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Biomedical subjects

R Grol

Publications and source records attributed to R Grol.

At least 73 records · Page 4Linked to original sources
PubMed1999

Practice visits as a tool in quality improvement: acceptance and feasibility.

OBJECTIVE: To evaluate the feasibility and acceptance of (a) two programmes of assessment of practice management in a practice visit: mutual practice visits and feedback by peers versus visits and feedback by non-physician observers and (2) the practice visit method used in these programmes (the visit instrument to assess practice management and organisation (VIP)--a validated Dutch tool). DESIGN: Prospective, randomised intervention study with the two programmes, follow up after one year. General practitioners (GPs) were visited after each programme and after the revisits by non-physician observers a year later. SETTING: General practices in the Netherlands in 1993 and 1994. SUBJECTS: A total of 90 GPs in 68 practices. At follow up after 1 year there were 81 GPs in 62 practices. MAIN MEASURES: Scores (mainly five point scales) for questions on appreciation and acceptance; after the follow up visit a year later, scores for questions on feasibility and practicality of the improved procedure and feedback report. RESULTS: Data of 44 mutual visits by peers were compared with data of 46 visits by non-physician observers. A visit by a non-physician observer was appreciated significantly more. After the practice visit at one year follow up, the participants reported to have appreciated the visit and the feedback report and to prefer feedback of a non-physician observer to that of a peer. Participants' reports on the procedure and the presentation of the feedback provided clues for the improvement of visit procedures. CONCLUSIONS: A practice visit and feedback by a non-physician observer is more appreciated than a visit and feedback by a colleague. A practice visit with the VIP by a non-physician observer is a simple, easy, and well accepted method for assessing practice management.

Family Practice↗
PubMed1999

[Topics in clinical dentistry. Trends in the Dutch dental literature].

Aim of the study was to evaluate a method for selecting topics suitable for developing dental clinical practice guidelines in the Netherlands, based on an analysis of Dutch dental journals. A search for dental clinical topics was conducted by analysing Dutch dental journals, magazines and series over the period 1992-1997. The numbers of publications per topic were plotted against the publication years. The number of publications as well as the value of the slope of the linear regression were considered to be indicators of the importance of a topic. 'Dental implants (indication)' had the highest number of publications, followed by 'orthodontic treatment planning' and 'periodontology (indication)'. The topic 'practice hygiene' showed the highest value of the slope of the linear regression, followed by 'TMJ dysfunction' and 'dental implants (indication)'. With this method, it is feasible to detect changes and tendencies in the Dutch dental literature. It permits a selection of clinically relevant topics over a time span. It was concluded that this method may be very useful in the selection of a topic, but should probably be combined with other methods.

Dental Implants↗
PubMed1998

Attributes of clinical guidelines that influence use of guidelines in general practice: observational study.

OBJECTIVE: To determine which attributes of clinical practice guidelines influence the use of guidelines in decision making in clinical practice. DESIGN: Observational study relating the use of 47 different recommendations from 10 national clinical guidelines to 12 different attributes of clinical guidelines-for example, evidence based, controversial, concrete. SETTING: General practice in the Netherlands. SUBJECTS: 61 general practitioners who made 12 880 decisions in their contacts with patients. MAIN OUTCOME MEASURES: Compliance of decisions with clinical guidelines according to the attribute of the guideline. RESULTS: Recommendations were followed in, on average, 61% (7915/12 880) of the decisions. Controversial recommendations were followed in 35% (886/2497) of decisions and non-controversial recommendations in 68% (7029/10 383) of decisions. Vague and non-specific recommendations were followed in 36% (826/2280) of decisions and clear recommendations in 67% (7089/10 600) of decisions. Recommendations that demanded a change in existing practice routines were followed in 44% (1278/2912) of decisions and those that did not in 67% (6637/9968) of decisions. Evidence based recommendations were used more than recommendations for practice that were not based on research evidence (71% (2745/3841) v 57% (5170/9039)). CONCLUSIONS: People and organisations setting evidence based clinical practice guidelines should take into account some of the other important attributes of effective recommendations for clinical practice.

