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Biomedical subjects

Richard Grol

Publications and source records attributed to Richard Grol.

At least 55 records · Page 3Linked to original sources
PubMed2004

Shared care and the management of lower urinary tract symptoms.

OBJECTIVE: To investigate associations between the level of shared care and the clinical management of patients with uncomplicated lower urinary tract symptoms (LUTS). SUBJECTS AND METHODS: A cross-sectional survey study was conducted comprising all urologists and a random selection of general practitioners (GPs) in the Netherlands. Questionnaire responses were obtained from 182 urologists (70%) and 261 GPs (55%). The first part of the questionnaire established the physicians' characteristics and the second the level of familiarity with the national shared-care guidelines, arrangements between urologists and GPs, and the availability of a shared-care prostate clinic. The third part presented a written case of a 50-year-old man with clinical uncomplicated LUTS, and asked questions about diagnostic and therapeutic care. RESULTS: The clinical management of LUTS by GPs and urologists differed, particularly for diagnostic procedures. Only a minority of GPs (8%) and urologists (18%) had a shared-care clinic at their disposal. Such clinics were associated with an increase in tests ordered by the GP, e.g. creatinine levels (odds ratio, OR 3.83) and PSA levels (OR 5.93), and a decrease in choosing a watchful-waiting strategy for patients with mild symptoms (OR 0.24). Furthermore, urologists more often chose surgical intervention for moderate symptoms (OR 9.80). CONCLUSION: A shared-care clinic may lead to a shift in primary care towards the working style of urologists. This healthcare may not be as cost-effective as expected by policy makers. Prospective studies are needed to provide better insight in the health outcomes and efficiency of shared-care clinics.

Ambulatory Care↗
PubMed2004

Engaging general practitioners in the management of hazardous and harmful alcohol consumption: results of a meta-analysis.

OBJECTIVE: A systematic review was undertaken of studies that test the effectiveness of different strategies used to increase general practitioners' rates of screening for and giving advice about hazardous and harmful alcohol consumption. METHOD: Resources were MEDLINE, EMBASE, Cinahl and the Cochrane Library (1966-2001). Inclusion criteria were those of the Effective Practice and Organisation of Care Group of the Cochrane Collaboration. A meta-analysis was undertaken, using a random effects model, of 15 programs identified in 12 trials. Effect sizes, calculated using the logged odds ratio, were adjusted by inverse variance weights to control for the sample sizes of the studies. RESULTS: Analysis of the intervention groups resulted in screening and advice-giving rates of 45% (95% CI: 33%-56%) and analysis of the comparison groups resulted in rates of 32% (95% CI: 20%-43%). The weighted mean effect size (logged odds ratio = 0.73; 95% CI: 0.56-0.90) was heterogeneous. Regression analysis to explain the heterogeneity found a significant effect for alcohol-specific programs compared with general prevention programs in which alcohol was included, and for multicomponent programs compared with single component programs. No significant differences were found between educational-based or office-based interventions. CONCLUSIONS: Although the small numbers of programs studied suggest caution be used in interpreting the results, it seems it is possible to increase the engagement of general practitioners in screening and giving advice for hazardous and harmful alcohol consumption. Although considerably more research of high quality is needed, promising programs are those that have a specific focus on alcohol and those that are multicomponent.

Alcohol Drinking↗
PubMed2004

Family medicine trainees still value continuity of care.

BACKGROUND AND OBJECTIVES: Continuity of care in family medicine is under pressure due to an increase in part-time work, delegation of tasks, and the development of walk-in centers. It is uncertain to what extent newly qualified professionals value personal continuity. Insight into trainees' views may be helpful for training purposes and for improving continuity of care for patients in the future. We explored trainees' views on continuity for hypothetical scenarios and related these to personal characteristics and trainers' views. METHODS: We sent a questionnaire to all trainees and trainers of the eight family medicine training institutes in The Netherlands. RESULTS: The response rate was 595/1048 (57%) for trainees and 478/776 (62%) for trainers. Trainees attached more importance to continuity than trainers. Both highly valued continuity for serious problems, such as discussing the future when seriously ill (99% and 97%, respectively) and valued it low for minor problems, such as an episode of flu (14% and 6%, respectively). Trainees' views were barely related to the views of their personal trainers and to personal characteristics such as age, gender, and training faculty to a minor extent only. CONCLUSIONS: The new generation of professionals still value continuity of care. It may remain one of the basic features of general practice in the future.

Adult↗
PubMed2004

Preference for a general practitioner and patients' evaluations of care: a cross-sectional study.

Personal continuity is no longer always evident in general practice. Changes in society and in general practice seem to have shifted away from an emphasis on personal patient-doctor relationships. We studied how patients' lack of preference for a particular general practitioner (GP) or preference for a different GP is related to patients' evaluations of care. Patients who were indifferent to the GP seen, and patients who would have preferred another GP, evaluated consultations significantly less positively than patients who saw their GP of preference. Developments towards less personal doctoring in general practice should, therefore, be considered carefully.

