PubMed Health⌕ Search

Biomedical subjects

M Wensing

Publications and source records attributed to M Wensing.

At least 19 recordsLinked to original sources
PubMed2003

Shared decision making: developing the OPTION scale for measuring patient involvement.

BACKGROUND: A systematic review has shown that no measures of the extent to which healthcare professionals involve patients in decisions within clinical consultations exist, despite the increasing interest in the benefits or otherwise of patient participation in these decisions. AIMS: To describe the development of a new instrument designed to assess the extent to which practitioners involve patients in decision making processes. DESIGN: The OPTION (observing patient involvement) scale was developed and used by two independent raters to assess primary care consultations in order to evaluate its psychometric qualities, validity, and reliability. STUDY SAMPLE: 186 audiotaped consultations collected from the routine clinics of 21 general practitioners in the UK. METHOD: Item response rates, Cronbach's alpha, and summed and scaled OPTION scores were calculated. Inter-item and item-total correlations were calculated and inter-rater agreements were calculated using Cohen's kappa. Classical inter-rater intraclass correlation coefficients and generalisability theory statistics were used to calculate inter-rater reliability coefficients. Basing the tool development on literature reviews, qualitative studies and consultations with practitioner and patients ensured content validity. Construct validity hypothesis testing was conducted by assessing score variation with respect to patient age, clinical topic "equipoise", sex of practitioner, and success of practitioners at a professional examination. RESULTS: The OPTION scale provided reliable scores for detecting differences between groups of consultations in the extent to which patients are involved in decision making processes in consultations. The results justify the use of the scale in further empirical studies. The inter-rater intraclass correlation coefficient (0.62), kappa scores for inter-rater agreement (0.71), and Cronbach's alpha (0.79) were all above acceptable thresholds. Based on a balanced design of five consultations per clinician, the inter-rater reliability generalisability coefficient was 0.68 (two raters) and the intra-rater reliability generalisability coefficient was 0.66. On average, mean practitioner scores were very similar (and low on the overall scale of possible involvement); some practitioner scores had more variation around the mean, indicating that they varied their communication styles to a greater extent than others. CONCLUSIONS: Involvement in decision making is a key facet of patient participation in health care and the OPTION scale provides a validated outcome measure for future empirical studies.

Decision Making↗
PubMed2003

Methods for evaluation of small scale quality improvement projects.

Evaluation is an integral component of quality improvement and there is much to be learned from the evaluation of small scale quality improvement initiatives at a local level. This type of evaluation is useful for a number of different reasons including monitoring the impact of local projects, identifying and dealing with issues as they arise within a project, comparing local projects to draw lessons, and collecting more detailed information as part of a bigger evaluation project. Focused audits and developmental studies can be used for evaluation within projects, while methods such as multiple case studies and process evaluations can be used to draw generalised lessons from local experiences and to provide examples of successful projects. Evaluations of small scale quality improvement projects help those involved in improvement initiatives to optimise their choice of interventions and use of resources. Important information to add to the knowledge base of quality improvement in health care can be derived by undertaking formal evaluation of local projects, particularly in relation to building theory around the processes of implementation and increasing understanding of the complex change processes involved.

Family Practice↗
PubMed2002

The range of minimum provoking doses in hazelnut-allergic patients as determined by double-blind, placebo-controlled food challenges.

