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Biomedical subjects

R Grol

Publications and source records attributed to R Grol.

At least 55 records · Page 3Linked to original sources
PubMed2000

Are general practitioners able to accurately diagnose dementia and identify Alzheimer's disease? A comparison with an outpatient memory clinic.

Since the introduction of agents for the treatment of Alzheimer's disease, and in order to increase understanding of a patient's changed behaviour, it has become particularly important that dementia is both diagnosed at an early stage and differentiated into its subtypes. This study aims to ascertain whether GPs were able to diagnose dementia and identify the type of dementia accurately and confidently. GPs were well able to assess the firmness of their own dementia diagnoses, which supposes that they are able to make appropriate selection for referral. Diagnostic support from a specialised team can particularly contribute to identifying the type of dementia.

Aged↗
PubMed2000

Low back pain in general practice: reported management and reasons for not adhering to the guidelines in The Netherlands.

BACKGROUND: Although guidelines for the management of low back pain have been published in the past decade, there is potential for further improvement in back pain care. AIM: To document the management of non-specific low back pain by general practitioners (GPs) in the Netherlands, to determine how this management of care is related to patient and physician factors, and to explore possible reasons for not adhering to the guidelines. METHOD: A prospective study was set up in which 57 GPs in 30 general practices completed a computerised questionnaire after each consultation for low back pain during a four-month period. RESULTS: Of 1640 back pain contacts, 1180 referred to non-specific low back pain. Diagnostic tests were ordered in 2% of first consultations and in 7% of follow-up consultations within one episode. The advice to stay active despite pain was given in 76% and 69% of these cases respectively. Patients were prescribed an analgesic in 53% and 41% of cases respectively (mainly NSAIDs [80%]). Patients were referred to a physiotherapist in 22% of first and in 50% of follow-up consultations. Older patients were physically examined less often, prescribed analgesics more often, and were told less often that staying active could benefit them. The advice to remain active was omitted more often when symptoms lasted longer. Only a small part of the variance in management was accounted for by patient characteristics or by differences between practices. CONCLUSION: The management of low back pain met the guidelines to a large extent. Management decisions were often related to characteristics in which the guidelines lack differentiation. Important reasons for non-adherence were perceived patients' preferences. Further implementation of guidelines will be difficult unless doctors' and patients' views are more explicitly known.

Adolescent↗
PubMed2000

Patients in Europe evaluate general practice care: an international comparison.

BACKGROUND: Patients' evaluations can be used to improve health care and compare general practice in different health systems. AIM: To identify aspects of general practice that are generally evaluated positively by patients and to compare opinions of patients in different European countries on actual care provision. METHOD: An internationally-validated questionnaire was distributed to and completed by patients in 10 European countries. A stratified sample of 36 practices per country, with at least 1080 patients per country, was included. A set of 23 validated questions on evaluations of different aspects of care was used, as well as questions on age, sex, overall health status, and frequency of visiting the GP. RESULTS: The patient sample included 17,391 patients in 10 different countries; the average response rate was 79% (range = 67% to 89%). In general, patients visiting their general practitioner (GP) were very positive about the care provided. For most of the 23 selected aspects of care more than 80% viewed care as good or excellent; in particular, keeping records confidential, GP listening to patients, time during consultations, and quick services in case of urgent problems were evaluated positively. Patients were relatively negative about organisational aspects of care. The evaluations in different countries were largely similar, with some interesting differences; for instance, service and organisational aspects were evaluated more positively in fee-for-service health systems. CONCLUSIONS: Patients in Europe are positive about general practice but improvements in practice management in some countries are requested. More research is needed to study the complex field of differences in expectations and evaluations between countries with different health systems.

Culture↗
PubMed2000

Shared decision making and the concept of equipoise: the competences of involving patients in healthcare choices.

