On the relevance of modulation transfer function measurements in digital mammography quality control.

Purpose: The relevance of presampling modulation transfer function (MTF) measurements in digital mammography (DM) quality control (QC) is examined. Two studies are presented: a case study on the impact of a reduction in MTF on the technical image quality score and analysis of the robustness of routine QC MTF measurements. Approach: In the first study, two needle computed radiography (CR) plates with identical sensitivities were used with differences in the 50% point of the MTF ( f MTF 0.5 ) larger than the limiting value in the European guidelines ( > 10 % change between successive measurements). Technical image quality was assessed via threshold gold thickness of the CDMAM phantom and threshold microcalcification diameter of the L1 structured phantom. For the second study, presampling MTF results from 595 half-yearly QC tests of 55 DM systems (16 types, six manufacturers) were analyzed for changes from the baseline value and changes in f MTF 0.5 between successive tests. Results: A reduction of 20% in f MTF 0.5 of the two CR plates was observed. There was a tendency to a lower score for task-based metrics, but none were significant. Averaging over 55 systems, the absolute relative change in f MTF 0.5 between consecutive tests (with 95% confidence interval) was 3% (2.5% to 3.4%). Analysis of the maximum relative change from baseline revealed changes of up to - 10 % for one a-Se based system and - 15 % for a group of CsI-based systems. Conclusions: A limit of 10% is a relevant action level for investigation. If exceeded, then the impact on performance has to be verified with extra metrics.

Effectiveness of personalised support for self-management in primary care: a cluster randomised controlled trial.

BACKGROUND: Self-management support is an important component of the clinical management of many chronic conditions. The validated Self-Management Screening questionnaire (SeMaS) assesses individual characteristics that influence a patient's ability to self-manage. AIM: To assess the effect of providing personalised self-management support in clinical practice on patients' activation and health-related behaviours. DESIGN AND SETTING: A cluster randomised controlled trial was conducted in 15 primary care group practices in the south of the Netherlands. METHOD: After attending a dedicated self-management support training session, practice nurses in the intervention arm discussed the results of SeMaS with the patient at baseline, and tailored the self-management support. Participants completed a 13-item Patient Activation Measure (PAM-13) and validated lifestyle questionnaires at baseline and after 6 months. Data, including individual care plans, referrals to self-management interventions, self-monitoring, and healthcare use, were extracted from patients' medical records. Multilevel multiple regression was used to assess the effect on outcomes. RESULTS: The PAM-13 score did not differ significantly between the control (n = 348) and intervention (n = 296) arms at 6 months. In the intervention arm, 29.4% of the patients performed self-monitoring, versus 15.2% in the control arm (effect size r = 0.9, P = 0.01). In the per protocol analysis (control n = 348; intervention n = 136), the effect of the intervention was significant on the number of individual care plans (effect size r = 1.3, P = 0.04) and on self-monitoring (effect size r = 1.0, P = 0.01). CONCLUSION: This study showed that discussing SeMaS and offering tailored support did not affect patient activation or lifestyle, but did stimulate patients to self-monitor and use individual care plans.

Validation of Self-Management Screening (SeMaS), a tool to facilitate personalised counselling and support of patients with chronic diseases.

BACKGROUND: A rising number of people with chronic conditions is offered interventions to enhance self-management. The responsiveness of individuals to these interventions depends on patient characteristics. We aimed to develop and validate a tool to facilitate personalised counselling and support for self-management in patients with chronic diseases in primary care. METHODS: We drafted a prototype of the tool for Self-Management Screening (SeMaS), comprising 27 questions that were mainly derived from validated questionnaires. To reach high content validity, we performed a literature review and held focus groups with patients and healthcare professionals as input for the tool. The characteristics self-efficacy, locus of control, depression, anxiety, coping, social support, and perceived burden of disease were incorporated into the tool. Three items were added to guide the type of support or intervention, being computer skills, functioning in groups, and willingness to perform self-monitoring. Subsequently, the construct and criterion validity of the tool were investigated in a sample of 204 chronic patients from two primary care practices. Patients filled in the SeMaS and a set of validated questionnaires for evaluation of SeMaS. The Patient Activation Measure (PAM-13), a generic instrument to measure patient health activation, was used to test the convergent construct validity. RESULTS: Patients had a mean age of 66.8 years and 46.6 % was female. 5.9 % did not experience any barrier to self-management, 28.9 % experienced one minor or major barrier, and 30.4 % two minor or major barriers. Compared to the criterion measures, the positive predictive value of the SeMaS characteristics ranged from 41.5 to 77.8 % and the negative predictive value ranged from 53.3 to 99.4 %. Crohnbach's alpha for internal consistency ranged from 0.56 to 0.87, except for locus of control (α = 0.02). The regression model with PAM-13 as a dependent variable showed that the SeMaS explained 31.7 % (r(2) = 0.317) of the variance in the PAM-13 score. CONCLUSIONS: SeMaS is a short validated tool that can signal potential barriers for self-management that need to be addressed in the dialogue with the patient. As such it can be used to facilitate personalised counselling and support to enhance self-management in patients with chronic conditions in primary care.