Adult↗
PubMed2003

From best evidence to best practice: effective implementation of change in patients' care.

Major difficulties arise when introducing evidence and clinical guidelines into routine daily practice. Data show that many patients do not receive appropriate care, or receive unnecessary or harmful care. Many approaches claim to offer solutions to this problem; which ones are as yet the most effective and efficient is unclear. We aim to provide an overview of present knowledge about initiatives to changing medical practice. Substantial evidence suggests that to change behaviour is possible, but this change generally requires comprehensive approaches at different levels (doctor, team practice, hospital, wider environment), tailored to specific settings and target groups. Plans for change should be based on characteristics of the evidence or guideline itself and barriers and facilitators to change. In general, evidence shows that none of the approaches for transferring evidence to practice is superior to all changes in all situations.

Evidence-Based Medicine↗
PubMed2003

The effect of small peer group continuous quality improvement on the clinical practice of midwives in The Netherlands.

OBJECTIVE: To study the effects of small group continuous quality improvement (CQI) on the clinical practice of midwives in the Netherlands. DESIGN: Randomised pre-/post-test (balanced block). INTERVENTION: The CQI groups were assigned to either the set of peer review topics including 'perineal repair' and 'artificial rupture of the membranes (ARM)', or to the set of topics including 'airway aspiration' and 'measuring blood pressure'. The two research groups acted as each other's control group. SETTING: The Netherlands. PARTICIPANTS: Two hundred and fifty-five individual midwives practising in primary and secondary care who made up 28 peer groups. MEASUREMENT AND KEY FINDINGS: Questionnaires were used to collect data on clinical practice prior to the start of the intervention and one year later. Pre- and post-test data were received from 156 respondents. The intervention had a positive effect on adherence to the recommendations with respect to airway aspiration of the baby and measuring blood pressure. For ARM, no difference was found between pre- and post-test adherence to recommendations in the intervention group, while in the control group, the percentage of midwives that adhered to the recommendations decreased in the period between pre- and post-test. No significant effect was found for perineal repair. IMPLICATIONS FOR PRACTICE: Small group CQI had a positive effect on changing clinical practice when the learning of new skills (e.g. learning a new suturing technique) was not necessary. Additional interventions are needed when implementing guidelines that recommend the learning of new skills.

Adult↗
PubMed2003

Feedback based on patient evaluations: a tool for quality improvement?

Feedback regarding patient evaluations of health care is expected to be a tool for quality improvement. This study examined the response of general practitioners to such feedback in a randomised trial. Practitioners in the intervention group read and discussed the feedback report and then reported on a range of actions that can be undertaken to improve the quality of care. Their communication behaviour was not found to change. All of the practitioners were highly motivated to learn from patient views, both at baseline and after the intervention period. Compared to the control group, the practitioners in the intervention group had less favourable views of the relevance of patient feedback for their practice after the receipt of such feedback. Furthermore, these practitioners felt that a patient survey required considerable time and energy and saw little reason for change. Although patient feedback can help identify areas for improvement, specific barriers must be addressed before such feedback can be put to more widespread use.

Adult↗
PubMed2003

Characteristics of high-quality guidelines: evaluation of 86 clinical guidelines developed in ten European countries and Canada.

OBJECTIVES: To identify predictors of high-quality clinical practice guidelines. METHODS: A total of 86 guidelines from 11 countries were assessed by four independent appraisers per guideline using the AGREE instrument (23 items). Six aspects of guideline development were considered to explain the variation in quality scores: care level (primary/secondary care), scope (diagnosis/treatment), type of guideline (new/update), year of publication, type of agency (governmental/professional), and whether the guideline was produced within a structured and coordinated program. RESULTS: Guidelines produced within a guideline program and by governmental agencies had higher scores than their counterparts. Differences in the applicability of the guidelines could not be explained by the variables studied. CONCLUSION: To ensure high quality, clinical guidelines should be produced within a structured and coordinated program. Professional organizations or specialist societies that aim to develop guidelines may adopt quality criteria from leading guideline agencies.

Canada↗
PubMed2003

Patient characteristics as predictors of primary health care preferences: a systematic literature analysis.

