Biomedical subjects
M Wensing
Publications and source records attributed to M Wensing.
Effect of mailed reminders on the response rate in surveys among patients in general practice.
Randomized trials were performed in Denmark and The Netherlands to determine the effect of mailed reminders on the response rate in surveys among patients in general practice. In both countries, general practitioners handed out questionnaires to 200 adult patients who came to visit them. An intervention group of 100 patients received reminders at 3 weeks after the visit, whereas a control group of the remaining 100 patients did not receive reminders. The response rate was significantly higher in the intervention groups than in the control group in The Netherlands (86% versus 55%, respectively) but not in Denmark (87% versus 81%, respectively). Mailed reminders can improve the response rate in surveys related to a general practice, but they are not effective in all situations.
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.
Interventions to improve the delivery of preventive services in primary care.
OBJECTIVES: This review was conducted to determine the effectiveness of different interventions to improve the delivery of preventive services in primary care. METHODS: MEDLINE searches and manual searches of 21 scientific journals and the Cochrane Effective Professional and Organization of Care of trials were used to identify relevant studies. Randomized controlled trials and controlled before-and-after studies were included if they focused on interventions designed to improve preventive activities by primary care clinicians. Two researchers independently assessed the quality of the studies and extracted data for use in constructing descriptive overviews. RESULTS: The 58 studies included comprised 86 comparisons between intervention and control groups. Postintervention 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 effective in other studies. CONCLUSIONS: Effective interventions to increase preventive activities in primary care are available. Detailed studies are needed to identify factors that influence the effectiveness of different interventions.
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.
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.
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".
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.
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.
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.
What makes a good general practitioner: do patients and doctors have different views?
BACKGROUND: General practitioners (GPs) are expected to be responsive to patients' expectations, but patients and doctors may have different views on what constitutes good general practice care. AIM: To elicit areas of controversy as well as areas of mutual agreement between the opinions of patients and GPs with regard to good general practice care. METHOD: A questionnaire, distributed to 850 patients and 400 GPs, measured which of 40 aspects of general practice care were given priority. A second questionnaire, distributed to 400 different GPs, measured the GPs' perception of the priorities of patients. RESULTS: The priority rank order of all 40 aspects was highly correlated for patients and GPs (0.72), as was the rank order of aspects for patients and the perception of them by GPs (0.71). Nevertheless, when comparing the priorities of patients and GPs, 23 out of 40 aspects differed significantly (P = 0.00125) in their rank number. Similarly, when comparing the priorities of patients with the perception of them by GPs, 23 aspects differed significantly. CONCLUSIONS: There is great similarity between the priorities of patients and those of GPs. GPs are quite capable of assessing most of the priorities of patients. However, potentially controversial areas of general practice care do exist.
Evaluation of general practice care by chronically ill patients: effect of the method of administration.
BACKGROUND: Although the patient survey has become a popular method for learning about patients' views and experiences, little attention has been paid to the validity and feasibility of different survey methods. OBJECTIVE: A study was undertaken to compare handing out written questionnaires to chronically ill patients who consecutively visited the general practice with mailing questionnaires to chronically ill patients who were sampled from the patient register. METHOD: Patient surveys were performed in eight general practices in The Netherlands, applying both methods of administering the questionnaire to patients in each practice (n = 345). RESULTS: The response rate was 63% in the mail survey and 72% in the hand-distributed survey. The sample composition was almost equal, except that patients in the hand-distributed survey more often reported having 'a different chronic disease.' The item-response for each aspect of care was similar in both methods of administration. CONCLUSION: Patients in the mail survey tended to use the extreme categories on the scale for certain aspects of care more often than patients in the hand-distributed survey, but the overall trend was not significant.
Indicators of the quality of general practice care of patients with chronic illness: a step towards the real involvement of patients in the assessment of the quality of care.