Decision Making↗
PubMed1998

General practice care and patients' priorities in Europe: an international comparison.

Insight into patients' priorities with respect to health care should complement the views of professionals and policy makers on what is thought to be appropriate health care. To determine the strengths and weaknesses of general practice care from patients' perspectives written surveys were performed among patients in Denmark, Germany, Israel, Netherlands, Norway, Portugal, Sweden and United Kingdom (n = 3540). The potential quality problems identified were spread over the different countries: the low involvement of general practitioners in out-of-hours services in Portugal; the low provision of routine screening in Sweden, Norway and The Netherlands; the lack of a defined patient population in Germany; the lack of a formal gatekeeper role to secondary care in general practice in Germany and Sweden; and the low number of home visits in Sweden.

Europe↗
PubMed1998

Which aspects of general practitioners' behaviour determine patients' evaluations of care?

This qualitative study explored those behaviours of a general practitioner which were used by patients in their evaluations of 14 aspects of general practice care. Thirty patients were interviewed immediately after visiting their general practitioner. Interview transcripts were analyzed by two authors, who independently marked general practitioners' behaviours used by patients. Then, these text fragments were categorised into task or affective behaviours according to an existing taxonomy of doctor behaviour in consultations. The results showed that patients reported using task oriented behaviours when they evaluated task oriented aspects of general practice care. However, when they evaluated affective aspects they reported using both affective behaviours and task behaviours, although the latter to a lesser extent. The evaluations of "tell you all you wanted to know about your illness", "explain the purpose and the course of the treatment", "pay attention to your feelings" and "kind and attentive" are clearly linked to specific general practitioners' behaviour. Therefore, evaluations of these aspects can be interpreted straightforwardly. Evaluation of the aspects "GP understands you", "having faith in your GP" and "were you involved in decisions about your medical treatment?" were based on a large variety of physician behaviours which may lead to interpretation problems. Thus, this study gives some important considerations for a better understanding of patients' evaluations of general practice care.

Adult↗
PubMed1998

A systematic review of the literature on patient priorities for general practice care. Part 1: Description of the research domain.

To make health care more responsive to patient needs, insight into patient priorities is needed. A systematic literature review, using electronic and manual searches, was made of studies on patient priorities with regard to primary health care. Data-extraction was performed by two researchers, followed by systematic analyses of study features. 57 studies were included. The aspects of care and methods used showed a wide variation. Aspects most often included were "informativeness", "humaneness" and "competence/accuracy". Based on an analysis of 19 studies, the following aspects were seen by patients as most important in more than 50% of the studies that included them: "humaneness", "competence/accuracy", "patients' involvement in decisions", "time for care", "other aspects of availability/accessibility", "informativeness", "exploring patients' needs", "other aspects of relation and communication" and "availability of special services".

Adult↗
PubMed1998

Structure and process: the relationship between practice management and actual clinical performance in general practice.

OBJECTIVES: The precise relationship between practice management (structure) and the doctor's actual performance (process) in general practice is tenuous. Analysis of their mutual relationship may yield insight into the way they contribute to outcome and into corresponding assessment procedures. METHOD: In a cross-sectional study, consultations of 93 GPs were videotaped in their own practice and assessed by peer-observers on medical performance and on communication with patients, followed by a practice visit by a non-physician observer using a validated Visitation Instrument to assess Practice management and organization (VIP). Pearson correlations (observed and disattenuated for unreliability of the instruments) between scores on 22 practice management dimensions and scores of 16 selected cases on medical performance and communication were calculated. The predictive value of specific practice management aspects for actual performance was determined by multiple regression analysis, with performance scores as dependent variables and scores on the 22 management dimensions and GPs' professional characteristics as independent variables. RESULTS: Nine practice management dimensions correlated significantly with medical performance and so did five dimensions with actual communication. Overall, most associations were weak. Combined with demographic variables (age for medical performance and working single-handedly for communication), 26% of variance in medical performance scores could be explained by only three practice management dimensions. One practice dimension (delegation of medical tasks to the practice assistant) explained 11% of variance in communication with patients. Organization of quality assessment activities explained most of the variation in medical performance. CONCLUSIONS: Practice management (structure) and actual performance (process) seem to be largely autonomous constructs. Quality improvement and assessment activities should emphasize that practice management is different from actual performance. Structure and process may contribute to patient outcome independently of each other.