COPD prognosis in relation to diagnostic criteria for airflow obstruction in smokers.

The aim of this study was to establish which cut-off point for the forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) ratio (i.e. fixed 0.70 or lower limit of normal (LLN) cut-off point) best predicts accelerated lung function decline and exacerbations in middle-aged smokers. We performed secondary analyses on the Lung Health Study dataset. 4045 smokers aged 35-60 years with mild-to-moderate obstructive pulmonary disease were subdivided into categories based on presence or absence of obstruction according to both FEV1/FVC cut-off points. Post-bronchodilator FEV1 decline served as the primary outcome to compare subjects between the categories. 583 (14.4%) subjects were nonobstructed and 3230 (79.8%) subjects were obstructed according to both FEV1/FVC cut-off points. 173 (4.3%) subjects were obstructed according to the fixed cut-off point, but not according to the LLN cut-off point ("discordant" subjects). Mean±SE post-bronchodilator FEV1 decline was 41.8±2.0 mL·year(-1) in nonobstructed subjects, 43.8±3.8 mL·year(-1) in discordant subjects and 53.5±0.9 mL·year(-1) in obstructed subjects (p<0.001). Our study showed that FEV1 decline in subjects deemed obstructed according to a fixed criterion (FEV1/FVC <0.70), but non-obstructed by a sex- and age-specific criterion (LLN) closely resembles FEV1 decline in subjects designated as non-obstructed by both criteria. Sex and age should be taken into account when assessing airflow obstruction in middle-aged smokers.

Adverse outcomes in maternity care for women with a low risk profile in The Netherlands: a case series analysis.

BACKGROUND: This study aimed to perform a structural analysis of determinants of risk of critical incidents in care for women with a low risk profile at the start of pregnancy with a view on improving patient safety. METHODS: We included 71 critical incidents in primary midwifery care and subsequent hospital care in case of referral after 36 weeks of pregnancy that were related to substandard care and for that reason were reported to the Health Care Inspectorate in The Netherlands in 36 months (n = 357). We performed a case-by-case analysis, using a previously validated instrument which covered five broad domains: healthcare organization, communication between healthcare providers, patient risk factors, clinical management, and clinical outcomes. RESULTS: Determinants that were associated with risk concerned healthcare organization (n = 20 incidents), communication about treatment procedures (n = 39), referral processes (n = 19), risk assessment by telephone triage (n = 10), and clinical management in an out of hours setting (n = 19). The 71 critical incidents included three cases of maternal death, eight cases of severe maternal morbidity, 42 perinatal deaths and 12 critical incidents with severe morbidity for the child. Suboptimal prenatal risk assessment, a delay in availability of health care providers in urgent situations, miscommunication about treatment between care providers, and miscommunication with patients in situations with a language barrier were associated with safety risks. CONCLUSIONS: Systematic analysis of critical incidents improves insight in determinants of safety risk. The wide variety of determinants of risk of critical incidents implies that there is no single intervention to improve patient safety in the care for pregnant women with initially a low risk profile.

Implementation of personalized self-management support using the self-management screening questionnaire SeMaS; a study protocol for a cluster randomized trial.

