Applicability of Motivational Interviewing for Chronic Disease Management in Primary Care Following a Web-Based E-Learning Course: Cross-Sectional Study.

BACKGROUND: Motivational interviewing (MI) is an established communication method for enhancing intrinsic motivation for changing health behavior. E-learning can reduce the cost and time involved in providing continuing education and can be easily integrated into individual working arrangements and the daily routines of medical professionals. Thus, a Web-based course was devised to familiarize health professionals with different levels of education and expertise with MI techniques for patients with chronic conditions. OBJECTIVE: The aim of this study was to report participants' opinion on the practicality of MI (as learned in the course) in daily practice, stratified by the level of education. METHODS: Participants (N=607) of the MI Web-based training course evaluated the course over 18 months, using a self-administered questionnaire. The evaluation was analyzed descriptively and stratified for the level of education (medical students, physicians in specialist training [PSTs], and general practitioners [GPs]). RESULTS: Participants rated the applicability of the skills and knowledge gained by the course as positive (medical students: 94% [79/84] good; PSTs: 88.6% [109/123] excellent; and GPs: 51.3% [182/355] excellent). When asked whether they envisage the use of MI in the future, 79% (67/84) of the students stated to a certain extent, 88.6% (109/123) of the PSTs stated to a great extent, and 38.6% (137/355) of GPs stated to a great extent. Participants acknowledged an improvement of communication skills such as inviting (medical students: 85% [72/84]; PSTs: 90.2% [111/123]; GPs: 37.2% [132/355]) and encouraging (medical students: 81% [68/84]; PSTs: 45.5% [56/123]; GPs: 36.3% [129/355]) patients to talk about behavior change and conveying respect for patient's choices (medical students: 72% [61/84]; PSTs: 50.0% [61/123]; GPs: 23.4% [83/355]). CONCLUSIONS: Participants confirmed the practicality of MI. However, the extent to which the practicality of MI was acknowledged as well as its expected benefits depended on the individual's level of education/expertise.

Does patient self-management education of primary care professionals improve patient outcomes: a systematic review.

BACKGROUND: Patient self-management support is recognised as a key component of chronic care. Education and training for health professionals has been shown in the literature to be associated with better uptake, implementation and effectiveness of self-management programs, however, there is no clear evidence regarding whether this training results in improved health outcomes for patients with chronic conditions. METHODS: A systematic review was undertaken using the PRISMA guidelines using the Cochrane Library, PubMEd, ERIC, EMBASE, CINAHL, PsycINFO, Web searches, Hand searches and Bibliographies. Articles published from inception to September 1st, 2013 were included. Systematic reviews, Meta-analysis, Randomized controlled trials (RCTs), Controlled clinical trials, Interrupted time series and Controlled before and after studies, which reported on primary care health professionals' continuing education or evidence-based medicine/education on patient self-management for any chronic condition, were included. A minimum of two reviewers participated independently at each stage of review. RESULTS: From 7533 abstracts found, only two papers provided evidence on the effectiveness of self-management education for primary healthcare professionals in terms of measured outcomes in patients. These two articles show improvement in patient outcomes for chronic back pain and diabetes based on RCTs. The educational interventions with health professionals spanned a range of techniques and modalities but both RCTs included a motivational interviewing component. CONCLUSIONS: Before and up to 2 years after the incorporation of patient empowerment for self-management into the WONCA Europe definition of general practice, there was a scarcity of high quality evidence showing improved outcomes for patients as a result of educating health professionals in patient self-management of chronic conditions.

Survey of 5 European countries suggests that more elements of patient-centered medical homes could improve primary care.

The patient-centered medical home is a US model for comprehensive care. This model features a personal physician or registered nurse who is augmented by a proactive team and information technology. Such a model could prove useful for advanced European systems as they strive to improve primary care, particularly for chronically ill patients. We surveyed 6,428 chronically ill patients and 152 primary care providers in five European countries to assess aspects of the patient-centered medical home. Although most patients reported that they had a personal physician and no problems in contacting the practice after hours, for example, other aspects of the patient-centered medical home, such as provision of written self-management support to patients, were not as widespread. We conclude that despite strong organizational structures, European primary care systems need additional efforts to recognize chronically ill patients as partners in care and can embrace patient-centered medical homes to improve care for European patients.

