Does an in-house internist at a GP practice result in reduced referrals to hospital-based specialist care?

OBJECTIVE: Consistent evidence on the effects of specialist services in the primary care setting is lacking. Therefore, this study evaluated the effects of an in-house internist at a GP practice on the number of referrals to specialist care in the hospital setting. Additionally, the involved GPs and internist were asked to share their experiences with the intervention. DESIGN: A retrospective interrupted times series study. SETTING: Two multidisciplinary general practitioner (GP) practices. INTERVENTION: An internist provided in-house patient consultations in two GP practices and participated in the multidisciplinary meetings. SUBJECTS: The referral data extracted from the electronic medical record system of the GP practices, including all referral letters from the GPs to specialist care in the hospital setting. MAIN OUTCOME MEASURES: The number of referrals to internal medicine in the hospital setting. This study used an autoregressive integrated moving average model to estimate the effect of the intervention taking account of a time trend and autocorrelation among the observations, comparing the pre-intervention period with the intervention period. RESULTS: It was found that the referrals to internal medicine did not statistically significant decrease during the intervention period. CONCLUSIONS: This small explorative study did not find any clues to support that an in-house internist at a primary care setting results in a decrease of referrals to internal medicine in the hospital setting. Key Points An in-house internist at a primary care setting did not result in a significant decrease of referrals to specialist care in the hospital setting. The GPs and internist experience a learning-effect, i.e. an increase of knowledge about internal medicine issues.

Symptomatic pectus excavatum in seniors: an exploratory study on clinical presentation and incidence in daily practice.

Objectives. Doctors all over the world consider a pectus excavatum usually as an incidental finding. There is some evidence suggesting that a pectus excavatum may cause symptoms in the elderly. It is not known how often a pectus excavatum occurs and how strong the relation is with symptoms. Methods. In hospitals and general practice data, we searched for evidence of a connection between cardiac symptoms and the presence of a pectus excavatum in a retrospective survey among patients in whom a pectus excavatum was found in a chest X-ray. In radiology reports, we searched for "pectus excavat(∗) " in almost 160000 chest X-rays. The identified X-rays were reviewed by 2 radiologists. Reported symptoms were combined to a severity sum score and the relation with pectus excavatum was assessed through logistic regression. Results. Pectus excavatum was found in 1 to 2 per 1000 chest X-rays. In 32% of patients (N = 117), we found symptoms that might reflect the presence of symptomatic pectus excavatum. We found a significant relation between the SPES sum score and the radiological level of pectus excavatum. Conclusions. A pectus excavatum found when examining the patient should not be neglected and should be considered as a possible explanation for symptoms like dyspnoea, fatigue, or palpitations.

Consumer satisfaction among patients and their general practitioners about involving nurse specialists in primary care for patients with urinary incontinence.

BACKGROUND: Urinary incontinence (UI) is a very common problem, but existing guidelines on UI are not followed. To bring care in line with guidelines, we planned an intervention to involve nurse specialists on UI in primary care and assessed this in a randomised controlled trial. Alongside this intervention, we assessed consumer satisfaction among patients and general practitioners (GPs). METHODS: Patients' satisfaction with the care provided by either nurse specialists (intervention group) or GPs (control group), respectively, was measured with a self-completed questionnaire. GPs' views on the involvement of nurse specialists were measured in a structured telephone interview. RESULTS: The patient satisfaction score on the care offered by nurse specialists was 8.4 (scale 1-10), vs. 6.7 for care-as-usual by GPs. Over 85% of patients would recommend nurse specialist care to their best friends and 77% of the GPs considered the role of the nurse specialist to be beneficial, giving it a mean score of 7.2. CONCLUSIONS: Although the sample was relatively small and the stability of the results only provisionally established, substituting UI care from GP to nurse specialist appears to be welcomed by both patients and GPs. Small changes like giving additional UI-specific information and devoting more attention to UI (which had been given little attention before) would provide a simple instrument to stimulate patients to change their behaviour in the right direction.

Effectiveness of involving a nurse specialist for patients with urinary incontinence in primary care: results of a pragmatic multicentre randomised controlled trial.