BACKGROUND: The risk for allergic reactions depends on the sensitivity of individuals and the quantities of offending food ingested. The sensitivity varies among allergic individuals, as does the threshold dose of a food allergen capable of inducing an allergic reaction. OBJECTIVE: This study aimed at determining the distribution of minimum provoking doses of hazelnut in a hazelnut-allergic population. METHODS: Thirty-one patients with a history of hazelnut-related allergic symptoms, a positive skin prick test to hazelnut and/or an elevated specific IgE level, were included. Double-blind, placebo-controlled food challenges (DBPCFC) were performed with seven increasing doses of dried hazelnut (1 mg to 1 g hazelnut protein) randomly interspersed with seven placebo doses. RESULTS: Twenty-nine patients had a positive challenge. Itching of the oral cavity and/or lips was the first symptom in all cases. Additional gastrointestinal symptoms were reported in five patients and difficulty in swallowing in one patient. Lip swelling was observed in two patients, followed by generalized urticaria in one of these. Threshold doses for eliciting subjective reactions varied from a dose of 1 mg up to 100 mg hazelnut protein (equivalent to 6.4-640 mg hazelnut meal). Extrapolation of the dose-response curve showed that 50% of our hazelnut-allergic population will suffer from an allergic reaction after ingestion of 6 mg (95% CI, 2-11 mg) of hazelnut protein. Objective symptoms were observed in two patients after 1 and 1,000 mg, respectively. CONCLUSION: DBPCFCs demonstrated threshold doses in half of the hazelnut-allergic patients similar to doses previously described to be hidden in consumer products. This stresses the need for careful labelling and strategies to prevent and detect contamination of food products with hazelnut residues.

Adolescent↗
PubMed2002

Lower urinary tract symptoms: social influence is more important than symptoms in seeking medical care.

OBJECTIVE: To determine associations among lower urinary tract symptoms (LUTS), symptom severity, subjective beliefs and social influences when seeking primary medical care in men aged > or = 50 years. SUBJECTS AND METHODS: A population-based survey was conducted among 5052 men aged > or = 50 years, using patient registers of 22 general practitioners (GPs) in the Netherlands from November 1999 to May 2000. The questionnaire contained items concerning age, educational level, International Prostate Symptom Score (IPSS), bothersome score (BS), and questions from the Health Belief Model on attitude and social influences. The study population comprised men with an IPSS openface> 7. The odds ratios (ORs) corrected for the IPSS were calculated. RESULTS: In all, 3544 questionnaires (70.2%) were returned. Two groups of men with an IPSS openface> 7 were compared: those who consulted their GP in the previous 2 years because of voiding problems (268 cases) and the controls (272) who did not visit a GP for these symptoms. Cases more often thought a physician could improve their condition (OR 2.85), appeared to be more often advised by others to seek medical care (OR 6.36) and thought more often that this advice influenced their decision (OR 13.95). They also had more frequently received information from the media (OR 2.66) which affected their attendance (OR 12.52). In a multiple regression analysis, advice from others or information from the media were stronger predictors of seeking care than the influence of symptoms on daily life, the IPSS or the BS. CONCLUSION: Social influences, i.e. advice from others or the media, were more important factors in the decision to seek medical care than symptom severity.

Aged↗
PubMed2002

Research on patients' views in the evaluation and improvement of quality of care.

The identification of methods for assessing the views of patients on health care has only developed over the last decade or so. The use of patients' views to improve healthcare delivery requires valid and reliable measurement methods. Four approaches are recognised: inclusion of patients' views in the information to those seeking health care, identification of patient preferences in episodes of care, patient feedback on delivery of health care, and patients' views in decision making on healthcare systems. Outcome measures for the evaluation of the use of patients' views should reflect the aims in terms of processes or outcomes of care, including possible negative consequences. Rigorous methodologies for the evaluation of methods have yet to be implemented.

Attitude to Health↗
PubMed2002

Comparison of patients' and general practitioners' evaluations of general practice care.

