[Summary of the Dutch College of General Practitioners (NHG) practice guideline on 'Diverticulitis']. / Samenvatting van de NHG-standaard 'Diverticulitis'.

The NHG practice guideline on 'Diverticulitis' provides general practitioners with directions on the diagnosis and treatment of uncomplicated and complicated diverticulitis. Diverticulitis is primarily a clinical diagnosis which can be supported by assessment of CRP. Uncomplicated diverticulitis is strongly suspected if the patient reports the development of persistent sharp, stabbing pain in the lower left abdomen within a couple of days; if there is pressure or rebound tenderness only in the lower left abdomen; and if there are no alarm signals. Alarm signals of complicated diverticulitis are: guarded muscle response, signs of intestinal obstruction, locally palpable resistance, rectal loss of blood, hypotension, and high fever. The policy for uncomplicated diverticulitis is waiting without specific measures, provided that the general practitioner monitors the course actively. There is no indication for antibiotics in patients with uncomplicated diverticulitis. Patients with signs of complicated diverticulitis or with persisting symptoms should be referred.

Patient safety in primary care has many aspects: an interview study in primary care doctors and nurses.

RATIONALE, AIMS AND OBJECTIVES: Scientific definitions of patient safety may be difficult to apply in routine health care delivery. It is unknown what primary care workers consider patient safety. This study aimed to clarify the concept of patient safety in primary care. METHODS: We held 29 semi-structured interviews with a purposeful sample of primary care doctors and nurses regarding their perceptions of patient safety. The answers were analysed in an iterative procedure with respect to common themes. RESULTS: A broad range of specific aspects of primary care were named in relation with patient safety. Medication safety was most frequently mentioned. Most items were categorized as organizational, while the remaining aspects were linked to culture or professionalism. Scientific definitions of patient safety were not mentioned, but some primary care workers gave 'do not harm the patient' as a short definition for patient safety. CONCLUSION: Patient safety programmes have mostly targeted specific issues, such as incident reporting and medication safety. However, doctors and practice nurses had a broad view of what constitutes patient safety in primary care. This has implications for the measurement and improvement of patient safety in primary care.

Harm caused by adverse events in primary care: a clinical observational study.

RATIONALE, AIMS AND OBJECTIVES: Patient safety in primary care is important, but not well studied. The aim of our study was to determine the actual and potential harm caused by adverse events in primary care. METHOD: Observational study in two general practices, including the patients of five doctors. Two methods were used to identify adverse events; (1) a prospective registration of adverse events by the general practitioner and (2) a retrospective audit of medical records. Actual harm was registered and a clinical analysis was made to estimate potential harm. RESULTS: A total of 31 adverse events were collected and analysed. The adverse events were spread over different adverse event categories. About half of the events did not have health consequences, but a third led to worsening of symptoms and a few resulted in unplanned hospital admission. Potential negative health consequences were likely in three-quarters of the events. CONCLUSIONS: The identified adverse events had some impact on health outcomes, but a risk for harm existed in a majority of the events. Patient safety programmes in primary care should focus on adverse events and not just on harm.

Mix of methods is needed to identify adverse events in general practice: a prospective observational study.

BACKGROUND: The validity and usefulness of incident reporting and other methods for identifying adverse events remains unclear. This study aimed to compare five methods in general practice. METHODS: In a prospective observational study, with five general practitioners, five methods were applied and compared. The five methods were physician reported adverse events, pharmacist reported adverse events, patients' experiences of adverse events, assessment of a random sample of medical records, and assessment of all deceased patients. RESULTS: A total of 68 events were identified using these methods. The patient survey accounted for the highest number of events and the pharmacist reports for the lowest number. No overlap between the methods was detected. The patient survey accounted for the highest number of events and the pharmacist reports for the lowest number. CONCLUSION: A mix of methods is needed to identify adverse events in general practice.

How do older patients and their GPs evaluate shared decision-making in healthcare?