Documenting organisational development in general practice using a group-based assessment method: the Maturity Matrix.

OBJECTIVE: The Maturity Matrix (MM) comprises a formative evaluation instrument for primary care practices to self-assess their degree of organisational development in a group setting, guided by an external facilitator. The practice teams discuss organisational development, score their own performance and set improvement goals for the following year. The objective of this project was to introduce a translated and culturally adapted version of the MM in Denmark, to test its feasibility, to promote and document organisational change in general practices and to analyse associations between the recorded change(s) and structural factors in practices and the factors associated with the MM process. SETTING: MM was used by general practices in three counties in Denmark, in two assessment sessions 1 year apart. First rounds of MM visits were carried out in 2006-2007 in 60 practice teams (320 participants (163 GPs, 157 staff)) and the second round in 2007-2008. A total of 48 practice teams (228 participants (117 GPs; 111 staff) participated in both sessions. METHOD: The MM sessions were the primary intervention. Moreover, in about half of the practices, the facilitator reminded practice teams of their goals by sending them the written report of the initial session and contacted the practices regularly by telephone reminding them of the goals they had set. Those practice teams had password-protected access to their own and benchmark data. RESULTS: Where the minimum possible is 0 and maximum possible is 8, the mean overall MM score increased from 4.4 to 5.3 (difference=0.9, 95%, CI 0.76 to 1.06) from first to second sessions, indicating that development had taken place as measured by this group-based self-evaluation method. There was some evidence that lower-scoring dimensions were prioritised and more limited evidence that the prioritisation and interventions between meetings were helpful to achieve changes. CONCLUSIONS: This study provides evidence that MM worked well in general practices in Denmark. Practice teams appeared to be learning about the process, directing their efforts more efficiently after a year's experience of the project. This experience also informs the further improvement of the facilitation and follow-up components of the intervention.

Facilitating organisational development using a group-based formative assessment and benchmarking method: design and implementation of the International Family Practice Maturity Matrix.

INTRODUCTION: Well-organised practices deliver higher-quality care. Yet there has been very little effort so far to help primary care organisations achieve higher levels of team performance and to help them identify and prioritise areas where quality improvement efforts should be concentrated. No attempt at all has been made to achieve a method which would be capable of providing comparisons--and the stimulus for further improvement--at an international level. METHODS: The development of the International Family Practice Maturity Matrix took place in three phases: (1) selection and refinement of organisational dimensions; (2) development of incremental scales based on a recognised theoretical framework; and (3) testing the feasibility of the approach on an international basis, including generation of an automated web-based benchmarking system. RESULTS: This work has demonstrated the feasibility of developing an organisational assessment tool for primary care organisations that is sufficiently generic to cross international borders and is applicable across a diverse range of health settings, from state-organised systems to insurer-based health economies. It proved possible to introduce this assessment method in 11 countries in Europe and one in Africa, and to generate comparison benchmarks based on the data collected. The evaluation of the assessment process was uniformly positive with the view that the approach efficiently enables the identification of priorities for organisational development and quality improvement at the same time as motivating change by virtue of the group dynamics. CONCLUSIONS: We are not aware of any other organisational assessment method for primary care which has been 'born international,' and that has involved attention to theory, dimension selection and item refinement. The principal aims were to achieve an organisational assessment which gains added value by using interaction, engagement comparative benchmarks: aims which have been achieved. The next step is to achieve wider implementation and to ensure that those who undertake the assessment method ensure linkages are made to planned investment in organisational development and quality improvement. Knowing the problems is only half the story.

Quality improvement in general practice: enabling general practitioners to judge ethical dilemmas.