OBJECTIVES: To compare patients' and general practitioners' (GPs') evaluations of the quality of general practice care. DESIGN: Written surveys among patients and GPs. SETTING: General practice in the Netherlands. SUBJECTS: 1772 patients (from 45 GPs) and a random sample of 315 GPs. MAIN OUTCOME MEASURES: Patients' and GPs' evaluations of 23 aspects of general practice care and GPs' perceptions of patients' evaluations using a 5 point scale. RESULTS: The response rate was 88% in the patient sample and 63% in the GP sample. The patients' ratings of care were significantly more positive (mean 4.0) than those of the GPs (mean 3.7) as well as GPs' perceptions of patients' evaluations (mean 3.5) (p<0.001). The overall rank order correlations between the patients' evaluations, GPs' evaluations, and GPs' perceptions of the patients' evaluations were 0.75 or higher (p<0.001). Patients and practitioners gave the most positive evaluations of specific aspects of the doctor-patient relationship ("keeping patients' records and data confidential", "listening to patients", and "making patients feel they had enough time during consultations") and aspects of the organisation of care ("provide quick service for urgent health problems" and "helpfulness of the staff (other than the doctor)"). The aspects of care evaluated least positively by patients as well as by GPs were other organisational aspects ("preparing patients for what to expect from specialist or hospital care" and "getting through to practice on the telephone"). CONCLUSIONS: GPs and patients have to some extent a shared perspective on general practice care. However, GPs were more critical about the quality of care than patients and they underestimated how positive patients were about the care they provide. Furthermore, specific aspects of care were evaluated differently, so surveys and other consultations with patients are necessary to integrate their perspective into quality improvement activities.

Adolescent↗
PubMed2001

Implementation barriers for general practice guidelines on low back pain a qualitative study.

STUDY DESIGN: Qualitative study design, using semi-structured interviews. OBJECTIVE: To explore factors that determine non-adherence to the guidelines for low back pain. SUMMARY OF BACKGROUND DATA: Guidelines for low back pain have been published in the past decade in various countries. In the Netherlands, general practitioners adhere to them to a fair extent, and it is unclear whether room for improvement remains. METHODS: Forty semistructured, in-depth interviews were conducted with twenty patients who consulted for low back pain, and with their general practitioners. The interviews were fully transcribed and analyzed qualitatively. RESULTS: Patients often had limited expectations of the consultation. They wanted to hear a diagnosis or expected to receive simple advice. The general practitioners said they were well informed about the guideline and mostly agreed with its content. Reasons for non-adherence were mainly related to patients' experiences in the past and general practitioners' interpretations of their preferences. General practitioners stated that they were inclined to give in to patients' demands, for example the request for radiographic films or a referral to a physical therapist. In general, patients and their general practitioners were satisfied with the chosen management. CONCLUSIONS: Improvement of the quality of back pain care may still be possible. Implementation strategies should aim at training physicians in communication skills, especially about subjects for debate, where patients' beliefs and experiences color their expectations.

Adult↗
PubMed2001

Interventions to implement prevention in primary care.

BACKGROUND: Primary care physicians hold a strategic position in delivering preventive services. However discrepancies exist between evidence based guidelines and practice. OBJECTIVES: To assess the effects of interventions to improve the delivery of preventive services in primary care. SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care Group specialised register (November 1995; August 1999), MEDLINE (1980 to 1995) and hand searched relevant journals. SELECTION CRITERIA: Randomised trials, controlled before and after studies, and interrupted time series analyses of interventions to improve preventive services by primary care professionals responsible for patient care. DATA COLLECTION AND ANALYSIS: Two researchers independently extracted data and assessed study quality. MAIN RESULTS: Fifty-five studies were included, involving more than 2000 health professionals and 99,000 people, with 83 comparisons between intervention and control groups. Post intervention differences between intervention and control groups varied widely within and across categories of interventions. Most interventions were found to be effective in some studies, but not in others. Five comparisons of group education versus no intervention showed absolute change of preventive services varying between -4% and +31%. Nine comparisons of physician reminders versus no intervention showed absolute change of preventive services varying between 5% and 24%. Fourteen comparisons of multifaceted interventions versus no intervention showed absolute change of preventive services varying between -3% and +64%. Six comparisons of multifaceted interventions versus group education reported absolute changes varying between -31% and +28%. All these comparisons used randomised groups. Ten comparisons of multifaceted interventions versus no intervention used non-randomised groups and showed absolute change of preventive services varying between -5% and +21%. The remaining planned comparisons within categories of interventions contained less than five comparisons. REVIEWER'S CONCLUSIONS: There is currently no solid basis for assuming that a particular intervention or package of interventions will work. Effective interventions to increase preventive activities in primary care exist, but there is considerable variation in the level of change achieved, with effect sizes usually small or moderate. Tailoring interventions to address specific barriers to change in a particular setting is probably important. Multifaceted interventions may be more effective than single interventions, because more barriers to change can be addressed. Future research should analyse barriers to change and interventions to implement preventive services in more detail, to clarify how interventions relate to specific barriers. Since more complex interventions are likely to be more effective but also more costly, economic evaluations should also be included.