BACKGROUND: Involving patients in healthcare decisions makes a potentially significant and enduring difference to healthcare outcomes. One difficulty (among many) is that the 'involvement' of patients in decisions has been left undefined. It is usually conceptualised as 'patient centredness', which is a broad and variably interpreted concept that is difficult to assess using current tools. This paper attempts to gauge general practitioners' (GPs') attitudes to patient involvement in decision making and their views about the contextual factors, competences, and stages required to achieve shared decisions within consultations. AIM: To explore and understand what constitutes the appropriate involvement of patients in decision making within consultations, to consider previous theory in this field, and to propose a set of competences (skills) and steps that would enable clinical practitioners (generalists) to undertake 'shared decision making' in their clinical environment. METHOD: Qualitative study using focus group interviews of key informants. RESULTS: Experienced GPs with educational roles have positive attitudes to the involvement of patients in decisions, provided the process matches the role individuals wish to play. They perceive some clinical problems as being more suited to a cooperative approach to decision making and conceptualised the existence of professional equipoise towards the existence of legitimate treatment options as an important facilitative factor. A sequence of skills was proposed as follows: 1) implicit or explicit involvement of patients in the decision-making process; 2) explore ideas, fears, and expectations of the problem and possible treatments; 3) portrayal of equipoise and options; 4) identify preferred data format and provide tailor-made information; 5) checking process: understanding of information and reactions (e.g. ideas, fears, and expectations of possible options); 6) acceptance of process and decision making role preference; 7) make, discuss or defer decisions; 8) arrange follow-up. CONCLUSIONS: These clinicians viewed involvement as an implicit ethos that should permeate medical practice, provided that clinicians respect and remain alert to patients' individual preferred roles in decision making. The interpersonal skills and the information requirements needed to successfully share decisions are major challenges to the clinical consultation process in medical practice. The benefits of patient involvement and the skills required to achieve this approach need to be given much higher priority at all levels: at policy, education, and within further professional development strategies.

Attitude of Health Personnel↗
PubMed1999

Towards a feasible model for shared decision making: focus group study with general practice registrars.

OBJECTIVES: To explore the views of general practice registrars about involving patients in decisions and to assess the feasibility of using the shared decision making model by means of simulated general practice consultations. DESIGN: Qualitative study based on focus group interviews. SETTING: General practice vocational training schemes in south Wales. PARTICIPANTS: 39 general practice registrars and eight course organisers (acting as observers) attended four sessions; three simulated patients attended each time. METHOD: After an introduction to the principles and suggested stages of shared decision making the registrars conducted and observed a series of consultations about choices of treatment with simulated patients using verbal, numerical, and graphical data formats. Reactions were elicited by using focus group interviews after each consultation and content analysis undertaken. RESULTS: Registrars in general practice report not being trained in the skills required to involve patients in clinical decisions. They had a wide range of opinions about "involving patients in decisions," ranging from protective paternalism ("doctor knows best"), through enlightened self interest (lightening the load), to the potential rewards of a more egalitarian relationship with patients. The work points to three contextual precursors for the process: the availability of reliable information, appropriate timing of the decision making process, and the readiness of patients to accept an active role in their own management. CONCLUSIONS: Sharing decisions entails sharing the uncertainties about the outcomes of medical processes and involves exposing the fact that data are often unavailable or not known; this can cause anxiety to both patient and clinician. Movement towards further patient involvement will depend on both the skills and the attitudes of professionals, and this work shows the steps that need to be taken if further progress is to be made in this direction.

Attitude of Health Personnel↗
PubMed1999

Evidence-based implementation of evidence-based medicine.

BACKGROUND: The slow and haphazard process of translating research findings into clinical practice compromises the potential benefits of clinical research. Most quality improvement (QI) initiatives are based on the beliefs of decision makers rather than on the growing theoretical and empirical knowledge about organizational and provider behavior change. If future QI activities are to improve the translation of evidence into practice, they should be based on an understanding of the different models and strategies for implementing research evidence and the evidence base supporting their use. Evidence-based medicine should be complemented by evidence-based implementation. THE EVIDENCE FOR DIFFERENT STRATEGIES OF IMPLEMENTING CHANGE: A general framework for changing practice based on theoretical perspectives and research evidence considers a variety of theoretical approaches and their contribution to an understanding of provider behavior change. The framework summarizes evidence from systematic reviews of provider behavior change, which suggest the potential of several dissemination and implementation strategies that are effective under certain conditions. Passive dissemination approaches are largely ineffective; specific strategies to implement research-based recommendations appear to be necessary to ensure practice change. Multifaceted interventions that address specific barriers to change are more likely to lead to changes in practice. PRACTICAL, FIVE-STAGE FRAMEWORK: A practical, five-stage framework for changing practice, which is illustrated with experiences from a comprehensive program on implementing evidence-based clinical guidelines in primary care, includes development of a concrete proposal for change; analysis of the target setting and group to identify obstacles to change; linking interventions to needs, facilitators, and obstacles to change; development of an implementation plan; and monitoring progress with implementation.