BACKGROUND: Urinary incontinence (UI) primary care management is substandard, offering care rather than cure despite the existence of guidelines that help to improve cure. Involving nurse specialists on incontinence in general practice could be a way to improve care for UI patients. AIMS: We studied whether involving nurse specialists on UI in general practice reduced severity and impact of UI. METHODS: Between 2005 and 2008 a pragmatic multicentre randomised controlled trial was performed comparing a 1-year intervention by trained nurse specialists with care-as-usual after initial diagnosis and assessment by general practitioners in adult patients with stress, urgency or mixed UI in four Dutch regions (Maastricht, Nijmegen, Helmond, The Hague). Simple randomisation was computer-generated with allocation concealment. Analysis was performed by intention-to-treat principles. Main outcome measure was the International Consultation on Incontinence Questionnaire Short Form (ICIQ-UI SF) severity sum score. RESULTS: A total of 186 patients followed the intervention and 198 received care-as-usual. Patients in both study groups improved significantly in UI severity and impact on health-related quality of life. After correction for effect modifiers [type of UI, body mass index (BMI)], we found significant differences between groups in favour of the intervention group at 3 months (p = 0.04); no differences were found in the 1-year linear trend (p = 0.15). Patients in the intervention group without baseline anxiety/depression improved significantly better compared with care-as-usual after 1 year (p = 0.03). CONCLUSION: Involving nurse specialists in care for UI patients supplementary to general practitioners can improve severity and impact of UI, after correction for effect modifiers. This is also the case in specific situations such as anxiety/depression.

Experiences and attitudes of nurse specialists in primary care regarding their role in care for patients with urinary incontinence.

AIM: To explore experiences and attitudes of nurse specialists in primary care regarding their role in care for patients with urinary incontinence (UI), thereby identifying facilitators and barriers for wider implementation. BACKGROUND: Currently, primary care for patients with UI lacks sufficient adherence to existing guidelines on UI and is far from optimal. Studies in various countries show that involving nurse specialists may offer a solution to the inadequate care for UI. As qualitative studies on experiences of nurses with this type of intervention are lacking, we performed this study with a qualitative approach and data collection method within the course of a randomized controlled trial (RCT). METHOD: A focus group study was conducted in 2007 with six nurse specialists who were trained in caring for patients with UI in our pragmatic RCT. The focus group interview was audio-taped and transcribed verbatim. The data were analysed using qualitative content analysis to identify themes. To understand obstacles and incentives for change, we relied on an existing 'implementation model'. FINDINGS: Nurse specialists feel competent to provide advice and information, to offer possible solutions and to give attention and guidance to the process of care of people with UI. They feel appreciated by patients and feel they offer an added value to the usual care of general practitioners (GPs). Nurses sometimes notice that GPs lack interest in UI. Personal contact with the GPs, availability of enough time, adequate equipment and financial resources are important preconditions for effective nurse specialist care. Nurse specialists value continuous education and feedback in daily care for patients with UI. CONCLUSION: Trained nurse specialists appeared to feel competent and satisfied to support GPs in care for patients with UI. They feel highly appreciated by both patients and GPs.

'Quod scripsi, scripsi.' The quality of the report of telephone consultations at Dutch out-of-hours centres.

OBJECTIVE: To assess the quality of the content of reports of telephone consultations at out-of-hours centres and to investigate to what extent the reports reflect the actual telephone consultation. DESIGN AND SETTING: Cross-sectional qualitative study; 17 out-of-hours centres in The Netherlands. METHOD: To assess the quality of the content of reports, a focus group developed the Reason for calling, Information gathered, Care advice given, Evaluation of the care advice with the patient (RICE) report rating instrument. Telephone Incognito Standardised Patients presented seven different clinical problems three times to 17 out-of-hours centres. All calls were recorded and transcribed. The out-of-hours centres being called were asked for a copy of the report of the call. The authors assessed the quality of the content of the reports and compared this with the transcripts. RESULTS: The out-of-hours centres returned a report for 78% of the 357 calls. For the remaining 22% of the calls, no report was written. Reports contained almost always information about the medical reason for calling but little information about details of the clinical history. Patients' expectation, personal situation or perception of the care advice was seldom documented. In all but one out-of-hours centre, answers to obligatory questions were reported by triagists, although they had not been asked, varying between 1% and 54% of all questions entered. Triagists entered a subjective evaluation of a patients' condition in 12% of the reports. CONCLUSION: Reports of telephone consultations of out-of-hours centres contained little information on patients' clinical and personal condition. This could potentially endanger patients' continuity of care and might pose legal consequences for the triagist.

