[Risk factors for class II dental restoration survival:a practice-based study]. / Risicofactoren voor klasse II-restauratieoverleving: een praktijkgebaseerd onderzoek.

The aim of this practice-based cohort study was to determine the performance and influence of possible variables in class II restorations related to practice, patient, tooth, and restoration. To do this, electronic patient files from 11 general practices in the Netherlands were collected, and 31,472 restorations placed between January 2015 and October 2017 were analysed. The observation time of restorations varied from 0 to 2.7 years, resulting in a mean annual failure rate (AFR) of 7.8% at 2 years. However, wide variation in AFRs existed among the operators, varying between 3.6% and 11.4%. An excess of patient-related variables, such as age, general health, periodontal status, caries risk and the presence of parafunctional habits and tooth or restoration-related factors, increases the risk of reintervention. Restorations placed due to fracture were more prone to fail than restorations placed due to caries. This study demonstrated that a wide variety of risk factors on the practice, patient, and tooth levels influences the survival of class II restorations.

Risk Factors for Dental Restoration Survival: A Practice-Based Study.

To improve patient dental care, it is necessary to identify possible risk factors for the failing of restorations. This practice-based cohort study investigated the performance and influence of possible risk factors at the level of the practice, patient, tooth, and restoration on survival of direct class II restorations. Electronic patient files from 11 Dutch general practices were collected, and 31,472 restorations placed between January 2015 and October 2017 were analyzed. Kaplan-Meier statistics were performed; annual failure rates (AFRs) were calculated; and variables were assessed by multivariable Cox regression analysis. The observation time of restorations varied from 0 to 2.7 y, resulting in a mean AFR of 7.8% at 2 y. However, wide variation in AFRs existed among the operators, varying between 3.6% and 11.4%. A wide range of patient-related variables is related to a high risk for reintervention: patient age (elderly: hazard ratio [HR], 1.372), general health (medically compromised: HR, 1.478), periodontal status (periodontal problems: HR, 1.207), caries risk and risk for parafunctional habits (high: HR, 1.687), restorations in molar teeth (HR, 1.383), restorations placed in endodontically treated teeth (HR, 1.890), and multisurface restorations (≥4 surfaces: HR, 1.345). Restorations placed due to fracture were more prone to fail than restorations placed due to caries. When patient-related risk factors were excluded, remaining risk factors considerably changed in their effect and significance: the effect of operator, age of the patient, and endodontic treatment increased; the effect of the diagnosis decreased; and the socioeconomic status became significant (high: HR, 0.873). This study demonstrated that a wide variation of risk factors on the practice, patient, and tooth levels influences the survival of class II restorations. To provide personalized dental care, it is important to identify and record potential risk factors. Therefore, we recommend further clinical studies to include these patient risk factors in data collection and analysis.

Needs and preferences of patients with head and neck cancer in integrated care.

OBJECTIVES: Incorporation of patients' perspectives in daily practice is necessary to adapt care to users' needs. However, information on patients' needs and preferences for integrated care is lacking. The aim was to explore these needs and preferences, taking patients with head and neck cancer (HNC) as example, to adapt current integrated care to be more patient-centred. DESIGN: Semi-structured interviews were held with current and former patients and chairmen of patient associations. Relevant needs and preferences were identified and categorised using the eight-dimension Picker model of patient-centred care. SETTING: Integrated HNC in the Netherlands. PARTICIPANTS: Patients with HNC and chairmen of two Dutch HNC patient associations. MAIN OUTCOME MEASURES: Patients' needs and preferences of integrated HNC care categorised according the Picker model. RESULTS: A total of 34 themes of needs and preferences were identified, by 14 patients with HNC or their delegates, using the Picker dimensions. Themes often emerged were as follows: personalisation of health care regarding patient values; clear insight into the healthcare process at organisational level; use of personalised communication, education and information that meets patients' requirements; adequate involvement of allied health professionals for physical support; more attention to the impact of HNC and its treatment; adequate involvement of family and friends; adequate general practitioner involvement in the aftercare; and waiting time reduction. CONCLUSIONS: Monitoring the identified themes in integrated HNC care, fitting in the Picker model, will enable us to respond better to the needs and preferences of patients, and patient-centred care in oncological care can be enhanced.

