Objectives: We evaluated the psychometric properties of a newly developed self-report questionnai... more Objectives: We evaluated the psychometric properties of a newly developed self-report questionnaire that aims for a more personcentered approach in primary care for patients with chronic conditions, the Primary Care Functioning Scale (PCFS). Study Design and Setting: To test the measurement properties of the PCFS, we asked patients with diabetes, cardiovascular disease, and chronic pulmonary disease to complete the PCFS questionnaire. The PCFS is entirely based on the International Classification of Functioning, Disability, and Health (ICF), consisting of 52 ICF-related items covering body functions, activities and participation, environmental factors, and personal factors. We analyzed three hypotheses representing different item sets of the 34 ICF-related items that assess the level of functioning (body functions, activities, and participation). We tested for unidimensionality, differential item functioning, reliability, and criterion-related validity. Results: Five hundred and eighty-two patients completed the questionnaire. The total scores of the polytomous and dichotomized items from the overall set 'body functions, activities and participation' demonstrated unidimensionality, good reliability (O0.80), and stability over time without bias from background variables. Conclusion: In sum, the PCFS can be used as a valid and reliable instrument to measure functioning in patients with chronic morbidity in primary care.
Objectives To assess the incidence of head injury and predictors of complication across the care ... more Objectives To assess the incidence of head injury and predictors of complication across the care continuum. Design Retrospective cohort study using data from a research network. We calculated the incidence of overall head injury in a longitudinal cohort covering 1-year interval (31 369 patient-years), and the incidence of complicated head injury in a longitudinal cohort covering 10 years interval (220 352 patient-ears). Incidence rates were calculated per 1000 patient-years with 95% CI using the Mid-P exact test. We calculated ORs to assess potential risk factors for a complicated head injury. setting A practice-based research network covering a population of >30 000 patients. Participants All patients listed in practices within the research network during the years 2005-2014. Main outcome measures Incidence of (complicated) head injury and predictors for clinical complications. results The incidence of overall head injury was 22.1 per 1000 person-years and the incidence of a complicated course following head injury was 0.16 per 1000 personyears. The following determinants were risk factors for a complicated course: high energy trauma, bicycle accident, traffic accident in general, use of anticoagulants, alcohol intoxication, age above 60 years and low Glasgow Coma Scale at initial presentation. A complicated course was very unlikely when the patients' first encounter with a healthcare professional was in primary care (OR 0.03, 95% CI 0.01 to 0.07). Conclusions Complication after head injury are rarely seen in general practice. Patients who do experience complications are often easily identifiable as requiring specialist care. A more reserved referral policy for general practice may be desirable, suggesting that current guidelines are too defensive.
Background. Personal continuity is considered a core feature of general practice care. Nowadays, ... more Background. Personal continuity is considered a core feature of general practice care. Nowadays, another important concept for general practice may be patients' familiarity with a GP. Objectives. We studied the extent to which patients see a familiar GP, and how this matches their preferences. Furthermore we studied the impact of knowing the GP on patients' evaluations of consultations. Methods. A cross-sectional design was used and 2400 patients visiting 17 general practices (30 GPs) in The Netherlands for a consultation were approached; 2152 patients completed the questionnaire. The main outcome measures were: i) the extent to which patients saw a familiar GP in relation to the reason for encounter, perceived seriousness of symptoms, and concern about symptoms; and ii) the impact of 'knowing the GP' on patients' overall satisfaction with the consultation, feeling of being helped to move forwards, trust in the GP, and perceived clearness of treatment plans. Results. Patients saw a familiar GP to a high extent, regardless of the reason for encounter, perceived seriousness of symptoms and worries. Higher levels of familiarity with a GP were associated with higher levels of satisfaction, with increased feelings of being helped forward, with more trust in the GP, and with the perception of clearer treatment plans made. A multivariate model including the variable 'knowing the GP' explained 11% of the observed variance in patients' evaluations of consultations. Conclusion. Familiarity with a GP improves patients' assessment of general practice care. Also in the future, personal continuity should be promoted.