BACKGROUND: Older persons represent a growing share of the population, yet very little is known about their specific healthcare needs, problems, and expectations. IMPROVE is an international research project that seeks to improve elderly persons' involvement in their healthcare. This paper analyzes perceptions of patient involvement by elderly patients and their GPs in family medicine in Slovenia. METHODS: Semi-structured interviews with patients over 70 and their GPs were audio-taped and transcribed. The interviews were analyzed using qualitative content analysis. RESULTS: Specific characteristics of old age must be taken into account in the involvement of older patients. It is important to know the patient's expectations and to communicate clearly with the patient. A trusting relationship between the GP and the patient is a prerequisite for involvement. GPs center involvement on the GP's side. Involvement of the elderly is linked to ethical dilemmas. CONCLUSION: Understanding the involvement of the elderly focuses more on building a relationship than on making decisions. It is reasonable to educate GPs and GPs' coworkers about caring relationships. Ethical aspects have often been treated in a theoretical manner, whereas empirical practice may be entirely different from theoretical premises. GPs and older patients must learn more about how to address their ethical dilemmas.

Family practice nurses supporting self-management in older patients with mild osteoarthritis: a randomized trial.

BACKGROUND: Supporting self-management intends to improve life-style, which is beneficial for patients with mild osteoarthritis (OA). We evaluated a nurse-based intervention on older OA patients' self-management with the aim to assess its effects on mobility and functioning. METHODS: Randomized controlled trial of patients (> or = 65 years) with mild hip or knee OA from nine family practices in the Netherlands. Intervention consisted of supporting patients' self-management of OA symptoms using a practice-based nurse. Outcome measures were patients' mobility, using the Timed Up and Go test (TUG), and patient reported functioning, using an arthritis specific scale (Dutch AIMS2 SF). RESULTS: Fifty-one patients were randomized to the intervention group and 53 to the control group. Patient-reported functioning improved on four scales in the intervention group compared to one scale in the control group. However, this result was not significant. Mobility improved in both groups, without a significant difference between the two groups. There were no differences between the groups regarding consultations with family physicians or physiotherapists, or medication use. CONCLUSION: A nurse-based intervention on older OA patients' self-management did not improve self-reported functioning, mobility or patients' use of health care resources.

Do elderly patients feel more enabled if they had been actively involved in primary care consultations?

OBJECTIVE: This study aimed to determine whether older patients' enablement was associated with their evaluation of the level of their involvement in primary care consultations. METHODS: Secondary analysis of data from an international cross-sectional study in seven European countries (n=625 patients). Patient enablement, preference for involvement in the consultation and evaluation of involvement in the consultation were measured with validated questionnaires. Random coefficient linear modelling was used to identify factors associated with patient enablement. RESULTS: The overall mean patient enablement score was 5.5 (theoretical range: 0-12; higher score indicated more enablement). Enablement was higher in patients who reported more positive compared to those reporting less positive evaluations of involvement (B=1.660; p<0.001). The impact of evaluation on enablement was higher in patients with a high preference for involvement compared to those with lower preference for involvement (B=0.743; p=0.015). CONCLUSION: Positive evaluations of involvement in primary care were associated with higher enablement in older patients, and even more if the patient had a high preference for involvement. PRACTICE IMPLICATIONS: Involving older patients actively may enhance their enablement, a particularly important goal for patients who have one or more chronic conditions.

Evaluation of an intervention designed to enhance involvement of older patients in their own care.

OBJECTIVE: To implement a programme for involvement of older patients aged 70+ in general practice, and to detect quality changes after its implementation. METHODS: The study was performed in 11 European countries as an uncontrolled before-and-after study, in which a number of GPs and patients answered a questionnaire before and after receiving an intervention. The intervention was aimed at motivating, instructing and facilitating GPs and older patients to increase patient involvement during consultation by use of a specially designed consultation leaflet. RESULTS: Valid data from seven countries exist. There was a total of 765 patients and 70 GPs in the pre-intervention phase, and 564 patients and 49 GPs in the post-intervention phase. In the post-intervention group, 43% of the patients thought that the consultation leaflet had improved the consultation and 62% of the GPs found it to be useful. There were no significant differences between pre- and post-intervention patient perceptions of the level of involvement, evaluations of consultations and perceptions of feeling enabled to deal with their health situation. CONCLUSION: Quality of consultations as measured by patient satisfaction and patient enablement did not improve as a result of the intervention, but nearly half of the patients and two thirds of the GPs found the intervention to be useful. Unselected use of this intervention on all patients cannot be advised without further studies on possible effects. Future studies should focus on the applicability and benefits of the methods for special patient groups.