Impact of primary care on hospital admission rates for diabetes patients: A systematic review.

High-quality primary care for diabetes patients may be related to lowered hospital admissions. A systematic search was performed to assess the impact of structure, process, and outcome of primary diabetes care on hospital admission rates, considering patient characteristics. Studies on diabetes patients in primary care with hospitalisation rates as outcomes published between January 1996 and December 2015 were included. Indicators of quality of care (access, continuity and structure of care, process, and outcome indicators) and patient characteristics (age, gender, ethnicity, insurance, socio-economic status, diabetes characteristics, co-morbidity, and health-related lifestyle) were extracted. After assessment of the strength of evidence, characteristics of care and diabetes patients were presented in relation to the likelihood of hospitalisation. Thirty-one studies were identified. A regular source of primary care and a well-controlled HbA1c level decreased the likelihood of hospitalisation. Other aspects of care were less consistent. Patients' age, co-morbidity, and socio-economic status were related to higher hospitalisation. Gender and health-related lifestyle showed no relationship. Studies were heterogeneous in design, sample, and healthcare system. Different definitions of diabetes and unscheduled admissions limited comparisons. In healthcare systems where diabetes patients have a regular source of primary care, hospital admission rates cannot be meaningfully related to primary care characteristics.

Patient reported outcome measures (PROMs) for goalsetting and outcome measurement in primary care physiotherapy, an explorative field study.

OBJECTIVES: Routine use of patient reported outcome measures (PROMs) may provide an effective way of monitoring patient valued outcomes. In this study we explored (1) the current use of PROMs; (2) to what extent the goals correspond with the selected PROMs; (3) the health outcomes based on PROMs. DESIGN: Observational clinical cohort study. SETTING: Dutch primary care physiotherapy practices (n=43). PARTICIPANTS: Patients (n=299) with neck pain or low back pain. MAIN OUTCOME MEASURES: The number of PROMs used per patient were calculated. The International Classification of Functioning, Disability and Health was used to map the patients' goals and the percentages of PROMS selected that match the domains of the goals were calculated. Health outcomes were assessed using two approaches for estimating the minimal clinically important difference (MCID). RESULTS: Repeated measurements with the Visual Analogue Scale, the Patient Specific Complaints questionnaire, the Quebec Back Pain Disability Scale, or the Neck Disability Index were completed by more than 60% of the patients. The PROMs used matched in 46% of the cases with goals for pain improvement, and in 43% with goals set at activity/participation level. The mean differences between baseline and follow up scores for all PROMs were statistically significant. Improvements of patients based on MCID varied from 57% to 90%. CONCLUSIONS: PROMs were used in the majority of the patients, showed improved health outcomes and fitted moderately with goals. The results of this study can be used for future research assessing the routine use of outcome measurements with PROMs.

Quality indicators of integrated care for patients with head and neck cancer.

OBJECTIVES: Oncological care is very complex, and delivery of integrated care with optimal alignment and collaboration of several disciplines is crucial. To monitor and effectively improve high-quality integrated oncological care, a dashboard of valid and reliable quality indicators (QIs) is indispensable. The aim was to develop multidisciplinary QIs to measure quality of integrated oncological care, specifically for head and neck cancer (HNC) patients. DESIGN: The RAND-modified Delphi method was used to decide on the outcome, process and structure QIs form three different perspectives. In addition, case-mix factors were determined. SETTING: Integrated HNC in the Netherlands. PARTICIPANTS: Head and neck cancer patients, chairmen of both patient organisations and medical specialists and allied health professionals involved in HNC care in the Netherlands. MAIN OUTCOME MEASURES: Outcome, process and structure indicators. RESULTS: Outcome indicators were assigned to healthcare status, tumour recurrence, complications, quality of life and patient experiences. The process indicators focused on the (allied health) care aspects during the diagnostic, treatment and follow-up phases, for example regarding waiting times, multidisciplinary team meetings and screening for the need of allied health care. CONCLUSIONS: This is the first set of multidisciplinary QIs for HNC care, to assess quality of integrated care agreed by patients and professionals. This set can be used to build other oncological quality dashboards for integrated care.