Adult↗
PubMed1998

Dissemination of guidelines: which sources do physicians use in order to be informed?

OBJECTIVE: To gain insight into processes of dissemination of clinical guidelines, sources of information physicians use to become informed about them, and factors influencing these processes. DESIGN: National survey among a random sample of family physicians using a structured questionnaire. SETTING: Family practice in The Netherlands; evaluation of a national programme of (evidence based) practice guidelines. STUDY PARTICIPANTS: A random sample of 1531 family physicians. MAIN MEASURES: Being informed about national guidelines and specific recommendations from these guidelines; being informed about specific educational programmes on the national guidelines; sources of information used in order to be informed; doctor and practice characteristics. RESULTS: The response rate was 67%, the responders being younger than the non-responders. The scientific journal for family physicians proved to be the most important source of information (85%), discussing the guidelines in the local family doctor group was also important (53%). Following continuing medical education courses was less important (33%). On average 80% knew about the different guidelines and recommendations, 63% about the educational programmes. Doctors who use the scientific journal as a source, who are members of the professional organization of family doctors, who are younger and who are actively involved in education on family medicine, proved to be better informed. CONCLUSIONS: Segmentation of the target group is necessary for effective dissemination of guidelines or new research findings. For some doctors it is desirable to make evidence available quickly, for others spreading the guidelines through the local network may be effective, while for another group a more active, personal approach may be necessary.

Adult↗
PubMed1998

Does the care given by general practitioners and midwives to patients with (imminent) miscarriage meet the wishes and expectations of the patients?

OBJECTIVE: In 1989 a Dutch national guideline on (imminent) miscarriage was developed for use in general practice. A prospective recording study was carried out to determine how the patients evaluated the care they received from general practitioners (GPs) and midwives who agreed to adhere to this (imminent) miscarriage guideline and to determine the aspects that influence this evaluation. SETTING: GP practices and midwifery practices in The Netherlands. DESIGN: Prospective recording of appointments during 4 consecutive weeks in a diary by patients who contacted their GP or midwife with symptoms of (imminent) miscarriage. STUDY PARTICIPANTS: Over a period of 12 months, 75 GPs and 43 midwives recorded all patients (n = 407) showing symptoms of (imminent) miscarriage. In total 265 patients had completed at least the first contact in the diary; 200 patients actually recorded all contacts. RESULTS: Most patients gave their GP or midwife a high evaluation score (8.2 or 8.7 respectively). Yet, 20% thought that the care could be improved if the GP or midwife gave more information, was more empathetic and carried out an ultrasound scan. In determining the aspects that have most influence on the patients' evaluation, empathy and support came first, followed by involvement of the patient in decision making, putting her at ease, and the total duration of the contacts. Although patients who wanted a referral gave a lower score, this seems to be of less importance than the above mentioned aspects. Expecting and getting an ultrasound scan did not influence the patient's evaluation.

Abortion, Threatened↗
PubMed1998

Assessment of management in general practice: validation of a practice visit method.

BACKGROUND: Practice management (PM) in general practice is as yet ill-defined; a systematic description of its domain, as well as a valid method to assess it, are necessary for research and assessment. AIM: To develop and validate a method to assess PM of general practitioners (GPs) and practices. METHOD: Relevant and potentially discriminating indicators were selected from a systematic framework of 2410 elements of PM to be used in an assessment method (VIP = visit instrument PM). The method was first tested in a pilot study and, after revision, was evaluated in order to select discriminating indicators and to determine validity of dimensions (factor and reliability analysis, linear regression). RESULTS: One hundred and ten GPs were assessed with the practice visit method using 249 indicators; 208 of these discriminated sufficiently at practice level or at GP level. Factor analysis resulted in 34 dimensions and in a taxonomy of PM. Dimensions and indicators showed marked variation between GPs and practices. Training practices scored higher on five dimensions; single-handed and dispensing practices scored lower on delegated tasks, but higher on accessibility and availability. CONCLUSION: A visit method to assess PM has been developed and its validity studied systematically. The taxonomy and dimensions of PM were in line with other classifications. Selection of a balanced number of useful and relevant indicators was nevertheless difficult. The dimensions could discriminate between groups of GPs and practices, establishing the value of the method for assessment. The VIP method could be an important contribution to the introduction of continuous quality improvement in the profession.