BACKGROUND: The number of patients with one or more chronic diseases is rising. In several standards of care there is a focus on enhancing self-management. We applied the concept of personalization on self-management support and developed a self-management screening questionnaire (SeMaS). The main research objective is to assess the effectiveness of the SeMaS questionnaire and subsequent personalized self-management on patients' self-management behaviors. METHODS/DESIGN: A cluster randomized controlled trial will be set up in 15 general practices in the Netherlands. The practices are all group practices, and member of one care group. The practices will be assigned to the control or intervention arms by stratified randomization. The strata are determined by the participation of the practice nurses in a course for behavioral change, and the nurse's workload. Patients can be included if they are over 18 years of age, have at least one chronic condition and have a checkup appointment with the practice nurse in the inclusion period. The intervention consists of screening patients with the SeMaS questionnaire, producing a graphic profile with the abilities or barriers for self-management. Patients will receive tailored feedback. Practice nurses are trained in using the profile to enhance self-management of the patient and provide personalized self-management support. The use of individual care plans and self-management interventions is stimulated. In the control arm patients will receive care as usual. Patients of both trial arms will be asked to fill in the SeMaS questionnaire and additional questionnaires at inclusion and after 6 months. The primary outcome is the difference in the level of patient activation (PAM-13) between baseline and 6 months. Secondary outcomes include patient measures for lifestyle factors (exercise, diet, smoking), and process measures from medical record data analysis. DISCUSSION: This manuscript presents the protocol for a cluster randomized clinical trial of personalized self-management support using the SeMaS questionnaire in chronically ill patients in primary care. By carrying out this study, scientific evidence is built for the effectiveness of personalized self-management support. TRIAL REGISTRATION: The Netherlands National Trial Register: NTR3960.

Patient safety in midwifery-led care in the Netherlands.

OBJECTIVE: to describe the incidence and characteristics of patient safety incidents in midwifery-led care for low-risk pregnant women. DESIGN: multi-method study. SETTING: 20 midwifery practices in the Netherlands; 1,000 patient records. POPULATION: low-risk pregnant women. METHODS: prospective incident reporting by midwives during 2 weeks; questionnaire on safety culture and retrospective content analysis of 1,000 patient records in 2009. MAIN OUTCOME MEASURES: incidence, type, impact and causes of safety incidents. RESULTS: in the 1,000 patient records involving 14,888 contacts, 86 safety incidents were found with 25 of these having a noticeable effect on the patient. Low-risk pregnant women in midwifery care had a probability of 8.6% for a safety incident (95% CI 4.8-14.4). In 9 safety incidents, temporary monitoring of the mother and/or child was necessary. In another 6 safety incidents, reviewers reported psychological distress for the patient. Hospital admission followed from 1 incident. No safety incidents were associated with mortality or permanent harm. The majority of incidents found in the patient records concerned treatment and organisational factors. CONCLUSIONS: a low prevalence of patient safety incidents was found in midwifery care for low-risk pregnant women. This first systematic study of patient safety in midwifery adds to the base of evidence regarding the safety of midwifery-led care for low-risk women. Nevertheless, some areas for improvement were found. Improvement of patient safety should address the better adherence to practice guidelines for patient risk assessment, better implementation of interventions for known lifestyle risk factors and better availability of midwives during birthing care.

Patient safety in midwifery care for low-risk women: instrument development.

INTRODUCTION: Few studies have examined the safety of midwife-led care for low-risk childbearing women. While most women have a low-risk profile at the start of pregnancy, validated measures to detect patient safety risks for this population are needed. The increased interest of midwife-led care for childbearing women to substitute for other models of care requires careful evaluation of safety aspects. In this study, we developed and tested an instrument for safety assessment of midwifery care. METHODS: A structured approach was followed for instrument development. First, we reviewed the literature on patient safety in general and obstetric and midwifery care in particular. We identified 5 domains of patient risk: organization, communication, patient-related risk factors, clinical management, and outcomes. We then developed a prototype to assess patient records and, in an iterative process, reviewed the prototype with the help of a review team of midwives and safety experts. The instrument was pilot tested for content validity, reliability, and feasibility. RESULTS: Trained reviewers with clinical midwifery expertise applied the instrument. We were able to reduce the original 100-item screening instrument to 32 items and applied the instrument to patient records in a reliable manner. With regard to the validity of the instrument, review of the literature and the validation procedure produced good content validity. DISCUSSION: A valid and feasible instrument to assess patient safety in low-risk childbearing women is now available and can be used for quantitative analyses of patient records and to identify unsafe situations. Identification and analysis of patient safety incidents required clinical judgment and consultation with the panel of safety experts. The instrument allows us to draw conclusions about safety and to recommend steps for specific, domain-based improvements. Studies on the use of the instrument for improving patient safety are recommended.