Evidence-Based Medicine↗
PubMed1999

Assessment in general practice: the predictive value of written-knowledge tests and a multiple-station examination for actual medical performance in daily practice.

This study compares the predictive values of written-knowledge tests and a standardized multiple-station examination for the actual medical performance of general practitioners (GPs) in order to select effective assessment methods to be used in quality-improvement activities. A comprehensive assessment was performed in four phases. First, 100 GPs from the southern part of the Netherlands were assessed by a general medical knowledge test and by a knowledge test on technical skills. Second, in order to check for time-order effects, participants were randomly divided into two groups of 50 each, comparable on scores of both knowledge tests and on professional characteristics. Finally, both groups went through a multiple station examination using standardized patients and a practice video assessment of real surgery, but in opposite orders. Consultations were videotaped and assessed by well-trained peer observers. The drop-out rate was 10%. In both groups the predictive value of medical knowledge tests, ranging from 0.43 to 0.56 (Pearson correlation disattenuated), proved to be comparable with the predictive value of the multiple-station examination for actual performance (0.33-0.59). The overall explained variance of scores of the practice video assessment, measured by multiple regression analysis with performance scores as dependent variables and scores on the knowledge tests and the multiple-station examination as independent variables was moderate (19%). A time-order effect showed in only one direction: from practice video assessment to the multiple-station examination. The GP's professional characteristics did not contribute to the explanation of variation in performance. Medical knowledge tests can predict actual clinical performance to the same extent as a multiple-station examination. Compared with a station examination, a knowledge test may be a good alternative method for assessment the procedures of a large number of practising GPs.

Clinical Competence↗
PubMed1999

Assessment of general practitioners by video observation of communicative and medical performance in daily practice: issues of validity, reliability and feasibility.

OBJECTIVES: To develop a video assessment method for General Practitioners (GPs) by analysing issues of validity, reliability and feasibility of observation of videotaped regular consultations. DESIGN: In a cross-sectional study consultations of 93 GPs were video recorded in the practice during 1 week. The GPs registered consultation and patient data in a logbook; 16 consultations per GP were selected using preset criteria. The quality of communicative and medical performance of these consultations was assessed by GP observers with a validated instrument. The validity of the procedure was evaluated by checking the content of each GP's sample using specific sample criteria. Selection bias was estimated by multiple regression analysis, with sample characteristics as independent variables and scores on communication and medical performance as dependent variables. The influence of observation on GPs and patients was assessed by a questionnaire. Generalizability theory was used to estimate reliability. Feasibility was assessed by conducting a questionnaire, by keeping accounts, and by checking the technical quality of the videotaped consultations. SETTING: Universities of Nijmegen and Maastricht, The Netherlands. SUBJECTS: General Practitioners (GPs). RESULTS: The domain of general practice was well covered in the samples; content validity was satisfactory. With regard to the sample characteristics, only the total duration of consultations appeared to correlate significantly with both the score on communication and the score on medical performance. A majority (71%) of GPs reported not being influenced by the observation, except in the first cases, and recognizing their usual daily performance in the videotaped consultations. An acceptable level of reliability was reached after 2.5 hours of observation, i.e. 12 cases by a single observer. The method was well accepted by both GPs and patients. The costs were pound250 per GP. CONCLUSIONS: Video assessment of GPs in daily practice according to the procedures described is a valid and reliable method, one which is useful for education and quality improvement. There is a trade-off between feasibility on one hand and validity, reliability and credibility on the other hand. Compared to investments in observation methods in standardized settings, the costs of video observation of GPs' actual performance are acceptable.