OBJECTIVE: To identify associations between various cultural and demographic factors and patients' primary health care preferences. SEARCH STRATEGY: Searches were performed in MEDLINE (1966-December 2000), PsycINFO (1977-May 2001) and Sociological Abstracts (1963-December 2000). Identified papers were checked for more papers. INCLUSION CRITERIA: Studies with a focus on primary health care or health care in general, asking patients about preferences with regard to health care, reporting quantitative results and examining the relations between specific patient characteristics and patient preferences. DATA EXTRACTION AND SYNTHESIS: Data were extracted from studies using a scoring form to register what methods were used, which patient characteristics were analysed and which patient characteristics significantly influenced patients' preferences with regard to different aspects of health care (P < 0.05). MAIN RESULTS: A total of 145 studies were included with 2276 comparisons between subgroups of patients. Of all the comparisons, 607 (27%) showed a significant association between patient characteristics and preferences with regard to primary health care. Age and economic status significantly related to patient preferences in 38 and 33% of the comparisons, respectively. Education, health status, family situation, sex, and utilization of health care related significantly to patient preferences in less than 25% of the comparisons. CONCLUSIONS: This review of the literature showed patient characteristics to be an important determinant of preferences regarding many aspects of primary health care defined as general practice care or health care, in general. All of the patient characteristics examined here showed at least some significant associations with preferences for primary health care.

Age Factors↗
PubMed2003

Continuity of information in general practice. Patient views on confidentiality.

OBJECTIVES: To explore patient views on access to a variety of information in the medical record by the on-call general practitioner and by the practice assistant in relation to the perceived importance of this information for the personal doctor. To relate patient views to patient and practice characteristics. DESIGN: Postal questionnaire survey. SETTING: General practice. SUBJECTS: 873 patients from 35 general practices dispersed throughout The Netherlands. RESULTS: 20% of the patients stated that the on-call GP should not have access to their entire medical record and 44% did not support full access for the practice assistant. Patient consent to the on-call GP being allowed to access a variety of information ranged from 62% for life events to 93% for medication; and to the practice assistant from 37% for home details to 82% for medication. Patients distinguished between "medically oriented information" and "lifestyle and psychosocial information". Their views could hardly be explained by patient and practice characteristics. CONCLUSION: Patient consent to access their medical record should not be taken for granted. We need research on the effectiveness of accessible prior knowledge, and on possibilities to segregate information. Patients should be informed more fully about everyday practice.

Access to Information↗
PubMed2003

Towards evidence-based clinical practice: an international survey of 18 clinical guideline programs.

OBJECTIVE: To describe systematically the structures and working methods of guideline programs. DESIGN: Descriptive survey using a questionnaire with 32 items based on a framework derived from the literature. Answers were tabulated and checked by participants. STUDY PARTICIPANTS: Key informants of 18 prominent guideline organizations in the United States, Canada, Australia, New Zealand, and nine European countries. MAIN OUTCOME MEASURES: History, aims, methodology, products and deliveries, implementation, evaluation, procedure for updating guidelines, and future plans. RESULTS: Most guideline programs were established to improve the quality and effectiveness of health care. Most use electronic databases to collect evidence and systematic reviews to analyze the evidence. Consensus procedures are used when evidence is lacking. All guidelines are reviewed before publication. Authorization is commonly used to endorse guidelines. All guidelines are furnished with tools for application and the Internet is widely used for dissemination. Implementation strategies vary among different organizations, with larger organizations leaving this to local organizations. Almost all have a quality assurance system for their programs. Half of the programs do not have formal update procedures. CONCLUSIONS: Principles of evidence-based medicine dominate current guideline programs. Recent programs are benefiting from the methodology created by long-standing programs. Differences are found in the emphasis on dissemination and implementation, probably due to differences in health care systems and political and cultural factors. International collaboration should be encouraged to improve guideline methodology and to globalize the collection and analysis of evidence needed for guideline development.

Consensus↗
PubMed2003

[International comparison of 19 clinical guideline programs--a survey of the AGREE Collaboration].

Clinical practice guidelines are being developed in many countries throughout the world to improve quality of patient care. However, the methods used to develop guidelines vary among organisations. Therefore an international task group, the AGREE (Appraisal Guideline Research and Evaluation Europe) Collaboration, started in 1998 to work on the harmonisation and coordination of guideline development. Within this context a survey of national guideline programmes was conducted. Nineteen programmes from nine European countries, Australia, Canada, New Zealand and United States were described using a questionnaire. The items concerned the type of organisation, scope and purpose of the guidelines, people involved, methodology, products, implementation, evaluation, update procedure, and future plans. The results of this survey revealed a growing international consensus on the essential features of good guideline programmes. Most guideline programmes combine an evidence-based approach with informal and/or formal consensus procedures. No significant differences were found between governmental agencies and professional organisations. The budget for developing a single guideline varies from 10,000 to 200,000 EURO.

Europe↗
PubMed2003

Communication at the interface: do better referral letters produce better consultant replies?

A study of the quality of 637 referral letters from general practitioners (GPs) and corresponding reply letters from medical specialists showed that both types of letters can be improved, and that specific requests by GPs were addressed explicitly by the specialists in only a limited number of cases. Better referral letters resulted only partly in better reply letters. A letter is considered to be of higher quality when a specialist commences a letter with a reference to the specific request by the GP. In conclusion, opportunities for optimal communication should be better used.