Background. The growing complexity of care with more professionals involved is a threat to the de... more Background. The growing complexity of care with more professionals involved is a threat to the delivery of coherent and consistent care. Excellent exchange of information between professionals may be a way to maintain continuity of care. Relevant information to be passed over includes thoughts about future management for individual patients. Aim. To explore the nature of GPs' thoughts about future management, and to determine the extent to which such thoughts are actually recorded in medical records. Design of study. Cross-sectional study of 5741 consultations. Setting. Thirty GPs from 17 practices in a region in the eastern part of The Netherlands. Methods. The GPs responded to an electronic questionnaire, directly after 200 successive consultations. The questionnaire included items on management considerations, consultation characteristics and personal continuity. We compared the data from the questionnaire to the actual recording of management considerations in the patient records. Results. The GPs had management considerations in 66.4% of the consultations, involving mainly considerations about additional testing (15.5%), adjustment of medication (22.5%), alternative treatment plans (18.6%), possible referral (11.8%) and coping behaviour (18.0%). These considerations were seldom recorded in the electronic patient record; additional testing (3.0%) adjustment of medication (2.9%) and alternative treatment plans (4.1%). Surprisingly however, GPs rarely found that management considerations from earlier consultations were lacking in the medical record. Conclusion. GPs often have thoughts on how to deal with this patient, but hardly ever record such considerations. We recommend the development of tools that facilitate the recording of management considerations in electronic patient records.
PURPOSE Our goal was to explore patients' anticipated needs for contact with their general practi... more PURPOSE Our goal was to explore patients' anticipated needs for contact with their general practitioner (GP) at the time of hospital admissions and other life events. METHODS We undertook a questionnaire survey of 875 patients from 35 general practices spread throughout the Netherlands and a qualitative interview study with 30 patients. RESULTS Most patients expected to need contact with their GP if admitted to a hospital for a serious condition, such as a malignancy (98%) or a heart attack (97%). For minor conditions, such as a minor foot operation, contact was considered less important (33%). At the time of major life events, many patients anticipated needing contact as well: 81% in the case of a birth within the family, 90% in the case of a death in the family. In the quantitative analysis patients' wants were related only to a minor extent to patient characteristics. The qualitative analysis, however, distinguished categories of patients with different needs. Some patients were more technical in their needs, others focussed primarily on the relationship. CONCLUSION Patients appear to have considerable need for contact with their physician at the time of hospital admission and other life events. The profession should refl ect on this underexplored fi eld and attempt to take a policy-making position toward initiating patient contact.
The Journal of the American Board of Family Medicine, 2021
Introduction: Structuring patient and practice data into episodes formed the foundation of the ea... more Introduction: Structuring patient and practice data into episodes formed the foundation of the earliest evidence base of family medicine. We aim to make patients' narratives part of the evidence base for family medicine by incorporating coded and structured information on the patient's reason to visit the family physician (FP) and adding the patient's personal and contextual characteristics to routine registration data. This documentation allows studies of relations between morbidity and elements of the patient story, providing more insight into the range of problems presented to primary care and in the patient-centeredness applied by FPs. Methods: The Dutch Practice-Based Research Network (PBRN), named FaMe-Net, is the world's oldest PBRN. Seven Dutch family practices provide regular primary care and participate in the PBRN. It contains all morbidity data of the approximately 40,000 listed patients (308,000 patient-years and 2.2 million encounters from 2005 until 2019). All information belonging to 1 health problem is ordered in 1 episode. Morbidity (diagnoses), reasons for encounter (RFE), and interventions are coded according to the International Classification of Primary Care (ICPC-2). Registration occurs within the electronic health record (EHR), specially designed to facilitate the extensive registration for the PBRN. Since 2016, the network expanded routine registration with the duration of symptoms and coded personal and contextual characteristics (eg, country of birth, level of education, family