Quality improvement (QI) is fundamental to maintaining high standards of health care. Significant debate exists concerning the necessity for an ethical approval system for those QI projects that push the boundaries, appearing more similar to research than QI. The authors discuss this issue identifying the core ethical issues in family medicine (FM), drawing upon the fundamental principles of medical ethics, including principles of autonomy, utility, justice and non-maleficence. Recent debate concerning the application of QI ethics boards is discussed with relevance to primary care and issues such as general practitioner (GP) intentions, the impact of QI on patients and the use of confidential patient data and the impact of dissemination. The authors conclude that a system of QI ethical approval leaves many issues unresolved and potentially creates several barriers to implementing QI. To ensure ethical QI work is generated within FM it is essential for GPs to learn about and engage in more ethical reflection so that they can better judge and resolve these issues.

GP and staff evaluation of the maturity matrix as a tool to assess and improve organisational development in primary care.

PURPOSE: This paper aims to evaluate the maturity matrix (MM) a facilitated formative self-assessment tool for organisational development in primary care) on satisfaction, differences between GP and staff, the extent to which practice teams worked on goals set, and to identify suggestions for change to MM. DESIGN/METHODOLOGY/APPROACH: The approach taken was a cross-sectional survey administered to all participants by mail in 57 family practices, 278 participants, (143 GPs; 135 staff) in Denmark, one year after participating in the MM project. FINDINGS: At practice level 44 returned at least one questionnaire. At participant level, 144 returned the questionnaire: 82 GPs; 62 staff. A total of 93 gave positive statements on satisfaction with MM, 16 stated initial expectations were not met, 79 would recommend MM to colleagues. Differences between GPs and staff were only statistically significant regarding "increased insight into organisation of work after participation in the MM project". There was a tendency that GPs were more positive and likely to give an opinion. A total of 22 planned how to meet the goals set at the first MM meeting and 18 felt that they achieved them. In 24 out of 44 practices MM was stated to contribute new ways of working. A total of 12 of 144 stated that they needed more follow-up support. PRACTICAL IMPLICATIONS: The results indicate that MM is a workable method to assess and gain insight into practice organisation with no major differences between GPs and staff. ORIGINALITY/VALUE: The paper examines participants views' on MM one year after introduction.

Participants' evaluation of a group-based organisational assessment tool in Danish general practice: the Maturity Matrix.

BACKGROUND: The Maturity Matrix is a group-based formative self-evaluation tool aimed at assessing the degree of organisational development in general practice and providing a starting point for local quality improvement. Earlier studies of the Maturity Matrix have shown that participants find the method a useful way of assessing their practice's organisational development. However, little is known about participants' views on the resulting efforts to implement intended changes. AIM: To explore users' perspectives on the Maturity Matrix method, the facilitation process, and drivers and barriers for implementation of intended changes. METHOD: Observation of two facilitated practice meetings, 17 semi-structured interviews with participating general practitioners (GPs) or their staff, and mapping of reasons for continuing or quitting the project. SETTING: General practices in Denmark Main outcomes: Successful change was associated with: a clearly identified anchor person within the practice, a shared and regular meeting structure, and an external facilitator who provides support and counselling during the implementation process. Failure to implement change was associated with: a high patient-related workload, staff or GP turnover (that seemed to affect small practices more), no clearly identified anchor person or anchor persons who did not do anything, no continuous support from an external facilitator, and no formal commitment to working with agreed changes. CONCLUSIONS: Future attempts to improve the impact of the Maturity Matrix, and similar tools for quality improvement, could include: (a) attention to matters of variation caused by practice size, (b) systematic counselling on barriers to implementation and support to structure the change processes, (c) a commitment from participants that goes beyond participation in two-yearly assessments, and (d) an anchor person for each identified goal who takes on the responsibility for improvement in practice.

[Accreditation of Danish general practice. Integrated quality development and continuing education]. / Akkreditering i almen praksis. Integreret kvalitetsudvikling og efteruddannelse.

