Study protocol for a nationwide implementation of internet-based vestibular rehabilitation for patients with chronic vestibular symptoms (I-RECOVER).

BACKGROUND: Vestibular rehabilitation is a safe and effective exercise-based treatment for patients with chronic vestibular symptoms. However, it is underused in general practice. Internet-based vestibular rehabilitation (Vertigo Training), which has proven to be effective as well, was developed to increase uptake. We now aim to improve the quality of care for patients with vestibular symptoms by carrying out a nationwide implementation of Vertigo Training. We will evaluate the effect of this implementation on primary care. METHODS: Our implementation study consists of three successive phases: 1) We will perform a retrospective observational cohort study and a qualitative interview study to evaluate the current management of patients with vestibular symptoms in primary care, in particular anti-vertigo drug prescriptions, and identify areas for improvement. We will use the results of this phase to tailor our implementation strategy to the needs of general practitioners (GPs) and patients. 2) This phase entails the implementation of Vertigo Training using a multicomponent implementation strategy, containing: guideline adaptations; marketing strategy; pharmacotherapeutic audit and feedback meetings; education; clinical decision support; and local champions. 3) In this phase, we will evaluate the effect of the implementation in three ways. a. Interrupted time series. We will use routine primary care data from adult patients with vestibular symptoms to compare the number of GP consultations for vestibular symptoms, referrals for vestibular rehabilitation, prescriptions for anti-vertigo drugs, and referrals to physiotherapy and secondary care before and after implementation. b. Prospective observational cohort study. We will extract data from Vertigo Training to investigate the usage and the characteristics of participants. We will also determine whether these characteristics are associated with successful treatment. c. Qualitative interview study. We will conduct interviews with GPs to explore their experiences with the implementation. DISCUSSION: This is one of the first studies to evaluate the effect of a nationwide implementation of an innovative treatment on Dutch primary care. Implementation strategies have been researched before, but it remains unclear which ones are the most effective and under what conditions. We therefore expect to gain relevant insights for future projects that aim to implement innovations in primary care.

Measuring Quality in Primary Healthcare - Opportunities and Weaknesses.

The easy access to data from electronic patient records has made using this type of data in pay-for-performance systems increasingly common. General practitioners (GPs) throughout Europe oppose this for several reasons. Not all data can be used to derive good quality indicators and quality indicators can't reflect the broad scope of primary care. Qualities like person-centred care and continuity are particularly difficult to measure. The indicators urge doctors and nurses to spend too much time on the registration and administration of required data. However, quality indicators can be very useful as starting points for discussions about quality in primary care, with the purpose being to initiate, stimulate and support local improvement work. This led to The European Society for Quality and Patient Safety in General Practice (EQuiP) feeling the urge to clarify the different aspects of quality indicators by updating their statement on measuring quality in Primary Care. The statement has been endorsed by the Wonca Europe Council in 2018.

Stratified patient-centered care in type 2 diabetes: a cluster-randomized, controlled clinical trial of effectiveness and cost-effectiveness.

OBJECTIVE: Diabetes treatment should be effective and cost-effective. HbA1c-associated complications are costly. Would patient-centered care be more (cost-) effective if it was targeted to patients within specific HbA1c ranges? RESEARCH DESIGN AND METHODS: This prospective, cluster-randomized, controlled trial involved 13 hospitals (clusters) in the Netherlands and 506 patients with type 2 diabetes randomized to patient-centered (n=237) or usual care (controls) (n=269). Primary outcomes were change in HbA1c and quality-adjusted life years (QALYs); costs and incremental costs (USD) after 1 year were secondary outcomes. We applied nonparametric bootstrapping and probabilistic modeling over a lifetime using a validated Dutch model. The baseline HbA1c strata were <7.0% (53 mmol/mol), 7.0-8.5%, and >8.5% (69 mmol/mol). RESULTS: Patient-centered care was most effective and cost-effective in those with baseline HbA1c>8.5% (69 mmol/mol). After 1 year, the HbA1c reduction was 0.83% (95% CI 0.81-0.84%) (6.7 mmol/mol [6.5-6.8]), and the incremental cost-effectiveness ratio (ICER) was 261 USD (235-288) per QALY. Over a lifetime, 0.54 QALYs (0.30-0.78) were gained at a cost of 3,482 USD (2,706-4,258); ICER 6,443 USD/QALY (3,199-9,686). For baseline HbA1c 7.0-8.5% (53-69 mmol/mol), 0.24 QALY (0.07-0.41) was gained at a cost of 4,731 USD (4,259-5,205); ICER 20,086 USD (5,979-34,193). Care was not cost-effective for patients at a baseline HbA1c<7.0% (53 mmol/mol). CONCLUSIONS: Patient-centered care is more valuable when targeted to patients with HbA1c>8.5% (69 mmol/mol), confirming clinical intuition. The findings support treatment in those with baseline HbA1c 7-8.5% (53-69 mmol/mol) and demonstrate little to no benefit among those with HbA1c<7% (53 mmol/mol). Further studies should assess different HbA1c strata and additional risk profiles to account for heterogeneity among patients.