Clinical Competence↗
PubMed1999

Patients' priorities with respect to general practice care: an international comparison. European Task Force on Patient Evaluations of General Practice (EUROPEP).

BACKGROUND AND OBJECTIVES: Improving the sensitivity of general practice to patients' needs demands a good understanding of patients' expectations and priorities in care provision. Insight into differences in expectations of patients in different cultures and health care systems may support decision-making on desirable models for care provision in general practice. An international study was conducted to determine priorities of patients in general practice care: which views do patients in different countries have in common and which views differ? METHODS: Written surveys in general practices in the UK, Norway, Sweden, Denmark, The Netherlands, Germany, Portugal and Israel were performed. Samples of patients from at least 12 practices per country, stratified according to area and type of practice, were included. Patients rated the importance of 38 different aspects of general practice care, selected on the basis of literature analysis, qualitative studies and consensus discussions. Rankings between countries were compared. RESULTS: A total number of 3540 patients (response rate on average 55%) completed the questionnaire. Patients in different countries had many opinions in common. Aspects that got the highest ranking were: getting enough time during the consultation; quick services in case of emergencies; confidentiality of information on patients; telling patients all they want to know about their illness; making patients feel free to talk about their problems; GPs going to courses regularly; and offering preventive services. However, differences between opinions of patients in different countries were also found for some of the selected aspects. A confounding effect of patients' characteristics may have played a role in these differences. DISCUSSION: The study provides information on what patients expect of and value in general practice care. It shows that patients in different cultures and health care systems may have different views on some aspects of care, but most of all that they have many views in common, particularly as far as doctor-patient communication and accessibility of services are concerned.

Adult↗
PubMed1999

Self-treatment of asthma: possibilities and perspectives from the practitioner's point of view.

OBJECTIVES: Self-management of asthma is becoming more and more widespread. The implementation of this treatment strategy requires changes in the role and attitude of the GP. These changes may be hindered by obstacles both expected and experienced. As self-treatment of asthma is more common in the UK, comparison between UK and Dutch GPs provides a good opportunity to identify possible obstacles in general practice to the implementation of self-treatment of asthma with inhaled corticosteroids. METHODS: We carried out a qualitative descriptive study with self-administered questionnaires and interviews. Questionnaires were sent to 500 randomly selected Dutch GPs. Interviews were held with 20 Dutch and 25 British GPs in order to acquire more in-depth information. The outcome measures were attitude towards, knowledge regarding and experiences with self-treatment of asthma; organizational requirements; and expectations of consequences of self-treatment in general practice. RESULTS: The Dutch and British GPs investigated have a positive attitude towards self-treatment of asthma. Though knowledge about self-treatment is present among a majority of the GPs, self-treatment by patients is not yet as common in The Netherlands as it is in the UK. Nineteen per cent of the Dutch GPs had experience with a written peak-flow-based self-treatment plan related to the usage of inhaled steroids. According to our findings, present expected obstacles are probably mainly of the organizational kind, such as the availability of time, money and materials. CONCLUSIONS: There is a positive attitude towards the implementation of self-treatment plans in general practice, but problems relating to certain identified obstacles need to be addressed. There is a need to define which patients might profit from self-treatment, and further proof of both the clinical effectiveness and the cost-effectiveness of self-treatment needs to be acquired.

Administration, Inhalation↗
PubMed1999

Assessment of practicing family physicians: comparison of observation in a multiple-station examination using standardized patients with observation of consultations in daily practice.