Factors associated with the impact of quality improvement collaboratives in mental healthcare: an exploratory study.

BACKGROUND: Quality improvement collaboratives (QICs) bring together groups of healthcare professionals to work in a structured manner to improve the quality of healthcare delivery within particular domains. We explored which characteristics of the composition, participation, functioning, and organization of these collaboratives related to changes in the healthcare for patients with anxiety disorders, dual diagnosis, or schizophrenia. METHODS: We studied three QICs involving 29 quality improvement (QI) teams representing a number of mental healthcare organizations in the Netherlands. The aims of the three QICs were the implementation of multidisciplinary practice guidelines in the domains of anxiety disorders, dual diagnosis, and schizophrenia, respectively. We used eight performance indicators to assess the impact of the QI teams on self-reported patient outcomes and process of care outcomes for 1,346 patients. The QI team members completed a questionnaire on the characteristics of the composition, participation in a national program, functioning, and organizational context for their teams. It was expected that an association would be found between these team characteristics and the quality of care for patients with anxiety disorders, dual diagnosis, and schizophrenia. RESULTS: No consistent patterns of association emerged. Theory-based factors did not perform better than practice-based factors. However, QI teams that received support from their management and both active and inspirational team leadership showed better results. Rather surprisingly, a lower average level of education among the team members was associated with better results, although less consistently than the management and leadership characteristics. Team views with regard to the QI goals of the team and attitudes towards multidisciplinary practice guidelines did not correlate with team success. CONCLUSIONS: No general conclusions about the impact of the characteristics of QI teams on the quality of healthcare can be drawn, but support of the management and active, inspirational team leadership appear to be important. Not only patient outcomes but also the performance indicators of monitoring and screening/assessment showed improvement in many but not all of the QI teams with such characteristics. More studies are needed to identify factors associated with the impact of multidisciplinary practice guidelines in mental healthcare.

Patient safety in Dutch primary care: a study protocol.

BACKGROUND: Insight into the frequency and seriousness of potentially unsafe situations may be the first step towards improving patient safety. Most patient safety attention has been paid to patient safety in hospitals. However, in many countries, patients receive most of their healthcare in primary care settings. There is little concrete information about patient safety in primary care in the Netherlands. The overall aim of this study was to provide insight into the current patient safety issues in Dutch general practices, out-of-hours primary care centres, general dental practices, midwifery practices, and allied healthcare practices. The objectives of this study are: to determine the frequency, type, impact, and causes of incidents found in the records of primary care patients; to determine the type, impact, and causes of incidents reported by Dutch healthcare professionals; and to provide insight into patient safety management in primary care practices. DESIGN AND METHODS: The study consists of three parts: a retrospective patient record study of 1,000 records per practice type was conducted to determine the frequency, type, impact, and causes of incidents found in the records of primary care patients (objective one); a prospective component concerns an incident-reporting study in each of the participating practices, during two successive weeks, to determine the type, impact, and causes of incidents reported by Dutch healthcare professionals (objective two); to provide insight into patient safety management in Dutch primary care practices (objective three), we surveyed organizational and cultural items relating to patient safety. We analysed the incidents found in the retrospective patient record study and the prospective incident-reporting study by type of incident, causes (Eindhoven Classification Model), actual harm (severity-of-outcome domain of the International Taxonomy of Medical Errors in Primary Care), and probability of severe harm or death. DISCUSSION: To estimate the frequency of incidents was difficult. Much depended on the accuracy of the patient records and the professionals' consensus about which types of adverse events have to be recognized as incidents.

Consensus Report: 2nd European Workshop on Tobacco Use Prevention and Cessation for Oral Health Professionals.