history, traumatic events) obtained through the self-reported 'context survey' of listed patients. These data are added to the EHR. Registered data are extracted from the EHR and processed for scientific research. We present data on the differences in RFEs of the most prominent symptoms of COVID-19 between 2019 and 2020; the relation between the diagnosis of pneumonia and presentation of the symptom 'cough,' and how personal determinants influence the chances of final diagnoses. Lastly, we show the relation of selfreported abuse with patient's contact frequency and psychosocial problems. Results: Prompt introduction of registration rules brought insight into COVID-19-related symptoms early in the pandemic. In March 2020, symptoms related to COVID-19 were presented more often than in March 2019. Chronic conditions and prevention showed a collapsing contact frequency. Telephone, email, and video consultations increased from 31% to 53%. Episodes of pneumonia most frequently started with the RFE 'cough.' A combination of 'cough' and 'fever' as RFE increases the likelihood of pneumonia, as does cough in the presence of comorbid COPD among older men. The prevalence of pneumonia is higher among patients with low socioeconomic status. Discussion: The Dutch PBRN FaMe-Net has started to add elements of patients' narratives and context to decades of morbidity registration, creating options for a scientific approach to primary care's core values. Assumptions of 'pre/post chances' of the final diagnosis, already existing implicitly in FPs minds, can be elaborated and quantified by investigating the associations between multiple registered variables, including parts of patients' 'stories.' This way, we aim to make visible what is intuitively already known by FPs.
Background: The Surprise Question (“ Would I be surprised if this patient were to die within the ... more Background: The Surprise Question (“ Would I be surprised if this patient were to die within the next 12 months?”) is widely used to identify palliative patients, though with low predictive value. To improve timely identification of palliative care needs, we propose an additional Surprise Question (“ Would I be surprised if this patient is still alive after 12 months?”) if the original Surprise Question is answered with “no.” The combination of the two questions is called the Double Surprise Question. Aim: To examine the prognostic accuracy of the Double Surprise Question in outpatients with cancer. Design: A prospective study. Participants: Twelve medical oncologists completed the Double Surprise Question for 379 patients. Results: In group 1 (original Surprise Question “yes”: surprised if dead) 92.1% (176/191) of the patients were still alive after 1 year, in group 2a (original and additional Surprise Question “no”: not surprised if dead and not surprised if alive) 60.0% (63/105...
Background: Quality indicators (QIs) are used to monitor quality of care and adherence to osteoar... more Background: Quality indicators (QIs) are used to monitor quality of care and adherence to osteoarthritis (OA) standards of care. Patient reported QIs can identify the most important gaps in quality of care and the most vulnerable patient groups. The aim of this study was to capture the perspective of people with knee OA (KOA) in the Netherlands on the quality of care received, and explore determinants related to lower achievement rates.Methods: We sent an online survey to all members of The Dutch Knee Panel (n = 622) of the Sint Maartenskliniek Nijmegen, the Netherlands. The survey consisted of a slightly adapted version of the “OsteoArthritis Quality Indicator” (OA-QI) questionnaire (18 items; yes, no, N/A); a rating of quality of KOA care on a 10-point scale; a question on whether or not one wanted to see change in the care for KOA; and an open-ended question asking recommendations for improvement of OA care. Furthermore, sociodemographic and disease related characteristics were c...
Background Continuity of care, in particular personal continuity, is a core principle of general ... more Background Continuity of care, in particular personal continuity, is a core principle of general practice and is associated with many benefits such as a better patient-provider relationship and lower mortality. However, personal continuity is under pressure due to changes in society and healthcare. This affects older patients more than younger patients. As the number of older patients will double the coming decades, an intervention to optimise personal continuity for this group is highly warranted. Methods Following the UK Medical Research Council framework for complex Interventions, we will develop and evaluate an intervention to optimise personal continuity for older patients in general practice. In phase 0, we will perform a literature study to provide the theoretical basis for the intervention. In phase I we will define the components of the intervention by performing surveys and focus groups among patients, general practitioners, practice assistants and practice nurses, conclud...