An accreditation system for Danish general practices is an important element in the Danish Healthcare Quality Programme. In the present article the Danish Quality Unit of General Practice (DAK-E) and the Danish Institute for Quality and Accreditation in Heath Care (IKAS) recommend a comprehensive and information and communication technology-based system of accreditation, feedback and facilitated systematic development and continuous medical education. The overall goal is to further a learning culture in the primary sector based on accountability, transparency and collaboration across sectors.

Quality improvement in primary care: ethical issues explored.

PURPOSE: Quality improvement (QI) processes in family medicine are becoming increasingly complex. Their influence on the organisation of the sector and on the daily work processes is profound and increasing. The literature indicates that many ethical issues are arising from QI work. Therefore this paper aims to identify the experiences of professionals involved in planning and performing QI programmes in European family medicine on the ethical implications involved in those processes. DESIGN/METHODOLOGY/APPROACH: Four focus groups were carried out with 29 general practitioners (GPs) and administrators of general practice quality work in Europe. Two focus groups comprised EQuiP members and two focus groups comprised attendees to an invitational conference on QI in family medicine held by EQuiP in Barcelona in November 2006. FINDINGS: Four overarching themes were identified, including implications of using patient data, prioritising QI projects, issues surrounding the ethical approval dilemma and the impact of QI. Each theme was accompanied by an identified solution. PRACTICAL IMPLICATIONS: Prioritising is necessary and in doing that GPs should ensure that a variety of work is conducted so that some patient groups are not neglected. Transparency and flexibility on various levels is necessary to avoid harmful consequences of QI in terms of bureaucratisation, increased workload and burnout on part of the GP and harmful effects on the doctor-patient relationship. There is a need to address the system of approval for national QI programmes and QI projects utilising more sophisticated methodologies. ORIGINALITY/VALUE: This study provides data from GPs who are experienced quality improvers across 17 countries. Many ethical issues were identified and it was possible to clearly map the themes and their relationships and to summarise the identified solutions from an international perspective.

To what extent do mass media health messages trigger patients' contacts with their GPs?

BACKGROUND: A recent Cochrane review concluded that mass media intervention may play an important role in influencing the use of health services, but little is known about the effects of unplanned untargeted information in the media. AIM: To investigate the influence of messages in mass media about health issues on patients' contacts with their GPs. DESIGN OF STUDY: A case crossover design study comparing the frequency of receiving mass media health messages in a period before contact with a GP versus the frequency in matching control time periods for the same individuals. The outcome measure was the odds of patients having received health messages in the period before they contacted their GP, compared to the odds in the control periods. SETTING: The practices of 21 single-handed Danish GPs. METHOD: Three hundred and twenty-two patients between 18 and 91 years of age were interviewed by telephone after an unscheduled contact with a GP, and 148 patients were interviewed again 3-6 months later. Health media messages were only recorded if patients could remember the topics. RESULT: More than a third (35%) of the patients remembered receiving health media messages in the week before contact. No significant relationship (odds ratio = 1.2, 95% confidence interval = 0.5 to 2.6) between health messages and contact with GPs could be observed. CONCLUSION: In the absence of health campaigns and drug advertisements, mass media health messages seldom directly trigger patients to consult their GPs.

Consultation with the general practitioner triggered by advice from social network members.

OBJECTIVE: To investigate whether advice from a person's social network triggers contact with the general practitioner (GP). DESIGN: Case-crossover design comparing the frequency of advice given to seek medical attention in the period before contact with a GP and the frequency in matching control time periods for the same individual. SETTING: Twenty-one Danish GPs working in single-handed practices. SUBJECTS: 322 patients, aged between 18 and 91 years, were interviewed by telephone after an unscheduled visit to their GP; 148 were interviewed again 3-6 months later. MAIN OUTCOME AND MEASURES: The odds of individuals consulting their GP after receiving advice from network members in the period before they contacted their GP compared with the odds of those consulting their GP in the control period(s). RESULTS: Being advised by others to seek medical attention increased the likelihood of seeking primary health care approximately fivefold--single men received advice significantly less frequently (7%) than women (18%) and cohabiting men (32%). CONCLUSION: Advice from other social network members to seek medical attention is a frequent and influential cue prompting individuals to contact their GP.