Pretest expectations strongly influence interpretation of abnormal laboratory results and further management.

BACKGROUND: Abnormal results of diagnostic laboratory tests can be difficult to interpret when disease probability is very low. Although most physicians generally do not use Bayesian calculations to interpret abnormal results, their estimates of pretest disease probability and reasons for ordering diagnostic tests may--in a more implicit manner--influence test interpretation and further management. A better understanding of this influence may help to improve test interpretation and management. Therefore, the objective of this study was to examine the influence of physicians' pretest disease probability estimates, and their reasons for ordering diagnostic tests, on test result interpretation, posttest probability estimates and further management. METHODS: Prospective study among 87 primary care physicians in the Netherlands who each ordered laboratory tests for 25 patients. They recorded their reasons for ordering the tests (to exclude or confirm disease or to reassure patients) and their pretest disease probability estimates. Upon receiving the results they recorded how they interpreted the tests, their posttest probability estimates and further management. Logistic regression was used to analyse whether the pretest probability and the reasons for ordering tests influenced the interpretation, the posttest probability estimates and the decisions on further management. RESULTS: The physicians ordered tests for diagnostic purposes for 1253 patients; 742 patients had an abnormal result (64%). Physicians' pretest probability estimates and their reasons for ordering diagnostic tests influenced test interpretation, posttest probability estimates and further management. Abnormal results of tests ordered for reasons of reassurance were significantly more likely to be interpreted as normal (65.8%) compared to tests ordered to confirm a diagnosis or exclude a disease (27.7% and 50.9%, respectively). The odds for abnormal results to be interpreted as normal were much lower when the physician estimated a high pretest disease probability, compared to a low pretest probability estimate (OR = 0.18, 95% CI = 0.07-0.52, p < 0.001). CONCLUSIONS: Interpretation and management of abnormal test results were strongly influenced by physicians' estimation of pretest disease probability and by the reason for ordering the test. By relating abnormal laboratory results to their pretest expectations, physicians may seek a balance between over- and under-reacting to laboratory test results.

Reasons for ordering laboratory tests and relationship with frequency of abnormal results.

OBJECTIVE: Laboratory tests are ordered on a daily basis, even though disease probability is often very low. Abnormal results, especially mildly abnormal results, can be difficult to interpret in these circumstances. Further insights into the occurrence of abnormalities can help improve rational test ordering and test interpretation. The objective was therefore to examine the frequency of mildly and markedly abnormal results and their relationship with physicians' reasons for ordering tests. DESIGN: Prospective study. Participants. A total of 87 primary care physicians in the Netherlands collected data on 1775 patients. MAIN OUTCOME MEASURES: The physicians recorded the reason for ordering the tests, the most probable diagnosis and the pretest probability. The laboratories' reference values and specified "action limits" were used to assess the number of abnormal results and markedly abnormal results, respectively. RESULTS: Laboratory results were received for 1621 patients and 15,603 tests were reported (mean 9.6). The proportion of abnormal test results increased with increasing pretest probability (from 13.9% to 34.7%) and was 13.4% for tests ordered to reassure the patient and 13.3% for psychosocial diagnoses. The proportion of patients with at least one abnormal test result was high: 53.1% for tests ordered to reassure and 57.7% in patients with low pretest probability. Corresponding values for a marked abnormality were 11.1% and 12.4%, respectively. CONCLUSION: Abnormal laboratory test results were frequent, even when pretest probability was low. Physicians should therefore carefully consider when tests are necessary. Future research could explore physicians' interpretation of test results and its impact on diagnosis and management.

Evaluation of an open access echocardiography service in the Netherlands: a mixed methods study of indications, outcomes, patient management and trends.