Patient participation is high on the public agenda, but multidisciplinary teams who offer care to... more Patient participation is high on the public agenda, but multidisciplinary teams who offer care to frail older people find it hard to incorporate patients views in their way of working. Our study focused on the care network of the older patient, and more specific on the role of the informal caregiver. In many networks, the informal caregiver was not or only moderately connected with professional actors. Elderly care networks can be rather vulnerable because the power (knowledge, contacts) lies entirely with the patient. Our study suggests that it would be relatively easy to develop materials to enable professionals to map the patient care network, which could then be used as the basis of conversations about the organisation of care,
Journal of the American Medical Directors Association, 2019
Objectives: Advance care planning (ACP) is seldom initiated with people with dementia (PWD) and m... more Objectives: Advance care planning (ACP) is seldom initiated with people with dementia (PWD) and mainly focuses on medical end-of-life decisions. We studied the effects of an educational intervention for general practitioners (GPs) aimed at initiating and optimizing ACP, with a focus on discussing medical and nonmedical preferences of future care. Design: A single-blinded cluster randomized controlled trial. Setting and participants: In 2016, 38 Dutch GPs (all from different practices) completed the study. They recruited 140 PWD, aged !65 years at any stage and with any type of dementia, from their practice. Methods: Intervention group GPs were trained in ACP, including shared decision-making and role-playing exercises. Control group GPs provided usual care. The primary outcome was ACP initiation: the proportion of PWD that had at least 1 ACP conversation documented in their medical file. Key secondary outcomes were the number of medical (ie, resuscitation, hospital admission) and nonmedical (ie, activities, social contacts) preferences discussed. At the 6-month follow-up, subjects' medical records were analyzed using random effect logistics and linear models with correction for GP clustering. Results: 38 GP clusters (19 intervention; 19 control) included 140 PWD (intervention 73; control 67). Four PWD (2.9%) dropped out on the primary and key secondary outcomes. After 6 months, intervention group GPs initiated ACP with 35 PWD (49.3%), and control group GPs initiated ACP with 9 PWD (13.9%) [odds ratio (OR) 1.99; P ¼ .002]. Intervention group GPs discussed 0.8 more medical [95% confidence interval (CI) 0.3, 1.3; P ¼ .003] and 1.5 more nonmedical (95% CI 0.8, 2.3; P < .001) preferences per person with dementia than control group GPs. Conclusions and Implications: Our educational intervention increased ACP initiation, and the number of nonmedical and medical preferences discussed. This intervention has the potential to better align future care of PWD with their preferences but because of the short follow-up, the GPs' long-term adoption remains unknown.
Background: Over the last 20 years, integrated care programs for frail elderly people aimed to pr... more Background: Over the last 20 years, integrated care programs for frail elderly people aimed to prevent functional dependence and reduce hospitalization and institutionalization. However, results have been inconsistent and merely modest. To date, evidence on the cost-effectiveness of these programs is scarce. We evaluated the costeffectiveness of the CareWell program, a multicomponent integrated care program for frail elderly people. Methods: Economic evaluation from a healthcare perspective embedded in a cluster controlled trial of 12 months in 12 general practices in (the region of) Nijmegen. Two hundred and four frail elderly from 6 general practices in the intervention group received care according to the CareWell program, consisting of multidisciplinary team meetings, proactive care planning, case management, and medication reviews; 165 frail elderly from 6 general practices in the control group received usual care. In cost-effectiveness analyses, we related costs to daily functioning (Katz-15 change score i.e. follow up score minus baseline score) and quality adjusted life years (EQ-5D-3 L). Results: Adjusted mean costs directly related to the intervention were €456 per person. Adjusted mean total costs, i.e. intervention costs plus healthcare utilization costs, were €1583 (95% CI-4647 to 1481) higher in the intervention group than in the control group. Incremental Net Monetary Benefits did not show significant differences between groups, but on average tended to favour usual care. Conclusions: The CareWell primary program was not cost-effective after 12 months. From a cost-effectiveness perspective, widespread implementation of the program in its current form cannot be recommended. Trial registration: The study was registered in the ClinicalTrials.govProtocol Registration System: (NCT01499797; December 26, 2011). Retrospectively registered.