Tobacco use has been identified as a major risk factor for oral disorders such as cancer and periodontal disease. Tobacco use cessation (TUC) is associated with the potential for reversal of precancer, enhanced outcomes following periodontal treatment, and better periodontal status compared to patients who continue to smoke. Consequently, helping tobacco users to quit has become a part of both the responsibility of oral health professionals and the general practice of dentistry. TUC should consist of behavioural support, and if accompanied by pharmacotherapy, is more likely to be successful. It is widely accepted that appropriate compensation of TUC counselling would give oral health professionals greater incentives to provide these measures. Therefore, TUC-related compensation should be made accessible to all dental professionals and be in appropriate relation to other therapeutic interventions. International and national associations for oral health professionals are urged to act as advocates to promote population, community and individual initiatives in support of tobacco use prevention and cessation (TUPAC) counselling, including integration in undergraduate and graduate dental curricula. In order to facilitate the adoption of TUPAC strategies by oral health professionals, we propose a level of care model which includes 1) basic care: brief interventions for all patients in the dental practice to identify tobacco users, assess readiness to quit, and request permission to re-address at a subsequent visit, 2) intermediate care: interventions consisting of (brief) motivational interviewing sessions to build on readiness to quit, enlist resources to support change, and to include cessation medications, and 3) advanced care: intensive interventions to develop a detailed quit plan including the use of suitable pharmacotherapy. To ensure that the delivery of effective TUC becomes part of standard care, continuing education courses and updates should be implemented and offered to all oral health professionals on a regular basis.

Public health aspects of tobacco control revisited.

The tobacco epidemic presents a major public health challenge, globally, and within Europe. The aim of the Public Health Work Stream at the 2nd European Workshop on Tobacco Use Prevention and Cessation for Oral Health Professionals was to review the public health aspects of tobacco control and make recommendations for action. The paper reports on the size of the tobacco challenge; from the associated mortality and morbidity to the prevalence of exposure to, and use of, tobacco. It provides a review of progress on tobacco control measures, as monitored by the World Health Organisation, and the impact of multiple influences on tobacco use. Every member of the dental team was considered to have a role as a public health advocate in promoting health and preventing disease in order to address health inequalities. A range of evidence-based approaches to tobacco control from clinical practice through to public policy are advocated, using the principles of the Ottawa Charter, recognising the multiple determinants of health. Tackling the tobacco epidemic may require a paradigm shift in oral healthcare. Therefore, key resources for health professionals on tobacco control are discussed and the implications of the findings for research, policy and practice in Europe are explored.

Monitoring of patients with COPD: a review of current guidelines' recommendations.

BACKGROUND: The goals for the management of COPD are to delay the process of disease progression and alleviate its manifestations. The follow-up of the patients' physical and mental condition is part of best practice management when monitoring routines results in information that contributes to the achievement of management goals. However, the recommendations on monitoring procedures may differ between guidelines and may not be based on scientific evidence. The aim of this article is to review the current guideline recommendations on monitoring routines for COPD. METHODS: Clinical practice guidelines on the management of COPD were identified by a Medline search, Internet search and expanded by experts in the respiratory field. Guidelines on the management of COPD were analysed on recommended monitoring routines, recommended frequency of monitoring. RESULTS: Eighteen clinical practice guidelines on the management of COPD were analysed. The follow-up of lung function indices was the most frequently recommended monitoring routine. Moreover, monitoring of symptoms, exercise tolerance, comorbidity, and smoking habits were recommended regularly. In none of the guidelines, the recommended monitoring routines were evidence based. Only one guideline provides a different set of monitoring parameters for advanced COPD compared to mild and moderate COPD. CONCLUSION: Some monitoring routines were recommended frequently, especially follow-up of lung function indices. However, evidence to support the guideline recommendations for the monitoring of patients with COPD is missing. The effect of monitoring on care process and outcomes should be assessed.

General practitioners' needs for ongoing support for the interpretation of spirometry tests.

BACKGROUND: Although one out of three general practitioners (GPs) carries out spirometry, the diagnostic interpretation of spirometric test results appears to be a common barrier for GPs towards its routine application. METHODS: Multivariate cross-sectional analysis of a questionnaire survey among 137 GPs who participated in a spirometry evaluation programme in the Netherlands. We identified characteristics of GPs and their practice settings associated with GPs' need for ongoing support for spirometry interpretation. RESULTS: Response rate on the survey questionnaire was 98%. The need for ongoing support among the participating GPs was 69%. GPs' recent spirometry training showed a statistically significant association with the need for ongoing support for the interpretation of spirometry (odds ratio 0.43, 95% CI 0.20-0.92). CONCLUSION: There is a need for ongoing support for spirometry interpretation among GPs. Recent spirometry training partially diminished this need.