Using psychological theory to understand the clinical management of type 2 diabetes in Primary Care: a comparison across two European countries.

BACKGROUND: Long term management of patients with Type 2 diabetes is well established within Primary Care. However, despite extensive efforts to implement high quality care both service provision and patient health outcomes remain sub-optimal. Several recent studies suggest that psychological theories about individuals' behaviour can provide a valuable framework for understanding generalisable factors underlying health professionals' clinical behaviour. In the context of the team management of chronic disease such as diabetes, however, the application of such models is less well established. The aim of this study was to identify motivational factors underlying health professional teams' clinical management of diabetes using a psychological model of human behaviour. METHODS: A predictive questionnaire based on the Theory of Planned Behaviour (TPB) investigated health professionals' (HPs') cognitions (e.g., beliefs, attitudes and intentions) about the provision of two aspects of care for patients with diabetes: prescribing statins and inspecting feet.General practitioners and practice nurses in England and the Netherlands completed parallel questionnaires, cross-validated for equivalence in English and Dutch. Behavioural data were practice-level patient-reported rates of foot examination and use of statin medication. Relationships between the cognitive antecedents of behaviour proposed by the TPB and healthcare teams' clinical behaviour were explored using multiple regression. RESULTS: In both countries, attitude and subjective norm were important predictors of health professionals' intention to inspect feet (Attitude: beta = .40; Subjective Norm: beta = .28; Adjusted R2 = .34, p < 0.01), and their intention to prescribe statins (Attitude: beta = .44; Adjusted R2 = .40, p < 0.01). Individuals' self-reported intention did not predict practice-level performance of either clinical behaviour. CONCLUSION: Using the TPB, we identified modifiable factors underlying health professionals' intentions to perform two clinical behaviours, providing a rationale for the development of targeted interventions. However, we did not observe a relationship between health professionals' intentions and our proxy measure of team behaviour. Significant methodological issues were highlighted concerning the use of models of individual behaviour to explain behaviours performed by teams. In order to investigate clinical behaviours performed by teams it may be necessary to develop measures that reflect the collective cognitions of the members of the team to facilitate the application of these theoretical models to team behaviours.

Organizational culture, team climate and diabetes care in small office-based practices.

BACKGROUND: Redesigning care has been proposed as a lever for improving chronic illness care. Within primary care, diabetes care is the most widespread example of restructured integrated care. Our goal was to assess to what extent important aspects of restructured care such as multidisciplinary teamwork and different types of organizational culture are associated with high quality diabetes care in small office-based general practices. METHODS: We conducted cross-sectional analyses of data from 83 health care professionals involved in diabetes care from 30 primary care practices in the Netherlands, with a total of 752 diabetes mellitus type II patients participating in an improvement study. We used self-reported measures of team climate (Team Climate Inventory) and organizational culture (Competing Values Framework), and measures of quality of diabetes care and clinical patient characteristics from medical records and self-report. We conducted multivariate analyses of the relationship between culture, climate and HbA1c, total cholesterol, systolic blood pressure and a sum score on process indicators for the quality of diabetes care, adjusting for potential patient- and practice level confounders and practice-level clustering. RESULTS: A strong group culture was negatively associated to the quality of diabetes care provided to patients (beta = -0.04; p = 0.04), whereas a more 'balanced culture' was positively associated to diabetes care quality (beta = 5.97; p = 0.03). No associations were found between organizational culture, team climate and clinical patient outcomes. CONCLUSION: Although some significant associations were found between high quality diabetes care in general practice and different organizational cultures, relations were rather marginal. Variation in clinical patient outcomes could not be attributed to organizational culture or teamwork. This study therefore contributes to the discussion about the legitimacy of the widespread idea that aspects of redesigning care such as teamwork and culture can contribute to higher quality of care. Future research should preferably combine quantitative and qualitative methods, focus on possible mediating or moderating factors and explore the use of instruments more sensitive to measure such complex constructs in small office-based practices.