Ten-Year Survival of Class II Restorations Placed by General Practitioners.

The aim of this retrospective practice-based study was to investigate the survival of direct class II restorations placed by a group of general dental practitioners (GDPs) and to analyze the effect of practice-, patient-, and tooth/restoration-related factors. Electronic patient files of 24 general dental practices were used for collecting the data for this study. From the patient files, survival rates of 222,836 composites, amalgams, glass ionomers, and compomers placed in 61,121 patients by 67 GDPs between 1999 and 2011 were analyzed by Kaplan-Meier statistics and a multiple Cox regression. The investigated group of GDPs placed restorations with a satisfactory survival (mean AFR10, 4.9%; 95% confidence interval, 2.1 to 7.7), although a wide variation in annual failure rate (AFR) existed between the different operators, varying between 2.6% and 7.0%. Restorations placed in young adults (21-30 y old) survived longest, whereas they showed a shorter survival in children (hazard ratio [HR], 1.553) and the elderly (HR, 1.593). Restorations in molar teeth, restorations placed in endodontically treated teeth, and multisurface restorations are more at risk for reintervention. However, restoration size (included surfaces) has a greater impact on restoration survival in premolar teeth. For the future, improved data collection at the practice/operator, patient, and tooth/restoration level (e.g., risk assessment and diagnoses) will provide the opportunity to evaluate even more extensively the risk factors involved. Knowledge Transfer Statement: The results of this study give insight into the long-term survival of direct dental restorations and the influencing practice-, patient-, and tooth/restoration-related variables.

[Evidence-based clinical oral healthcare guidelines 4. Adherence requires an implementation strategy]. / Evidencebased klinische praktijkrichtlijnen in de mondzorg 4. Toepassing vergt een implementatiestrategie.

Adherence to clinical guidelines requires support in practice. However, systematic implementation of evidence-based guidelines is not common practice in oral healthcare. The Knowledge Institute Oral Care (KiMo) offers the opportunity to take into account potential barriers and facilitators during the development of evidence-based clinical practice guidelines. These factors which are relevant to the guideline and the oral healthcare practice provide the ingredients for a tailor-made programme of implementation that has a scientific basis. Elements of any implementation programme are the quality indicators derived from the oral healthcare guidelines. These indicators should fit, on the one hand, the specific goals of the guidelines (patient safety, effectiveness, efficiency, patient-centred, timeliness, accessibility) and, onthe other hand, the various perspectives of the different stakeholders, such as patients, caregivers, health insurers and inspectorate. These quality indicators provide information on adherence to the guidelines, the results of a certain treatment and the success of the implementation strategy, all with the aim to improve the quality of oral healthcare.

Quality indicators for physiotherapy in Parkinson's disease.

AIM: The aim of this study was to develop quality indicators for physiotherapy in Parkinson's disease (PD) according to international criteria. METHODS: Indicators were based on an evidence-based guideline for physiotherapy in PD. Guideline recommendations were transformed into indicators and rated for their relevance by an expert panel. Relevant indicators were incorporated into a questionnaire termed ''Quality Indicators for Physiotherapy in PD'' (QIP-PD). The QIP-PD was piloted among 105 physiotherapists. The adjusted version was evaluated in 46 physiotherapists with specific expertise in PD and in 795 general physiotherapists. The following clinimetric aspects of the QIP-PD were tested: completeness of answers, response distribution, internal consistency, and discriminative power. The reliability of the QIP-PD was evaluated by interviews among a randomly selected cohort of 32 PD experts and 32 general physiotherapists. RESULTS: The expert panel selected 16 indicators, which were transformed into an adjusted 17-item QIP-PD. The adjusted QIP-PD was completed by 41 expert physiotherapists and 286 general physiotherapists. Comple-teness of item scores ranged from 95-98%. Six items were excluded from the final analyses as they showed ceiling effect among both groups, or lacked discriminative power. The total QIP-PD score for the 11 items was significantly higher for expert physiotherapists (35.1+/-4.2) compared to general physiotherapists (22.2+/-7.7; P=0.01). Internal consistency was good (Crohnbach's alpha 0.84). QIP-PD scores of therapists and interviewers (correlated using Intraclass Correlations Coefficients) ranged from 0.63 to 0.75. CONCLUSIONS: The QIP-PD is a relevant, feasible, valid, discriminative and reliable instrument to measure adherence to guidelines for physiotherapy in PD. In addition, the results underscore that quality improvement interventions for physiotherapy in PD are needed, as guideline adherence is suboptimal in physiotherapists without specific PD expertise.