BACKGROUND: In our region (Eastern South Limburg, The Netherlands) an open access echocardiography service started in 2002. It was the first service of this kind in The Netherlands. Our study aims were: (1) to evaluate demand for the service, participation, indications, echocardiography outcomes, and management by the general practitioner (GP); (2) to analyse changes in indications and outcomes over the years. METHODS: (1) Data from GP request forms, echocardiography reports and a retrospective GP questionnaire on management (response rate 83%) of 625 consecutive patients (Dec. 2002-March 2007) were analysed cross-sectionally. (2) For the analysis of changes over the years, data from GP request forms and echocardiography reports of the first and last 250 patients that visited the service between Dec. 2002 and Feb. 2008 (n = 1001) were compared. RESULTS: The echocardiography service was used by 81% of the regional GPs. On average, a GP referred one patient per year to the service. Intended indications for the service were dyspnoea (32%), cardiac murmur (59%), and peripheral oedema (17%). Of the other indications (22%), one-third was for evaluation of suspected left ventricular hypertrophy (LVH). Expected outcomes were left ventricular dysfunction (LVD) (43%, predominantly diastolic) and valve disease (25%). We also found a high proportion of LVH (50%). Only 24% of all echocardiograms showed no relevant disease. The GP followed the cardiologist's advice to refer the patient for further evaluation in 71%. In recent patients, more echocardiography requests were done for 'cardiac murmur' and 'other' indications, but less for 'dyspnoea'. The proportions of patients with LVD, LVH and valve disease decreased and the proportion of patients with no relevant disease increased. The number of advices by the cardiologists increased. CONCLUSION: Overall, GPs used the open access echocardiography service efficiently (i.e. with a high chance of finding relevant pathology), but efficiency decreased slightly over the years. To meet the needs of the GPs, indications might be widened with 'suspicion LVH'. Further specification of the indications for open access echocardiography--by defining a stepwise diagnostic approach including ECG and (NT-pro)BNP--might improve the service.

Cascade effects of laboratory testing are found to be rare in low disease probability situations: prospective cohort study.

OBJECTIVES: (1) To investigate the frequency of cascades of further diagnostic investigations and referrals after abnormal laboratory results in situations of low disease probability; (2) to investigate pretest and posttest determinants; and (3) to describe the cascades that occur. STUDY DESIGN AND SETTING: Prospective cohort study in primary care in The Netherlands. Numbers of investigations/referrals were recorded during 6 months of follow-up for 256 patients with normal and abnormal laboratory results. The influences of the reason for ordering tests, interpretation of results, and pretest/posttest disease probability were examined. RESULTS: After receiving the laboratory results, the physicians ordered further investigations for 22 (17.3%) patients with abnormal results and for two (1.6%) patients with normal results (P<0.001). They referred 12 (9.4%) patients with abnormal results and eight (6.2%) patients with normal results (P=0.33). Six patients had two investigations and/or referrals, and one patient had three referrals. There were significantly more investigations/referrals for results interpreted as abnormal (P=0.004) and for cases with a high posttest disease probability (P=0.001). CONCLUSION: This study suggests that cascade processes after laboratory testing in situations of low disease probability are limited in magnitude and frequency. Improving interpretations may help improve the appropriateness of further investigations and referrals.

A cluster randomized controlled trial aimed at implementation of local quality improvement collaboratives to improve prescribing and test ordering performance of general practitioners: study protocol.

BACKGROUND: The use of guidelines in general practice is not optimal. Although evidence-based methods to improve guideline adherence are available, variation in physician adherence to general practice guidelines remains relatively high. The objective for this study is to transfer a quality improvement strategy based on audit, feedback, educational materials, and peer group discussion moderated by local opinion leaders to the field. The research questions are: is the multifaceted strategy implemented on a large scale as planned?; what is the effect on general practitioners' (GPs) test ordering and prescribing behaviour?; and what are the costs of implementing the strategy? METHODS: In order to evaluate the effects, costs and feasibility of this new strategy we plan a multi-centre cluster randomized controlled trial (RCT) with a balanced incomplete block design. Local GP groups in the south of the Netherlands already taking part in pharmacotherapeutic audit meeting groups, will be recruited by regional health officers. Approximately 50 groups of GPs will be randomly allocated to two arms. These GPs will be offered two different balanced sets of clinical topics. Each GP within a group will receive comparative feedback on test ordering and prescribing performance. The feedback will be discussed in the group and working agreements will be created after discussion of the guidelines and barriers to change. The data for the feedback will be collected from existing and newly formed databases, both at baseline and after one year. DISCUSSION: We are not aware of published studies on successes and failures of attempts to transfer to the stakeholders in the field a multifaceted strategy aimed at GPs' test ordering and prescribing behaviour. This pragmatic study will focus on compatibility with existing infrastructure, while permitting a certain degree of adaptation to local needs and routines.