OBJECTIVE: To develop a list of indicators of the general practice care of people with chronic illnesses considered important by both patients and practitioners and to identify the indicators that are considered relevant for patient assessment of health care quality. DESIGN: Qualitative study with focus group interviews and a written consensus procedure. SETTING: General practice in the Netherlands in 1993. SUBJECTS: 34 patients with chronic illness, mostly members of patient organisations, and 19 general practitioners with expertise in either chronic disease management or experience with patient surveys. MAIN MEASURES: Aspects of general practice care considered important for the delivery of good quality care that emerged from focus group interviews; the relevance of evaluations of 41 aspects of care for patients explored through the written consensus procedure. Those aspects of general practice care agreed to be both important and relevant by patients and general practitioners were considered to be suitable indicators for patient assessment of the quality of care. RESULTS: Patients and general practitioners differed to some extent in their assessment of the aspects of care that they considered important for quality. They agreed that most indicators of care that related to the ¿doctor-patient relation¿ and to ¿information and support¿ were relevant and therefore suitable as indicators for patient assessment of health care quality. There was less agreement about the relevance of indicators of ¿medical and technical care,¿ ¿availability and accessibility,¿ and ¿organisation of services.¿ CONCLUSIONS: Several indicators of the quality of general practice care of patients with chronic illness were thought to be suitable for the patient assessment of healthcare quality, but other indicators were not, mainly because of reservations by general practitioners. IMPLICATIONS: Qualitative methods can contribute to the selection of indicators for assessment of the quality of health care in areas where scientific evidence is limited or where patients' and providers' preferences are particularly important.
Implementation of quality assurance and medical audit: general practitioners' perceived obstacles and requirements.
BACKGROUND: The introduction of quality assurance and medical audit has been an important development in general practice. However, the introduction of such programmes does not necessarily mean they are implemented by general practitioners. AIM: A study was undertaken to describe the problems and requirements perceived by general practitioners in relation to the implementation of quality assurance and medical audit in general practice. METHOD: Interviews were carried out with a stratified sample of 120 Dutch general practitioners. Knowledge, acceptance and application of quality assurance and medical audit activities were investigated, and perceived problems and requirements in implementing quality assurance and audit activities were explored. RESULTS: General practitioners in the Netherlands were generally positive towards quality assurance activities, but had little experience of carrying out such activities. The most frequently mentioned obstacles to implementing quality assurance activities concerned lack of time, colleagues' negative attitudes and fear of assessment and criticism by colleagues. Requirements for implementing quality assurance included having regular meetings with colleagues about quality assurance, having information on the aims and methods of quality assurance, having data from other practices with which to compare performance, having support in data collection, in audit in the practice and in setting up local peer review, and having financial support. The most important factor predicting the actual application of quality assurance activities was found to be knowledge of specific quality assurance activities. CONCLUSION: Well-designed programmes for the implementation of quality assurance and medical audit, using a variety of different interventions, have to be developed. Such programmes should include the training of professionals in the concepts and methods of quality assurance as well as the provision of financial support for quality assurance activities.
Quality judgements by patients on general practice care: a literature analysis.
Patient report seems to be a workable method for quality assurance. For the purpose of the development of such a method, a review was made of 40 studies into patient judgements on general practice care. Apparently, many aspects of care are only rarely included in patient report and the patients themselves are hardly ever involved in selecting these aspects. Furthermore, there appears to be a large variety in the methods that are used. The conclusion must be that in the field of general practice care only little progress has been made in the development of patient report as a method for quality assurance.
Quality assurance in general practice: the state of the art in Europe.
Quality assurance' (QA) is an important new development in general practice. In order to describe the state of the art in this field a preliminary survey was performed by the WONCA European Working Party on Quality in General Practice (EQuiP) in 17 European countries. The results revealed considerable differences in the systems and organization of general practice care [such as practice form, list size, the role of the general practitioner (GP), remuneration], which will have an impact on setting up QA. The preliminary findings demonstrated that most countries are only just beginning the implementation of QA. Nevertheless, there are many valuable developments and experiments concerned with the methodology, procedures and structures for it. In order to accelerate the speed of adoption of QA and to avoid the repetition of mistakes, policy makers and GPs from different parts of Europe should study examples in their fellow countries. A clearing house of QA projects in general practice can help to inform them on valuable developments.
Single and combined strategies for implementing changes in primary care: a literature review.
Doubts have been raised about the effectiveness of traditional types of continuing medical education. Different strategies or combinations of strategies could prove to be more effective for improving the care provided by the general practitioner. For this reason a systematic literature analysis was carried out involving 75 studies of different strategies applied in primary health care. The strategies most often studied were feedback, reminders and group education. Educational material or group education combined with feedback was the combination most frequently studied. One third of all studies could be characterized as randomized controlled trials. Individual instruction, feedback and reminders seem to be the most effective single strategies. The most effective combined strategies appeared to be all combinations with individual instruction and the combination of peer review and feedback.
Anaphylaxis caused by the unexpected presence of casein in salmon.
A new process for restructured meat and fish has been introduced to the market recently. Its main compound is casein, and it may therefore endanger patients with a milk allergy.