Patient-oriented intervention in addition to centrally organised checkups improves diabetic patient outcome in primary care.

BACKGROUND: Logistic support to general practitioners improves the care processes for patients with diabetes but is not sufficient to meet all criteria. AIM: To introduce patient-oriented interventions by a practice nurse in general practices which already use logistic support to improve the care processes for patients with diabetes. DESIGN OF STUDY: A controlled before-after study with delayed intervention in the control group. SETTING: 51 practices (n = 23 for the intervention and n = 28 for the control group) in the south of The Netherlands and 900 of their patients with type 2 diabetes. METHODS: Data were collected on the results of the checkups (fasting blood glucose, glycosylated haemoglobin (HbA1C), cholesterol, cholesterol/high-density lipoprotein ratio, triglycerides, creatinine, blood pressure, fundus photo, foot exam and body mass index), smoking status, physical activity and medication use. The effect of the patient-oriented intervention was analysed in a mixed model with repeated measurement covariance structure. RESULTS: The HbA1C improved in the intervention group (from 7.3 to 7.1), while that of the control group deteriorated (from 7.2 to 7.3). The percentage of patients with an HbA1C >or=8.5 was halved after the intervention (from 13 to 6). Patients in the intervention group started to exercise more besides their daily activities compared with the control group. The need for medication increased more in the control group than in the intervention group (more changes to insulin and more defined daily dose (DDD) oral medication). CONCLUSION: Patient-oriented interventions in addition to logistic support have a positive effect on diabetic patient outcomes.

Antibiotic prescribing in primary care: first choice and restrictive prescribing are two different traits.

OBJECTIVE: To investigate the quality of antibiotic prescribing in primary care using quality indicators and the relatedness of these indicators. To determine the influence of general practice and practice population characteristics on the indicator scores. METHODS: Data on performance were collected during the Second National Survey of General Practice over 1 year between May 2000 and April 2002 in The Netherlands. The study was carried out in 104 computerised general practices, comprising 195 general practitioners and about 400,000 patients. From a preliminary set of quality indicators on antibiotic prescribing (n = 15), eight were selected covering various medical conditions. Indicator scores were derived. A factor analysis was performed to examine the relatedness of these indicators. Composite scores were calculated for the indicators loading on the same factor. The influence of general practice and practice population characteristics on the quality of antibiotic prescribing was investigated. RESULTS: Considerable variation was found between indicator scores (32.8-94.2%) and between practices. The factor analysis discovered two interpretable factors-namely, "first choice prescribing" and "restrictive prescribing". The composite scores were 64% and 68%, respectively. No significant correlation was found between the two composite scores. Practice and population characteristics explained only a small proportion of the variance between practices. CONCLUSIONS: Although different quality indicators on antibiotic prescribing are grouped together over several medical conditions, there is large variation between those indicators. General practices performing well on first choice prescribing do not automatically perform well on restrictive prescribing. There is room for improvement on both aspects of prescribing. The variation between practices is clearly present and should be further investigated.

Loss to follow-up of cervical smears without endocervical columnar cells is not disturbing.