Background: Use of conservative treatment modalities in osteoarthritis (OA) is suboptimal, which ... more Background: Use of conservative treatment modalities in osteoarthritis (OA) is suboptimal, which appears to be partly due to patients' beliefs about treatments. The aim of this study was to develop a research instrument assessing patients' beliefs about various treatment modalities of hip and knee OA: the 'Treatment beliefs in OA (TOA) questionnaire'. Methods: The item pool that was retrieved from interviews with patients and healthcare providers comprised beliefs regarding five treatment modalities: physical activity, pain medication, physiotherapy, injections and arthroplasty. After an extensive selection procedure, a draft questionnaire with 200 items was constructed. Descriptive analyses and exploratory factor analyses with oblique rotation were conducted for each treatment modality separately to decide upon the final questionnaire. Internal consistency and test-retest reliability were determined. Results: The final questionnaire comprised 60 items. It was completed by 351 patients with knee or hip OA. Each of the five treatment modalities yielded a two factor solution with 37% to 51% explained variance and high face validity. Factor I included 'positive treatment beliefs' and factor II 'negative treatment beliefs'. Internal consistency (Cronbach α's from 0.72 to 0.87) and test-retest reliability (i.e. intraclass correlation coefficient from 0.66-0.88; standard error of measurement from 0.06-0.11) were satisfactory to good. Conclusions: The TOA questionnaire is the first questionnaire assessing positive and negative treatment beliefs regarding five treatment modalities for knee and hip OA. The instrument will help to understand whether and to what extent treatment beliefs influence treatment choices.
Background. Over the last 20 years, the effectiveness of complex care programs aiming to prevent ... more Background. Over the last 20 years, the effectiveness of complex care programs aiming to prevent adverse outcomes in frail elderly people has been disappointing. Recently, we found no effectiveness of the CareWell primary care program. It is largely unknown to what extent incomplete implementation of these complex interventions influences their outcomes. Objective. To examine the association between the degree of implementation of the CareWell program and the prevention of functional decline in frail elderly people. Methods. Quantitative process evaluation conducted alongside a cluster-controlled trial. Two hundred and four frail elderly participants from six general practitioner practices in the Netherlands received care according to the CareWell program, consisting of four key components: multidisciplinary team meetings, proactive care planning, case management and medication reviews. We measured time registrations of team meetings, case management and medication reviews and care plan data as stored in a digital information portal. These data were aggregated into a total implementation score (TIS) representing the program's overall implementation. We measured functional decline with the Katz-15 change score (follow-up score at 12 months minus the baseline score). The association between TIS and functional decline was analyzed with linear mixed model analyses. Results. We found no statistically significant differences in functional decline between TIS groups (F = 1.350, P = 0.245). In the groups with the highest TISs, we found more functional decline. Conclusion. A higher degree of implementation of the CareWell program did not lead to the prevention of functional decline in frail elderly people.