Family Practice↗
PubMed1998

Implementing guidelines and innovations in general practice: which interventions are effective?

BACKGROUND: It is crucial that research findings are implemented in general practice if high-quality care is to be achieved. Multifaceted interventions are usually assumed to be more effective than single interventions, but this hypothesis has yet to be tested for general practice care. This review evaluates the effectiveness of interventions in influencing the implementation of guidelines and adoption of innovations in general practice. A systematic literature study was carried out using MEDLINE searches for the period from January 1980 until June 1994, and 21 medical journals were searched manually. Randomized controlled trials and controlled before and after studies (with pre- and post-intervention measurements in all groups) were selected for the analysis. Clinical area, interventions used, methodological characteristics and effects on clinical behaviour were noted independently by two researchers using a standardized scoring form. Of 143 studies found, 61 were selected for the analysis, covering 86 intervention groups that could be compared with a control group without the intervention. Information transfer alone was effective in two out of 18 groups, whereas combinations of information transfer and learning through social influence or management support were effective in four out of eight and three out of seven groups respectively. Information linked to performance was effective in 10 out of 15 groups, but the combination of information transfer and information linked to performance was effective in only three out of 20 groups. Some, but not all, multifaceted interventions are effective in inducing change in general practice. Social influence and management support can improve the effectiveness of information transfer, but information linked to performance does not necessarily do so. The variation in the effectiveness of interventions needs further analysis.

Family Practice↗
PubMed1997

Does the health status of chronically ill patients predict their judgements of the quality of general practice care?

Patients' health status as well as patients' judgements of care are used for assessing patients' perspectives, but the relation between those two concepts is unclear. In this study we explored whether health status predicts patients' judgements of the quality of general practice care. Hand-distributed and mailed surveys were performed by 28 general practitioners in The Netherlands. Chronically ill patients were approached when visiting the general practice or drawn from the practice registers. Health status was measured by WONCA/COOP charts, and patients' judgements by the CEP, a previously validated questionnaire. The response rate was 63% (n = 762). When controlled for other patient characteristics, a poor overall health predicted less positive judgements of medical care, information, counselling, relation and communication, continuity of care and the organization of appointments (p < 0.01). Poor mental well-being predicted less positive judgements of the cooperation between care providers and a stronger need for more care (p < 0.001). The four other aspects of health status did not predict the patients' judgements. Judgements about the premises and the availability for emergencies were not predicted by health status. It can be concluded that a multidimensional approach should be used for interpreting the relations between patients' health status and their judgements of general practice care.

Adult↗
PubMed1997

Adherence by midwives to the Dutch national guidelines on threatened miscarriage in general practice: a prospective study.

OBJECTIVE: To determine the feasibility for midwives to adhere to Dutch national guidelines on threatened miscarriage in general practice. DESIGN: Prospective recording of appointments by midwives who agreed to adhere to the guidelines on threatened miscarriage. Interviews with the midwives after they had recorded appointments for one year. SETTING: Midwifery practices in The Netherlands. SUBJECTS: 56 midwives who agreed to adhere to the guidelines; 43 midwives actually made records from 156 clients during a period of 12 months. MAIN OUTCOME MEASURES: Adherence to each recommendation and reasons for non-adherence. RESULTS: The recommendation that a physical examination should take place on the first and also on the follow up appointment was not always adhered to. Reasons for non-adherence were the midwives' criticism of this recommendation, their lack of knowledge or skills, and the specific client situation. Adherence to a follow up appointment after 10 days, a counselling consultation after six weeks, and not performing an ultrasound scan was low. Reasons for non-adherence were mainly based on the midwives' criticism of these recommendations and reluctance on the part of the client. Furthermore, many midwives did not give information and instructions to the client. It is noteworthy that in 13% of the cases the midwife's policy was overridden by the obstetrician taking control of the situation after the midwife had requested an ultrasound scan. CONCLUSIONS: Those recommendations in the guidelines on threatened miscarriage that are most often not adhered to should be reviewed. To reduce conflicts about ultrasound scans and referrals, agreement on the policy on threatened miscarriage should be mutually established between midwives and obstetricians.