OBJECTIVE: To investigate the six-month recommended follow-up after mass screening of Pap smears because of the absence of endocervical columnar cells (ECC-) or ECC+ smears with atypical squamous or glandular cells of undetermined origin (ASCUS/AGUS) or low-grade squamous or glandular intraepithelial lesions (LSIL/LGIL) in a Dutch mass screening cervical cancer programme. METHODS: Data were extracted from computerised medical records of national representative Dutch general practices. We have studied the attendance at and the outcome of the subsequent Pap smears after a 6-month recommendation. RESULTS: The six-month follow-up was linked to 8.7% of the Pap smears (n = 1,002); 77.6% were without endocervical columnar cells (ECC-). Clear differences were found between the follow-up of ECC+ and ECC- smears; after 36 weeks of follow-up of 43.5% the women had an ECC- smear and 66.9% had other conditions. For initial ECC- Pap smears, 84.1% had no abnormalities in the subsequent Pap smear; for initial ECC+ Pap smears, in about 64% of the cases no abnormalities were found (p < 0.0001). CONCLUSIONS: Repeating ECC- smears has a low follow-up rate but also lacks evidence-based necessity. However, for the other 6-month recommended Pap smears, one in five women had still not responded within one year, so improvement is necessary.

Patient-centred and professional-directed implementation strategies for diabetes guidelines: a cluster-randomized trial-based cost-effectiveness analysis.

AIMS: Economic evaluations of diabetes interventions do not usually include analyses on effects and cost of implementation strategies. This leads to optimistic cost-effectiveness estimates. This study reports empirical findings on the cost-effectiveness of two implementation strategies compared with usual hospital outpatient care. It includes both patient-related and intervention-related cost. PATIENTS AND METHODS: In a clustered-randomized controlled trial design, 13 Dutch general hospitals were randomly assigned to a control group, a professional-directed or a patient-centred implementation programme. Professionals received feedback on baseline data, education and reminders. Patients in the patient-centred group received education and diabetes passports. A validated probabilistic Dutch diabetes model and the UKPDS risk engine are used to compute lifetime disease outcomes and cost in the three groups, including uncertainties. RESULTS: Glycated haemoglobin (HbA(1c)) at 1 year (the measure used to predict diabetes outcome changes over a lifetime) decreased by 0.2% in the professional-change group and by 0.3% in the patient-centred group, while it increased by 0.2% in the control group. Costs of primary implementation were < 5 Euro per head in both groups, but average lifetime costs of improved care and longer life expectancy rose by 9389 Euro and 9620 Euro, respectively. Life expectancy improved by 0.34 and 0.63 years, and quality-adjusted life years (QALY) by 0.29 and 0.59. Accordingly, the incremental cost per QALY was 32 218 Euro for professional-change care and 16 353 for patient-centred care compared with control, and 881 Euro for patient-centred vs. professional-change care. Uncertainties are presented in acceptability curves: above 65 Euro per annum the patient-directed strategy is most likely the optimum choice. CONCLUSION: Both guideline implementation strategies in secondary care are cost-effective compared with current care, by Dutch standards, for these patients. Additional annual costs per patient using patient passports are low. This analysis supports patient involvement in diabetes in the Netherlands, and probably also in other Western European settings.

Introduction of diabetes passports involving both patients and professionals to improve hospital outpatient diabetes care.

AIM: To investigate whether a comprehensive strategy involving both patients and professionals, with the introduction of a diabetes passport as a key component, improves diabetes care. METHODS: The first 150 consecutive patients who visited their internist for a diabetes check up at the internal medicine outpatient departments at each of nine Dutch general hospitals were included in this 1 year clustered, randomised, controlled trial. Health care professionals attended an educational meeting about the use and dissemination of the diabetes passport which is a patient held record. They also received aggregated feedback on baseline data and personal feedback. Educational meetings were also organised for patients. Patient files were used in conjunction with questionnaires to determine adherence rates. Data were analysed using multilevel regression analysis. RESULTS: Small but significant changes were found in mean HbA1c levels. In the intervention group, positive health changes for patients were found (-0.3%) when compared to those in the control group (+0.2%). Diastolic blood pressure improved slightly, but no changes were found in systolic blood pressure or cholesterol. Improvements were found with regard to levels of examination of patients' feet and in patient education. CONCLUSIONS: Efforts to improve professional practice involving both professionals and patients led to small improvements in HbA1c and diastolic blood pressure levels. Further study is needed to establish whether a better structured health care delivery, operating in a more supportive environment can enhance these effects.

Vaccination of high-risk patients against influenza: impact on primary care contact rates during epidemics. Analysis of routinely collected data.

