorporated into daily practice, for example, by keeping it small, discussing information from professional journals, and using creative methods such as quizzes. Influencing factors of an EBN culture were: (a) support of managers, (b) inspiring facilitators close to the team, and (c) stable teams with driving forces and student nurses. Conclusions: Integrating EBN into daily practice in creative and motivating ways contributes to the development of an EBN culture in nursing homes. To facilitate this, managers should support teams in the process and content of EBN, and internal facilitators should collaborate with driving forces on the teams.

Developing an interprofessional learning and working culture to improve person-centred care in nursing homes: a realist action research protocol.

INTRODUCTION: Healthcare is changing due to the ageing of the general population, complex care demands and growing attention to person-centred care. To deal with these changes and provide the best possible person-centred care, the different professionals in nursing homes should all collaborate intensively. However, most professionals work within the field of their own expertise and share very little knowledge, experiences and insights. A lack of an interprofessional learning and working culture also prevents professionals with different expertise from working and learning intensively together to achieve high-quality person-centred care. There is a gap of knowledge about how to develop such a culture. Our aim is to provide insights into what actions, in what context and to what extent can contribute to an impactful development of an interprofessional learning and working culture. METHODS AND ANALYSIS: The realist action research design will be applied. It consists of three iterative steps: plan, act and observe, and reflect. First, we will formulate the theory about interprofessional learning and working culture and measure this culture by means of interviews, focus groups and questionnaires. Second, we will apply the nine principles of Practice Development to coach professionals from six Dutch nursing homes to improve their interprofessional learning and working culture. Finally, we will evaluate the impact of the changed attitudes and skills on healthcare practice. ETHICS AND DISSEMINATION: Approval for the project was given by the Hogeschool van Arnhem en Nijmegen (HAN) Research Ethics Committee, the Netherlands, registration number EACO 164.12/19. All organisations, professionals and residents/family members will be informed verbally and by letter about the study and asked for informed consent. The results will be presented in peer-reviewed scientific journals, professional journals and at symposia and conferences. The findings will be transferred to an online toolbox and e-learning modules for graduated professionals and students.

Outcomes for depression and anxiety in primary care and details of treatment: a naturalistic longitudinal study.

BACKGROUND: There is little evidence as to whether or not guideline concordant care in general practice results in better clinical outcomes for people with anxiety and depression. This study aims to determine possible associations between guideline concordant care and clinical outcomes in general practice patients with depression and anxiety, and identify patient and treatment characteristics associated with clinical improvement. METHODS: This study forms part of the Netherlands Study of Depression and Anxiety (NESDA).Adult patients, recruited in general practice (67 GPs), were interviewed to assess DSM-IV diagnoses during baseline assessment of NESDA, and also completed questionnaires measuring symptom severity, received care, socio-demographic variables and social support both at baseline and 12 months later. The definition of guideline adherence was based on an algorithm on care received. Information on guideline adherence was obtained from GP medical records. RESULTS: 721 patients with a current (6-month recency) anxiety or depressive disorder participated. While patients who received guideline concordant care (N=281) suffered from more severe symptoms than patients who received non-guideline concordant care (N=440), both groups showed equal improvement in their depressive or anxiety symptoms after 12 months. Patients who (still) had moderate or severe symptoms at follow-up, were more often unemployed, had smaller personal networks and more severe depressive symptoms at baseline than patients with mild symptoms at follow-up. The particular type of treatment followed made no difference to clinical outcomes. CONCLUSION: The added value of guideline concordant care could not be demonstrated in this study. Symptom severity, employment status, social support and comorbidity of anxiety and depression all play a role in poor clinical outcomes.

Patient factors associated with guideline-concordant treatment of anxiety and depression in primary care.

OBJECTIVE: To identify associations of patient characteristics (predisposing, enabling and need factors) with guideline-concordant care for anxiety and depression in primary care. DESIGN: Analysis of data from the Netherlands Study of Depression and Anxiety (NESDA). PARTICIPANTS: Seven hundred and twenty-one patients with a current anxiety or depressive disorder, recruited from 67 general practitioners (GPs), were included. MEASURES: Diagnoses according to the Diagnostic and Statistic Manual of Mental Disorders, fourth edition (DSM-IV) were made using a structured and widely validated assessment. Socio-demographic and enabling characteristics, severity of symptoms, disability, (under treatment for) chronic somatic conditions, perceived need for care, beliefs and evaluations of care were measured by questionnaires. Actual care data were derived from electronic medical records. Criteria for guideline-concordant care were based on general practice guidelines, issued by the Dutch College of General Practitioners. RESULTS: Two hundred and eighty-one (39%) patients received guideline-concordant care. High education level, accessibility of care, comorbidity of anxiety and depression, and severity and disability scores were positively associated with receiving guideline-concordant care in univariate analyses. In multivariate multi-level logistic regression models, significant associations with the clinical need factors disappeared. Positive evaluations of accessibility of care increased the chance (OR = 1.31; 95%-CI = 1.05-1.65; p = 0.02) of receiving guideline-concordant care, as well as perceiving any need for medication (OR = 2.99; 95%-CI = 1.84-4.85; p < 0.001), counseling (OR = 2.25; 95%-CI = 1.29-3.95; p = 0.005) or a referral (OR = 1.83; 95%-CI = 1.09-3.09; p = 0.02). A low educational level decreased the odds (OR = 0.33; 95%-CI = 0.11-0.98; p = 0.04) of receiving guideline-concordant care. CONCLUSIONS: This study shows that education level, accessibility of care and patients' perceived needs for care are more strongly associated with the delivery of guideline-concordant care for anxiety or depression than clinical need factors. Initiatives to improve GPs' communication skills around mental health issues, and to improve recognition of people suffering from anxiety disorders, could increase the number of patients receiving treatment for depression and anxiety in primary 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.

The effects of substitution of hospital ward care from medical doctors to physician assistants on non-adherence to guidelines on medication prescribing.

AIM: This study determined the effect of substitution of inpatient care from medical doctors (MDs) to physician assistants (PAs) on non-adherence to guidelines on medication prescribing. METHODS: A multicenter matched-controlled study was performed comparing wards on which PAs provide medical care in collaboration with MDs (PA/MD model), with wards on which only MDs provide medical care (MD model). A set of 17 quality indicators to measure non-adherence to guidelines on medication prescribing by PAs and MDs was composed by 14 experts in a modified Delphi procedure. The indicators covered different pharmacotherapeutic subjects, such as gastric protection in case of use of NSAID or prevention of obstipation in case of use of opioids. These indicators were expressed in proportions by dividing the number of patients in which the prescriber did not adhere to a guideline, by all patients that were applicable. Multivariable regression analysis was performed in order to adjust for potential confounders. RESULTS: 1021 patients from 17 hospital wards in the 'PA/MD model' group and 1286 patients from 17 hospital wards in the 'MD model' group were included. Two of the 17 quality indicators showed significantly less non-adherence to guidelines for the PA/MD model; the indicators concerning prescribing gastric protection in case of use of NSAID in combination with corticosteroids (OR 0.42, 95% CI 0.19-0.90) and in case of use of NSAID in patients older than 70 years (OR 0.47, 95% 0.23-0.95). For none of the other quality indicators for prescribing of medication a difference between the MD model and the PA/MD model was found. CONCLUSION: This study suggests that the non-adherence to guidelines on medication prescribing on wards with the PA/MD model does not differ from wards with traditional house staffing by MDs only. Further research is needed to determine quality, efficiency and safety of prescribing behavior of PAs.