New methodology for using incognito standardised patients for telephone consultation in primary care.

Context Many countries now use call centres as an integral part of out-of-hours primary care. Although some research has been carried out on safety issues pertaining to telephone consultations, there has been no published research on how to train and use standardised patients calling for medical advice or on the accuracy of their role-play. Objectives This study aimed to assess the feasibility and validity of using telephone incognito standardised patients (TISPs), the accuracy of their role-play and the rate of detection. Further objectives included exploring the experiences of TISPs and the difficulties encountered in self-recording calls. Methods Twelve TISPs were trained in role-play by presenting their problem to a general practitioner and a nurse. They were also trained in self-recording calls. Calls were made to 17 different out-of-hours centres (OOHCs) from home. Of the four or five calls made per evening, one call was assessed for accuracy of role play. Retrospectively, the OOHCs were asked whether they had detected any calls made by a TISP. The TISPs filled in a questionnaire concerning their training, the self-recording technique and their personal experiences. Results The TISPs made 375 calls over 84 evenings. The accuracy of role-play was close to 100%. A TISP was called back the same evening for additional information in 11 cases. Self-recording caused extra tension for some TISPs. All fictitious calls remained undetected. Conclusions Using the method described, TISPs can be valuable both for training and assessment of performance in telephone consultation carried out by doctors, trainees and other personnel involved in medical services.

Novel strategies for the detection of systolic and diastolic heart failure.

The incidence and prevalence of dyspnea increases with age. Frequently, for the general practitioner with his limited diagnostic facilities, it is impossible to separate dyspnea from cardiac causes and non-cardiac causes. Without cardiac imaging it is also impossible to separate systolic dysfunction from diastolic dysfunction. After a thorough physical examination, initial screening of systolic and diastolic heart failure can be done by measurement of plasma NT-pro BNP or plasma BNP. Additionally a Chest X-Ray or ECG can be performed. To improve diagnostic performance an open access echocardiographic service can be initiated. Recent studies showed, that open access echocardiography can easily detect systolic and diastolic dysfunction in the community and can separate cardiac from non-cardiac dyspnea.

Pectus excavatum, not always as harmless as it seems.

Pectus excavatum is usually considered meaningless and without clinical significance. The following case may put a different complexion on the matter. A healthy 59-year-old male patient complained of progressive heart palpitations, fatigue and postural dyspnoea; bending over caused a clear increase of dyspnoea. At repeated examinations no overt abnormality or explanation was found, except a supraventricular arrhythmia and a nodal tachycardia. In the years to follow the symptoms led to considerable physical impairments. Finally, the patient himself, after searching the web, came up with a possible cause: his pectus excavatum. A lateral chest x-ray with the patient bending over and a lateral computed tomography of the thorax revealed an impression of the heart by the sternum. Ten years after the patient's signs and symptoms first appeared, a modified Ravitch procedure was carried out, after which the physical condition of the patient improved rapidly.

Quality of communication during telephone triage at Dutch out-of-hours centres.

OBJECTIVE: To assess the quality of communication skills of triagists, working at out-of-hours (OOH) centres, and to determine the correlation between the communication score and the duration of the telephone consultation. METHODS: Telephone incognito standardised patients (TISPs) called 17 OOH centres presenting different clinical cases. The assessment of communication skills was carried out using the RICE-communication rating list. The duration of each telephone consultation was determined. RESULTS: The mean overall score for communication skills was 35% of the maximum feasible. Triagists usually asked questions about the clinical situation correctly and little about the patients' personal situation, perception of the problem or expectation. Advice about the outcome of triage and self-care advice was usually given without checking for patients' understanding and acceptance of the advice. Calls were often handled in an unstructured way, without summarizing or clarifying the different steps within the consultation. There was a positive correlation of 0.86 (p<0.01) between the overall communication score and the duration of the telephone consultation. CONCLUSION: Assessment of communication skills of triagists revealed specific shortcomings and learning points to improve the quality of communication skills during telephone triage. PRACTICE IMPLICATIONS: Training in telephone consultation should focus more on patient-centred communication with active listening, active advising and structuring the call. Apart from adequate communication skills, triagists need sufficient time for telephone consultation to enable high quality performance.

Interventions to improve outpatient referrals from primary care to secondary care.