A general practice (GP) based retrospective cohort study was conducted to assess the effects of influenza vaccination on the primary care contact rate during influenza epidemics. Given the rising workload of family physicians, particularly due to ageing of the population, it is very relevant to know to whether influenza vaccination of high-risk patients reduces the contact rate during epidemics. No effect of vaccination was found on the contact rate of GP during a mild epidemic period. During a 'normal' influenza epidemic, the workload was reduced through fewer contacts by patients with cardiovascular or diabetic diseases. Epidemic periods severe enough to show contact rate reduction occurred approximately every other year.

Patients and nurses determine variation in adherence to guidelines at Dutch hospitals more than internists or settings.

AIMS: To measure adherence to recently developed diabetes guidelines at Dutch hospital outpatient clinics and distinguish determinants for variations in care on hospital, internist and patient levels. METHODS: Thirteen general hospitals with 58 internists recruited 1950 diabetic patients. Data were extracted from medical files (n = 1915) and from patient questionnaires (n = 1465). Multilevel logistic regression analysis was performed to explain differences in adherence rates to the guidelines. RESULTS: Adherence to process measures was high, except for the examination of feet, calculation of the body mass index and patient education activities (the mean of 12 process measures was 64%). Adherence to intermediate outcome indicators was moderate. The mean percentage of patients with HbA(1c) < 7.0% was 23%. Adherence variation on a hospital level was very small (0.6-7.9%), on an internist level moderate (0.4-18.8%) and on a patient level high (74.4-98.8%). Adherence to all process measures and most of the intermediate outcome indicators was highest in the patients seen by a diabetes specialist nurse. DISCUSSION: More focus on patient involvement in diabetic care and the contribution of diabetes specialist nurses may be important factors in improving the quality of diabetes care.

Possibilities and barriers in the implementation of a preconceptional screening programme for cystic fibrosis carriers: a focus group study.

OBJECTIVE: This qualitative study aimed to explore possibilities and barriers in the implementation of a nationwide preconceptional cystic fibrosis (CF) carrier screening programme. METHODS: Sessions were held with two focus groups of CF patients and CF relatives, one focus group of people from the target population (couples planning a pregnancy), and two focus groups of potential providers (general practitioners (GPs) and municipal health service workers). RESULTS: Important barriers in the implementation of a preconceptional CF carrier screening programme included the problem of reaching the target population, the heavy workload of GPs, the limited public knowledge about CF in general, and the absence of a preconceptional consultation setting. In general, there was a positive attitude among the participants towards CF carrier screening. CONCLUSION: This study revealed some important barriers in the implementation of CF carrier screening programmes. More research is needed to specify and quantify the importance of the various barriers. Eventually, different intervention strategies should be included in an implementation plan to overcome the most important barriers in the organization and execution of screening.

Multifaceted support to improve clinical decision making in diabetes care: a randomized controlled trial in general practice.

AIMS: To evaluate the effectiveness of a multifaceted intervention to improve the clinical decision making of general practitioners (GPs) for patients with diabetes. To identify practice characteristics which predict success. METHODS: Cluster randomized controlled trial with 124 practices and 185 GPs in The Netherlands. The intervention group received feedback reports and support from a facilitator; the control group received no special attention. Outcome measures were the compliance rates with evidence-based recommendations pertaining to discussion of body weight control, discussion of problems with medication, blood pressure measurement, foot examination, eye examination, initiating anti-diabetic medication or increasing the dosage in cases of uncontrolled blood glucose, and scheduling a follow-up appointment. RESULTS: The GPs reported on their clinical decision making in 1410 consultations with Type 2 diabetic patients at baseline and 1449 consultations after the intervention period. The intervention resulted in statistically significant improvement for two of the seven outcome measures: foot examination (odds ratio 1.68; 95% confidence interval 1.19-2.39) and eye examination (1.52; 1.07-2.16). Discussion of problems with medication showed a near significant trend towards increased benefit for the intervention group (1.52; 0.99-2.32). Practice characteristics were not found to be related to the success of the intervention. CONCLUSIONS: Feedback reports with support from facilitators appear to increase rates of foot examination and eye examination in general practice. Alternative interventions should be explored to improve the pursuit of metabolic control by GPs.