Variation in spirometry utilization between trained general practitioners in practices equipped with a spirometer.

OBJECTIVE: To explore spirometry utilization among general practitioners and identify practitioner and practice-related factors associated with spirometry utilization. DESIGN: Multivariate multilevel cross-sectional analysis of a questionnaire survey. SETTING: Some 61 general practices involved in a spirometry evaluation programme in the Netherlands. All practices owned a spirometer and were trained to perform spirometry. SUBJECTS: A total of 144 general practitioners and 179 practice assistants. MAIN OUTCOME MEASURES: Extent of spirometry utilization for five indications from national COPD/asthma guidelines, practitioner and practice-related factors associated with spirometry utilization. RESULTS: The response rate was 97%. General practitioners used spirometry mostly to evaluate treatment with inhaled steroids (58%). Significant practitioner-related factors associated with spirometry utilization were: general practitioners' job satisfaction, general practitioners' general interest in research, and prior participation in spirometry training. Practice-related factors associated with spirometry utilization were: presence of a practice nurse, delegation of medical tasks to practice assistants, use of spirometry in different rooms, and use of protocols in practice. CONCLUSION: Practitioner- as well as practice-related factors were associated with the extent of spirometry utilization. In particular, it is essential to improve practice-related factors (e.g. presence of a practice nurse, more delegation of medical tasks to the practice assistant).

Asthma education tailored to individual patient needs can optimise partnerships in asthma self-management.

This paper studies the effects of patient education, tailored to individual needs of patients as part of an asthma self-management program. A tailored education program was designed which took into account individual information needs of patients by using a feedback instrument. Totally 98 steroid dependent asthmatics entered the tailored education program, 95 patients received usual care. Outcome measures were information exchanged and patient satisfaction. Study duration was 6 months. Patients in the tailored education group showed a significant reduction in information need (P=0.005). Patient satisfaction increased from 87.9 to 93.7 in this group while this did not change in the usual care group (P=0.000). Use of this tailored education program improved the GP-patient interaction within the context of a clinically effective asthma self-management program. Findings from this study may be applicable to other chronic conditions as well.

Feedback information from flow volume curves to the practice.

OBJECTIVE: To investigate whether the use of feedback information provided by viewing flow volume (F/V) curves during spirometry performed by practice assistants improves spirometry test quality. METHODS: Randomised controlled single session crossover study. Eight practice assistants performed spirometry in healthy subjects (n=47). Two measurement conditions were applied, one allowing viewing of F/V curves during the tests ('unblinded') the other not ('blinded'). Outcomes were differences in FEV1, FVC, FEV1/FVC ratio, PEF, FEV1 repeatability and number of manoeuvres per test. Two lung function technicians indicated their preference for either the blinded or unblinded F/V curve. RESULTS: Higher PEF values were observed for the unblinded condition (0.43 L/s, 95% CI 0.08, 0.77). The other outcomes showed no differences. One lung function technician judged that in 62% (p=0.012) of the pairs the F/V curve from the unblinded condition was better, the other technician judged so in 51% (p=0.349). CONCLUSION: This study in healthy subjects showed that the use of information from F/V curves leads to a modest quality improvement of spirometric tests performed by practice assistants and can therefore be recommended for use in general practice.

The value of spirometry for primary care: Asthma and COPD.

In this paper, the need for widespread use of spirometry in primary healthcare is appraised through a literature review. The added value of spirometry for and the quality of measurements made by general practitioners (GPs), and the economic consequences of greater use of spirometry in primary care are discussed. Appropriate application of spirometry in general practice may lead to improved health status of patients with chronic obstructive pulmonary disease (COPD) or asthma, but consistent attention to quality assurance measures is vital. If good quality cannot be guaranteed in the general practice setting, the reliability and validity of the tests is uncertain. Pulmonary function laboratories, nurse-run asthma clinics, primary care group (PCG)-commissioned and mobile community-based spirometry services may be other choices, but it depends on local availability as to which choice is most suitable for organising primary care spirometry. It is concluded that spirometry is a potentially useful and feasible tool for GPs, provided that test results are easily integrated into the Gp's usual management of patients with obstructive lung disease. At this time, the health costs of widespread application of spirometry in primary care are unknown.