BACKGROUND: The primary care specialist interface is a key organisational feature of many health care systems. Patients are referred to specialist care when investigation or therapeutic options are exhausted in primary care and more specialised care is needed. Referral has considerable implications for patients, the health care system and health care costs. There is considerable evidence that the referral processes can be improved. OBJECTIVES: To estimate the effectiveness and efficiency of interventions to change outpatient referral rates or improve outpatient referral appropriateness. SEARCH STRATEGY: We conducted electronic searches of the Cochrane Effective Practice and Organisation of Care (EPOC) group specialised register (developed through extensive searches of MEDLINE, EMBASE, Healthstar and the Cochrane Library) (February 2002) and the National Research Register. Updated searches were conducted in MEDLINE and the EPOC specialised register up to October 2007. SELECTION CRITERIA: Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series of interventions to change or improve outpatient referrals. Participants were primary care physicians. The outcomes were objectively measured provider performance or health outcomes. DATA COLLECTION AND ANALYSIS: A minimum of two reviewers independently extracted data and assessed study quality. MAIN RESULTS: Seventeen studies involving 23 separate comparisons were included. Nine studies (14 comparisons) evaluated professional educational interventions. Ineffective strategies included: passive dissemination of local referral guidelines (two studies), feedback of referral rates (one study) and discussion with an independent medical adviser (one study). Generally effective strategies included dissemination of guidelines with structured referral sheets (four out of five studies) and involvement of consultants in educational activities (two out of three studies). Four studies evaluated organisational interventions (patient management by family physicians compared to general internists, attachment of a physiotherapist to general practices, a new slot system for referrals and requiring a second 'in-house' opinion prior to referral), all of which were effective. Four studies (five comparisons) evaluated financial interventions. One study evaluating change from a capitation based to mixed capitation and fee-for-service system and from a fee-for-service to a capitation based system (with an element of risk sharing for secondary care services) observed a reduction in referral rates. Modest reductions in referral rates of uncertain significance were observed following the introduction of the general practice fundholding scheme in the United Kingdom (UK). One study evaluating the effect of providing access to private specialists demonstrated an increase in the proportion of patients referred to specialist services but no overall effect on referral rates. AUTHORS' CONCLUSIONS: There are a limited number of rigorous evaluations to base policy on. Active local educational interventions involving secondary care specialists and structured referral sheets are the only interventions shown to impact on referral rates based on current evidence. The effects of 'in-house' second opinion and other intermediate primary care based alternatives to outpatient referral appear promising.

Treatment adherence and patients' acceptance of home infusions with adenosine 5'-triphosphate (ATP) in palliative home care.

GOALS OF WORK: In preterminal cancer patients, provision of palliative care in the patients' own environment is preferred. The aim of the present study was to evaluate patients' and caregivers' treatment adherence and patients' acceptance of home infusions with adenosine 5'-triphosphate (ATP). PATIENTS AND METHODS: Preterminal cancer patients (life expectancy <6 months) with mixed tumor types were eligible for the study. Patients received a maximum of eight weekly intravenous 8-10 h ATP infusions. Evaluation of treatment adherence was based on registration of protocol deviations and patients' acceptance by structured interviews with patients. MAIN RESULTS: Fifty-one patients received a total of 266 intravenous ATP infusions. The infusion protocol was well executed: mean duration approximately 8.30 h, stepwise achievement of the maximum infusion rate within 30 min in 65% of the infusions, and almost no delay in weekly administration. All except one patient were not burdened by the administration of the infusions at home and none of them had felt afraid. The majority of patients found the advantages of the ATP infusions outweighing the disadvantages. However, an important bottleneck in the administration of ATP infusions at home was difficulty in establishing venous access. CONCLUSION: ATP infusions at home are well accepted by patients. Difficulties in establishing venous access might be reduced by composing specialized home infusion teams working both at the day care center and at home or by adopting an alternative route of venous access.

Quality of clinical aspects of call handling at Dutch out of hours centres: cross sectional national study.