A consultation leaflet to improve an older patient's involvement in general practice care: a randomized trial.

OBJECTIVE: To evaluate the effects of a programme to enhance the involvement of older patients in their consultations in general practice. DESIGN: Cluster randomized trial, in which data was collected from different cohorts. SETTING AND PARTICIPANTS: Twenty-five general practices in the south-east part of the Netherlands and their patients aged 70 years and over. INTERVENTION: Patients in the intervention group received a leaflet to help them prepare for the consultation. General practitioners (GPs) received an outreach visit to optimize older patients' involvement when visiting their GP. Patients in the control group received usual care. MAIN OUTCOME MEASURES: Questionnaires measuring involvement (COMRADE), enablement (Patient Enablement Index) and satisfaction with their care (EUROPEP). RESULTS: Pre-intervention 315 patients and post-intervention 263 patients were included. Subjects were satisfied with their involvement and the GP's behaviour during the consultation. No differences in effect as a result of the leaflet on involvement, enablement or satisfaction were found between the intervention and the control group. Of 318 patients who received the leaflet and visited their GP in the intervention period, 47 patients used the leaflet. These users were more accustomed to prepare themselves for consultations. Users reported more psychological problems than non-users. CONCLUSIONS: No relevant effects of the implementation programme on involvement, enablement or satisfaction were found. Other strategies are needed to enhance involvement of older patients in their care. Alternatively, older patients may perceive themselves sufficiently involved.

Elderly patients' and GPs' views on different methods for patient involvement: an international qualitative interview study.

BACKGROUND: Elderly patients' interaction with the GP may be improved through patient involvement techniques, and there is a variety of such techniques which improve patients' involvement in their own care, although little is known about their acceptability. OBJECTIVES: The aim of this study was to identify barriers and facilitators for using patient information leaflets and patient satisfaction questionnaires as methods for increasing elderly patients' involvement in general practice care by comparing their views with the GPs' views on these two types of methods. METHODS: In seven countries (Austria, Denmark, Germany, The Netherlands, Portugal, Slovenia and Switzerland) 146 GPs and 284 patients aged 70 and over were interviewed about the use and the acceptability of these two methods. Interviewers followed a semi-structured interview guide, and all interviews were tape-recorded and transcribed verbatim. RESULTS: The arguments for using patient satisfaction questionnaires were that they would provide the GP with more information, function as a basis for change, increase patients' self-confidence and make them more conscious of what to expect. Barriers for their use were cognitive impairment among patients, fear that they would not answer honestly and opposition to written material. The arguments for patient information leaflets were that they could support patients' memories, educate patients and promote their self-responsibility. The barriers were cognitive impairment among patients and fear that they would give them false impressions of what to expect. CONCLUSION: Both instruments were generally well accepted by both GPs and patients. Their use seemed to be dependent upon the individual GP's attitude and the patients' cognitive capacities.

GPs' views on involvement of older patients: an European qualitative study.

Involvement of older patients in general practice care is regarded as important, but is not widespread. To determine specific barriers to the involvement of older patients in general practice care and to identify variations between countries, we performed an international comparative study based on qualitative interviews with 233 general practitioners (GPs) in 11 countries. Most GPs thought that involving older patients had positive outcomes. GPs saw patient involvement as a process taking place solely during consultations. The main barrier for GPs was lack of time. Barriers related to older patients were their feelings of respect for doctors, their lack of experience in being involved and possible mental and physical impairments. To conclude, increasing involvement of older patients is not easy and will only be effective when GPs have adopted a more developed concept of patient involvement and are supported with the different methods for achieving this. The range of appropriate interventions may be similar in all countries.