Clinical Competence↗
PubMed2002

Deconstructing patient centred communication and uncovering shared decision making: an observational study.

BACKGROUND: Patient centred communication (PCC) has been described as a method for doctor-patient communication. The principles of shared decision making (SDM) have been proposed more recently. AIMS: This study aimed to examine PCC and SDM empirically with respect to their mutual association, the variation in practitioners' working styles, and the associations with patient characteristics. METHODS: Sixty general practitioners recruited 596 adult patients who gave written consent to have their consultations videotaped. The tapes were assessed by two researchers, using a standardised instrument for global communication. For the purpose of this exploratory study, scales for PCC and SDM were based on subsamples of items in the MAAS. RESULTS: The scales for PCC and SDM were weakly associated (Pearson correlation: 0.25). Physicians varied more on SDM than on PCC. The intracluster correlation of the PCC and SDM scales were, respectively, 0.34 and 0.19. However, hypotheses regarding associations with patient characteristics were not confirmed. Neither PCC nor SDM scores were related to patient gender, education, age, functional health status or existence of chronic conditions. CONCLUSION: The study provides evidence that PCC and SDM can be differentiated and comprise approaches to communication between clinicians and patients which may be more clearly distinguished by further focused research and training developments.

Adult↗
PubMed2002

Changing physicians' competence and performance: finding the balance between the individual and the organization.

There are serious problems associated with the underuse, overuse, and misuse of health care. Part of the solution involves changing practicing physicians' competence and performance, but this proves to be a difficult task. People differ widely in their views of how the behavior of physicians can be effectively changed. Some approaches focus on improving the knowledge, skills, or attitudes of professionals, whereas others believe in changing the social interaction and collaboration within teams or changing the organizational or political context. Some believe in self-motivation and regulation by those who need to change, whereas others emphasize external stimuli, pressure, or control. However, systematic reviews show that no current approach is superior for all purposes and target groups and that we may need them all, well integrated, to achieve effective improvements in patient care. Educational activities for professionals are not sufficient and should be combined with activities and measures at other levels. Those wishing to improve the competence and performance of physicians must be aware of the limitations of educational approaches and know how to integrate these with approaches that focus on teams, organizations, or the political or economic context. Teachers of physicians need to develop their knowledge and skills in these areas to be successful.

Clinical Competence↗
PubMed2002

Patient characteristics determine differences in the influenza vaccination rate more so than practice features.

BACKGROUND: World-wide each year 30-55% of the target population is vaccinated against influenza. Determinants of successful vaccination programs are not clear. This study was aimed at identifying practice- and patient-related factors that determine differences in vaccination rates. METHODS: Data on patients of the target population were extracted from the computerized medical record systems of 48 family practices. Information about organizational factors was collected by a questionnaire for GP's. Multilevel logistic regression analyses were used to assess the determinants. RESULTS: Of all patients at risk (42,426), 76% were vaccinated. The vaccination rate for patients above age 65 was 15% higher when a medical indication was present. Patients with cardiac diseases or diabetes mellitus attained a relatively higher vaccination rate than other groups at risk. Special hours for vaccination led to significantly higher vaccination rates for the elderly and cardiac patients. Patients below 65 years of age were particularly influenced by special information pamphlets. CONCLUSION: Explanations of differences in uptake rates were found at the patient level. All practices in this study were well organized; nevertheless, subgroup analyses showed that special vaccination hours for elderly people and information pamphlets for young people could improve results further.

Adolescent↗
PubMed2002

Empowering patients: how to implement a diabetes passport in hospital care.

The purpose was to ascertain the views of patients with diabetes and patient care teams on the introduction of a recently developed diabetes passport in order to plan effective implementation. A semi-qualitative study by eight semi-structured focus group discussions with patient care teams and patients in four Dutch hospitals was organised. In total 29 patients participated (range five to nine per hospital). Patient care teams ranged from four to six participants. Each team included at least one specialised diabetic nurse and an internist. Taped views were transcribed and coded on the basis of a structured checklist. Various potential barriers to the implementation of the diabetes passport were found. Although patients recognized the diabetes passport as a handy tool, most of them expected starting problems and little co-operation from the internists; in this respect they rely more on the diabetes specialist nurse (DSN). Internists had mixed feelings about the diabetes passport. Lack of motivation and lack of time were important perceived barriers. The specialised diabetes nurses had the highest expectations of the diabetes passport and perceived themselves as those who would effectuate implementation. The main potential barriers to effective implementation of the diabetes passport were found in setting the agenda of the passport and fitting it into the organization of diabetes care. These barriers need to be considered when implementing the passport. The DSN could play an important part in its implementation.

Attitude of Health Personnel↗