Abortion, Threatened↗
PubMed1997

The reliability of patients' judgements of care in general practice: how many questions and patients are needed?

OBJECTIVES: To estimate the number of questions and patients that are needed to achieve reliable measurements of patients' judgements of care in general practice. DESIGN: Sensitivity study, using generalisibility theory and real data from surveys of patients. SUBJECTS: 739 patients with chronic illness from 23 general practitioners in The Netherlands. MAIN MEASURES: The reliability coefficients of scores per patient and scores per general practitioner for patients' judgements of nine dimensions of care in general practice. RESULTS: For most dimensions the reliability per patient was 0.80 or higher if three questions were used, but for the evaluation of the "organisation of appointments" and "premises" five questions had to be used. To reach a reliability coefficient of 0.80 per general practitioner three questions and 90 patients, or five questions and 60 patients, were needed for most dimensions. Even more patients or questions were needed for the dimensions "availability for emergencies", premises, and "continuity". A reliability of 0.70 per general practitioner could be achieved if three questions and 60 patients were used, except for availability for emergencies and premises, for which more patients or questions were required. CONCLUSIONS: Surveys of patients can only provide reliable information if the samples of questions and patients are large enough. It is important to distinguish between the reliability of scores per patient and the reliability per care provider, as well as between different dimensions of care. The reliability per patient is good for most dimensions if three questions are used, but a good reliability per care provider requires more questions or patients.

Aged↗
PubMed1997

[Practice guidelines in dentistry. An insight into the Dutch situation].

Practice guidelines provide opportunities for monitoring and improving dental health care. A survey was conducted among 78 departments at dental societies, scientific dental associations and health care insurance companies in the Netherlands to obtain insight into the number and quality of practice guidelines available. The response rate was 67%. Written materials were analysed and 21 practice guidelines were identified as such. The results of the analysis indicate that many initiatives to construct and implement practice guidelines have been taken. However, these initiatives were insufficiently coordinated and existing guidelines may be subject to improvement. Main improvement would be to demonstrate the validity and reliability of the existing guidelines and, more in general, to provide a sound scientific basis to the development and implementation of practice guidelines.

Data Collection↗
PubMed1997

Selection for postgraduate training for general practice: the role of knowledge tests.

BACKGROUND: Postgraduate training for general practice is a legal requirement in most countries of the European Community, and includes posts in general practice as well as in hospitals. The effectiveness of the training has not been fully evaluated, and it is largely unknown whether the results are satisfactory or what the impact of the separate training components is--nor is it known which characteristics or prior achievements of the trainee influence the end-of-training performance. AIM: To determine the value of knowledge tests in the context of entry selection for postgraduate training in general practice. METHODS: Three (equated) knowledge tests were administered during the two years' postgraduate training of 85 Dutch trainees. The first test was taken at entrance, the second eight months later, and the third shortly before the end of the entire training period. Complete data for 57 trainees were available for analysis. A multiple regression analysis was performed to estimate the predictive values of test 1 and test 2 scores, separately and in combination, for test 3 scores. Since the knowledge test may be used for selection purposes, the analysis was repeated using logistic regression with two pass/fail criteria: a 'minimum criterion' and an 'excellence criterion'. RESULTS: Neither of the two analyses yielded a predictive value of test 1 that was high enough to warrant the use of knowledge tests in the context of entry selection. A 'below minimum' score on test 2 correlated 100% with a 'below minimum' score on test 3. However, the positive predictive value of an above minimum score on test 2 was only 86%. CONCLUSIONS: The knowledge tests used in this study are not suitable in the context of entry selection. However, trainees that score 'below minimum' after eight months of training may be regarded as 'at risk' in that they will probably score 'below minimum' at the end of training.

Education, Medical, Continuing↗