Humans↗
PubMed2001

Measuring the involvement of patients in shared decision-making: a systematic review of instruments.

We wanted to determine whether research instruments exist which focus on measuring to what extent health professionals involve patients in treatment and management decisions. A systematic search and appraisal of the relevant literature was conducted by electronic searching techniques, snowball sampling and correspondence with field specialists. The instruments had to concentrate on assessing patient involvement in decision-making by observation techniques (either direct or using audio or videotaped data) and contain assessments of the core aspects of 'involvement', namely evidence of patients being involved (explicitly or implicitly) in decision-making processes, a portrayal of options and a decision-making or deferring stage. Eight instruments met the inclusion criteria. But we did not find any instruments that had been specifically designed to measure the concept of 'involving patients' in decisions. The results reveal that little attention has been given to a detailed assessment of the processes of patient involvement in decision-making. The existing instrumentation only includes these concepts as sub-units within broader assessments, and does not allow the construct of patient involvement to be measured accurately. Instruments developed to measure 'patient-centeredness' are unable to provide enough focus on 'involvement' because of their attempt to cover so many dimensions. The concept of patient involvement (shared decision-making; informed collaborative choice) is emerging in the literature and requires an accurate method of assessment.

Decision Making↗
PubMed2001

Functional status, health problems, age and comorbidity in primary care patients.

OBJECTIVES: To determine the relationship between functional status and health problems, age and comorbidity in primary care patients. METHODS: Patients from 60 general practitioners who visited their general practitioner were recruited and asked to complete a written questionnaire, including a list of 25 health problems and the SF-36 to measure functional status. The response rate was 67% (n = 4,112). Differences between subgroups were tested with p < 0.01. RESULTS: Poorer functional status which was associated with increased age (except for vitality) and increased co-morbidity. Patients with asthma/ bronchitis/COPD, severe heart disease/infarction, chronic backpain, arthrosis of knees, hips or hands, or an 'other disease' had poorer scores on at least five dimensions of functional status. Patients with hypertension, diabetes mellitus or cancer did not differ from patients without these conditions on more than one dimension of functional status. In the multiple regression analysis age, had a negative effect on functional status (standardised beta-coefficients between -0.03 and -0.34) except for vitality. Co-morbidity had a negative effect on physical role constraints (-0.15) and bodily pain (-0.09). All health problems had effects on dimensions of functional status (coefficients between -0.04 and -0.13). General health and physical dimensions of functional status were better predicted by health problems, age and co-morbidity (between 6.4 and 16.5% of variation explained) than mental dimensions of functional status (between 1.1 and 3.2%). CONCLUSION: Higher age was a predictor of poorer functional status, but there was little evidence for an independent effect of co-morbidity on functional status. Health problems had differential impact on functional status among primary care patients.

Adolescent↗
PubMed2001

Shared decision making observed in clinical practice: visual displays of communication sequence and patterns.