PURPOSE: Looking for a valid, reliable, and feasible method to collect data on the performances of practicing family physicians, the authors compare the measurement characteristics of a multiple-station examination (MSE) using standardized patients with those of a video assessment of regular consultations in daily practice (practice video assessment, PVA). METHOD: In a cross-sectional study, consultations of 90 family physicians were videotaped both in an MSE and in their daily practices. Peer-observers used a validated instrument (MAAS-Global) to assess the physicians' communication with patients and their medical performances. The physicians were randomly divided into two groups, comparable for demographic characteristics, and half underwent the assessments in reverse order to test for time-order effects. Content validity, criterion validity, reliability, and feasibility of the two methods were compared. RESULTS: Content validity of the PVA was superior to that of the MSE, since the domain of general family practice care was better covered. Observed participants judged the videotaped practice consultations to be "natural," whereas hardly any family physician, after reviewing the videotaped consultations of the MSE, recognized his or her usual working style. Specific criteria made it possible to standardize real practice. Concerning criterion validity, only the medical-performance components of the two methods correlated. No correlation was found for the communication components. Real-practice performance proved to be less influenced by observation than was performance during the MSE. The reliabilities of the two methods, expected to be better in the controlled MSE, were comparable. The administration of the PVA was more flexible, less costly, and better accepted by the family physicians than was that of the MSE. CONCLUSION: Assessment for quality improvement of family physicians' practices by video observation in daily practice is superior to video assessment in a simulated setting using standardized patients.

Adult↗
PubMed1999

Setting up improvement projects in small scale primary care practices: feasibility of a model for continuous quality improvement.

OBJECTIVES: To evaluate the feasibility of a model for continuous quality improvement in small scale general practice and the improvement projects that practices ran after the introduction of continuous quality improvement. DESIGN: A descriptive study. SETTING: Twenty general practices in the Netherlands tested the model in an intervention period of 18 months. INTERVENTION: A model for continuous quality improvement adapted for general practice was introduced into the practices using a structured strategy. Practices were supported by trained facilitators. MAIN OUTCOME MEASURES: Acceptance at introduction and continued application of the model; the topics of improvement projects that were set up in the practices; whether the improvement projects had been completed; whether they had met the criteria (the use of the "quality cycle" and the Oxford audit score); and whether the self set objectives had been met. RESULTS: The model was introduced and accepted in all participating practices. Practices started 51 improvement projects. At the end of the study period 33 improvement projects had been completed. Practices chose a wide variety of objectives for these projects; most of them concerned medical or organisational topics. Practices started projects mainly because the topic was felt to be a problem or was causing a bottleneck in the organisation. The quality cycle was used in all projects, but practices did not always collect data and evaluate the outcomes. Fourteen projects could be discerned as "full audit". No differences existed in the quality of improvement projects among the various types of practice or between the topics addressed. At the end of the study period half of the practices continued applying the model. CONCLUSION: This study showed that the model was feasible for small scale general practice. However, application of the model tended to disintegrate after the facilitator had left the practice. Practices succeeded reasonably well in running improvement projects. Introduction of continuous quality improvement should particularly focus on this. It is suggested that intensive support is necessary to implement and maintain continuous quality improvement in small scale practices.

Evaluation Studies as Topic↗
PubMed1999

Practice visits as a tool in quality improvement: mutual visits and feedback by peers compared with visits and feedback by non-physician observers.

OBJECTIVE: To evaluate and compare the effects of two programmes of assessment of practice management in a practice visit: mutual visits and feedback by peers compared with visits and feedback by non-physician observers. DESIGN: Prospective, randomised intervention study, with follow up after one year. SETTING: General practices in the Netherlands in 1993 and 1994. SUBJECTS: A total of 90 general practitioners (GPs) in 68 practices; follow up after one year comprised 81 GPs in 62 practices. MAIN MEASURES: Scores on indicators and dimensions of practice management in the visit instrument to assess practice management and organisation (a validated Dutch method to assess practice management in a practice visit). Change was defined as the difference in score between the first visit and the visit after one year on 208 indicators and on 33 dimensions of practice management. RESULTS: Data of 44 mutual visits by peers were compared with data of 46 visits by non-physician observers. After a year both programmes showed improvements on many aspects of practice management, but different aspects changed in each of the two programmes. After mutual practice visits, GPs scored significantly higher on content of the doctor's bag, on collaboration with colleagues, on collaboration with other care providers, and on accessibility of patient information than after a visit by a non-physician observer. The visits by non-physician observers resulted in a higher score on extent of use of records and on assessment on outcome and year report. CONCLUSION: Change after mutual practice visits and feedback by peers is more marked than after a visit and feedback by a non-physician observer.

Family Practice↗