OBJECTIVE: To assess the quality of telephone triage by following the consecutive phases of its care process and the quality of the clinical questions asked about the patient's clinical condition, of the triage outcome, of the content of the home management advice, and of the safety net advice given at out of hours centres. DESIGN: Cross sectional national study using telephone incognito standardised patients. SETTING: The Netherlands. PARTICIPANTS: 17 out of hours centres. MAIN OUTCOME MEASURES: Percentages of clinical obligatory questions asked and items within home management and safety net advice, both in relation to pre-agreed standards, and of care advice given in relation to the required care advice. RESULTS: The telephone incognito standardised patients presented seven clinical cases three times each over a period of 12 months, making a total of 357 calls. The mean percentage of obligatory questions asked compared with the standard was 21%. Answers to questions about the clinical condition were not always correctly evaluated from a clinical viewpoint, either by triagists or by general practitioners. The quality of information on home management and safety net advice varied, but it was consistently poor for all cases and for all out of hours centres. Triagists achieved the appropriate triage outcome in 58% of calls. CONCLUSION: In determining the outcome of the care process, triagists often reached a conclusion after asking a minimal number of questions. By analysing the quality of different phases within the process of telephone triage, evaluation of whether an appropriate triage outcome has been arrived at by means of good clinical reasoning or by an educated guess is possible. In terms of enhancing the overall clinical safety of telephone triage, apart from obtaining an appropriate clinical history, adequate home management and safety net advice must also be given.

Adherence to professional guidelines for patients with urinary incontinence by general practitioners: a cross-sectional study.

BACKGROUND: Urinary incontinence is a common problem, affecting quality of life and leading to high costs. There is doubt about the use of clinical practice guidelines on urinary incontinence in primary care. OBJECTIVE: To assess adherence levels and reasons for (non)adherence to the Guideline on Urinary Incontinence of the Dutch College of General Practitioners. Design, setting and participants A postal survey among Dutch general practitioners (GPs). MAIN OUTCOME MEASURE: Adherence of GPs to the guideline. RESULTS: We analysed 264 questionnaires. Almost all GPs adhered to the guideline when diagnosing the type of urinary incontinence. A bladder diary is not often used (35%). Adherence to therapeutic procedures was only high for mild/moderate stress urinary incontinence: most GPs (82.6%) used adequate advice on bladder retraining and pelvic floor muscle training. One out of four GPs agreed that adhering to the guideline is difficult, mainly owing to lack of time, staff, diagnostic tools, competences to provide this care and low motivation of patients. CONCLUSIONS: Dutch GPs follow the guideline only partially: compliance with diagnostic advices is fairly good; compliance with treatment advices is low. Further research should focus on solutions how to support GPs to tackle major barriers to facilitate the adherence to guidelines (substitution of tasks to specialized nurses, reducing the threshold for referral and concentrating expertise in integrated continence care services).

The effects of involving a nurse practitioner in primary care for adult patients with urinary incontinence: the PromoCon study (Promoting Continence).

BACKGROUND: Urinary incontinence affects approximately 5% (800.000) of the Dutch population. Guidelines recommend pelvic floor muscle/bladder training for most patients. Unfortunately, general practitioners use this training only incidentally, but prescribe incontinence pads. Over 50% of patients get such pads, costing 160 million euros each year. Due to ageing of the population a further increase of expenses is expected. Several national reports recommend to involve nurse specialists to support general practitioners and improve patient care. The main objective of our study is to investigate the effectiveness and cost-effectiveness of involving nurse specialists in primary care for urinary incontinence. This paper describes the study protocol. METHODS/DESIGN: In a pragmatic prospective multi centre two-armed randomized controlled trial in the Netherlands the availability and involvement for the general practitioners of a nurse specialist will be compared with usual care. All consecutive patients consulting their general practitioner within 1 year for urinary incontinence and patients already diagnosed with urinary incontinence are eligible. Included patients will be followed for 12 months. Primary outcome is severity of urinary incontinence (measured with the International Consultation on Incontinence Questionnaire Short Form (ICIQ-UI SF)). Based on ICIQ-UI SF outcome data the number of patients needed to include is 350. For the economic evaluation quality of life and costs will be measured alongside the clinical trial. For the longer term extrapolation of the economic evaluation a Markov modelling approach will be used. DISCUSSION/CONCLUSION: This is, to our knowledge, the first trial on care for patients with urinary incontinence in primary care that includes a full economic evaluation and cost-effectiveness modelling exercise from the societal perspective. If this intervention proves to be effective and cost-effective, implementation of this intervention is considered and anticipated. TRIAL REGISTRATION: Current Controlled Trials ISRCTN62722772.