UNLABELLED: The aim of the study was to examine the communication strategies of general practitioners attempting to involve patients in treatment or management decisions. This empirical data was then compared with theoretical 'competences' derived for 'shared decision making'. The subjects were four general practitioners, who taped conducted consultations with the specific intent of involving patients in the decision-making process. The consultations were transcribed, coded into skill categorizations and presented as visual display using a specifically devised sequential banding METHOD: The empirical data from these purposively selected consultation from clinicians who are experienced in shared decision making did not match suggested theoretical frameworks. The views of patients about treatment possibilities and their preferred role in decision making were not explored. The interactions were initiated by a problem-defining phase, statements of 'equipoise' consistently appeared and the portrayal of option information was often intermingled with opportunities to allow patients to question and reflect. A decision-making stage occurred consistently after approximately 80% of the total consultation duration and arrangements were consistently made for follow-up and review. Eight of the 10 consultations took more than 11 min - these specific consultations were characterized by significant proportions of time provided for information exchange and patient interaction. The results demonstrate that some theoretical competences are not distinguishable in practice and other stages, not previously described, such as the 'portrayal of equipoise', are observed. The suggested ideal of a shared decision-making interaction will either require more time than currently allocated, or alternative strategies to enable information exchange outside the consultation.

Adult↗
PubMed2001

Feedback of patients' evaluations of general practice care: a randomised trial.

OBJECTIVE: To assess the effects of feedback of patients' evaluations of care to general practitioners. DESIGN: Randomised trial. SETTING: General practice in the Netherlands. SUBJECTS: 55 GPs and samples of 3691 and 3595 adult patients before and after the intervention, respectively. INTERVENTIONS: GPs in the intervention group were given an individualised structured feedback report concerning evaluations of care provided by their own patients. Reference figures referring to other GPs were added as well as suggestions for interpretation of this feedback, an evidence-based overview of factors determining patients' evaluations of care, and methods to discuss and plan improvements. MAIN OUTCOME MEASURES: Patients' evaluations of nine dimensions of general practice measured with the CEP, a previously validated questionnaire consisting of 64 questions, using a six point answering scale (1= poor, 6 = very good). RESULTS: Mean scores per CEP dimension varied from 3.88 to 4.77. Multilevel regression analysis showed that, after correction for baseline scores, patients' evaluations of continuity and medical care were less positive after the intervention in the intervention group (4.60 v 4.77, p < 0.05 and 4.68 v 4.71, p < 0.05, respectively). No differences were found in the remaining seven CEP dimensions. CONCLUSIONS: Providing feedback on patients' evaluations of care to GPs did not result in changes in their evaluation of the care received. This conclusion challenges the relevance of feedback on patients' evaluations of care for quality improvement.

Adult↗
PubMed2000

Comparison of patients' preferences and evaluations regarding aspects of general practice care.

BACKGROUND: Although patients' views on health care are perceived to be crucial, insight into the different constructs capturing these views remains limited. OBJECTIVE: The aim of this study was to determine the relationship between patients' preferences and their evaluations of general practice care. METHODS: Patients visiting five rural practices in The Netherlands were asked to complete a questionnaire measuring either their evaluations or their preferences on 44 aspects of general practice care. After at least 3 weeks, those patients who had answered the evaluation questionnaire received the questionnaire measuring their preferences, and vice versa. RESULTS: A total of 449 patients answered both questionnaires (response 70%). The longer the period after the consultation, the lower was the mean percentage of all 44 aspects rated as 'good' in the evaluation questionnaire (P = 0.006) and the higher was the mean percentage of all 44 aspects rated as 'very important' in the preference questionnaire (P = 0.046). The Spearman rank order correlation between the ranking of patients' evaluations and patients' preferences was 0.34, a low although significant correlation (P = 0.024), i.e. the two rank orders do not resemble each other very much. CONCLUSIONS: Patients clearly distinguished their preferences from their evaluations of general practice care. Aspects of general practice care, whether important or not, can be evaluated positively or negatively. Patients' preferences and patients' evaluations are, however, both influenced by the length of the time elapsed since the consultation.

Adolescent↗
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↗