Implementing diabetes passports to focus practice reorganization on improving diabetes care.

OBJECTIVE: Although an active role of the patient is often stressed in diabetes care, it is not easily implemented in daily practice. The aim of the study was to measure the effects of introducing a diabetes passport to patients after embedding the passport in the organization of care. DESIGN: Randomized controlled trial. SETTING: Forty general practice in The Netherlands. PARTICIPANTS: Pre- and post-intervention data were obtained from 993 patients with type 2 diabetes mellitus. Patients treated in secondary care and patients over 80 years of age were excluded. INTERVENTION: The intervention consisted of clarifying the diabetes care tasks for all practice staff and embedding the diabetes passports in the structured care. Main outcome measure. Self-reported use of the diabetes passport. RESULTS: Diabetes passports were issued to 87% of the patients. After 15 months, 76% of the patients reported that the passport was being used during clinic visits. The process indicators of care improved by 10% on average in the intervention group. However, there were no changes in the outcome measures. CONCLUSION: Diabetes passports can be introduced successfully in structured primary care and they lead to improved effect measures for medical behaviour.

Stochastic league tables: an application to diabetes interventions in the Netherlands.

The aim of this paper is to discuss the use of stochastic league tables approach in cost-effectiveness analysis of diabetes interventions. It addresses the common grounds and differences with other methods of presenting uncertainty to decision-makers. This comparison uses the cost-effectiveness results of medical guidelines for Dutch diabetes type 2 patients in primary and secondary care. Stochastic league tables define the optimum expansion pathway as compared to baseline, starting with the least costly and most cost-effective intervention mix. Multi-intervention cost-effectiveness acceptability curves are used as a way to represent uncertainty information on the cost-effectiveness of single interventions as compared to a single alternative. The stochastic league table for diabetes interventions shows that in case of low budgets treatment of secondary care patients is the most likely optimum choice. Current care options of diabetes complications are shown to be inefficient compared to guidelines treatment. With more resources available one may implement all guidelines and improve efficiency. The stochastic league table approach and multi-intervention cost-effectiveness acceptability curves in uncertainty analysis lead to similar results. In addition, the stochastic league table approach provides policy makers with information on affordability by budget level. It fulfils more adequately the information requirements to choose between interventions, using the efficiency criterion.

Empowering patients: how to implement a diabetes passport in hospital care.

The purpose was to ascertain the views of patients with diabetes and patient care teams on the introduction of a recently developed diabetes passport in order to plan effective implementation. A semi-qualitative study by eight semi-structured focus group discussions with patient care teams and patients in four Dutch hospitals was organised. In total 29 patients participated (range five to nine per hospital). Patient care teams ranged from four to six participants. Each team included at least one specialised diabetic nurse and an internist. Taped views were transcribed and coded on the basis of a structured checklist. Various potential barriers to the implementation of the diabetes passport were found. Although patients recognized the diabetes passport as a handy tool, most of them expected starting problems and little co-operation from the internists; in this respect they rely more on the diabetes specialist nurse (DSN). Internists had mixed feelings about the diabetes passport. Lack of motivation and lack of time were important perceived barriers. The specialised diabetes nurses had the highest expectations of the diabetes passport and perceived themselves as those who would effectuate implementation. The main potential barriers to effective implementation of the diabetes passport were found in setting the agenda of the passport and fitting it into the organization of diabetes care. These barriers need to be considered when implementing the passport. The DSN could play an important part in its implementation.