Objective. We introduced a stepped-care strategy (SCS) for hip and knee osteoarthritis, focusing ... more Objective. We introduced a stepped-care strategy (SCS) for hip and knee osteoarthritis, focusing on delivery of highquality stepped care. In this study, we aimed to identify factors associated with various steps of the SCS. Methods. We used data from a 2-year observational prospective cohort study, including 313 patients visiting their general practitioner (GP) with a new episode of hip/knee osteoarthritis. We used logistic multilevel analyses to identify factors at the level of the patient, the GP, and the general practice, related to treatment limited to primary care, referral to nonsurgical secondary care, or surgical procedures. Results. Patients whose treatment had been limited to primary care tended to function physically better (odds ratio [OR] 1.03). Furthermore, they less often received exercise therapy (OR 0.46), intraarticular injections (OR 0.08), and radiologic assessments (OR 0.06). Continuation of nonsurgical care after referral was more likely in employed patients (OR 2.90) and patients who had no exercise therapy (OR 0.19) or nonsteroidal antiinflammatory drugs (OR 0.35). Surgically treated patients more often received exercise therapy (OR 7.42). Referral and surgical treatment depended only to a limited extent on the GP or the general practice. Conclusion. After implementation of the SCS in primary care, the performance of exercise therapy, rather than disease severity or psychologic factors, seems to play a key role in the decision whether or not to refer for surgical or nonsurgical treatment in secondary care. To optimize patient-tailored treatment, future research should be adressed to determine the optimal moment of switching from primary to secondary care in patients with hip/knee osteoarthritis.
Journal of the American Board of Family Medicine : JABFM
The increasing number of community-dwelling frail elderly people poses a challenge to general pra... more The increasing number of community-dwelling frail elderly people poses a challenge to general practice. We evaluated the effectiveness of a general practitioner-led extensive, multicomponent program integrating cure, care, and welfare for the prevention of functional decline. We performed a cluster controlled trial in 12 general practices in Nijmegen, the Netherlands. Community-dwelling frail elderly people aged ≥70 years were identified with the EASY-Care two-step older persons screening instrument. In 6 general practices, 287 frail elderly received care according to the CareWell primary care program. This consisted of proactive care planning, case management, medication reviews, and multidisciplinary team meetings with a general practitioner, practice and/or community nurse, elderly care physician, and social worker. In another 6 general practices, 249 participants received care as usual. The primary outcome was independence in functioning during (instrumental) activities of daily...
The British journal of general practice : the journal of the Royal College of General Practitioners, 2014
A stepped care strategy (SCS) to improve adequate healthcare use in patients with osteoarthritis ... more A stepped care strategy (SCS) to improve adequate healthcare use in patients with osteoarthritis was developed and implemented in a primary care region in the Netherlands. To assess the association between care that is in line with the SCS recommendations and health outcomes. Data were used from a 2-year observational study of 313 patients who had consulted their GP because of osteoarthritis. Care was considered 'SCS-consistent' if all advised modalities of the previous steps of the SCS were offered before more advanced modalities of subsequent steps. Pain and physical function were measured with the Western Ontario and McMaster Universities Osteoarthritis Index (range 0-100); active pain coping with the Pain Coping Inventory (range 10-40); and self-efficacy with the Dutch General Self-Efficacy Scale (range 12-48). Crude and adjusted associations between SCS-consistent care and outcomes were estimated with generalised estimating equations. No statistically significant differ...
International journal for quality in health care : journal of the International Society for Quality in Health Care / ISQua, 2014
To improve the management of hip or knee osteoarthritis (OA), a stepped care strategy (SCS) has b... more To improve the management of hip or knee osteoarthritis (OA), a stepped care strategy (SCS) has been developed that presents the optimal sequence for care in three steps. This study evaluates the extent to which clinical practice is consistent with the strategy after implementation and identifies determinants of SCS-consistent care. A 2-year observational prospective cohort study. General practices in the region of Nijmegen in the Netherlands. Three hundred and thirteen patients with hip or knee OA and their general practitioner (GP). Multifaceted interventions were developed to implement the strategy. Consistency between clinical practice and the strategy was examined regarding three aspects of care: (i) timing of radiological assessment, (ii) sequence of non-surgical treatment options and (iii) making follow-up appointments. Out of the 212 patients who reported to have had an X-ray, 92 (44%) received it in line with the SCS. The sequence of treatment was inconsistent with the SCS ...
The British journal of general practice : the journal of the Royal College of General Practitioners, 2006
We conducted a study in which we measured GPs' attitudes towards personal continuity directly... more We conducted a study in which we measured GPs' attitudes towards personal continuity directly after consultations, and identified which factors predicted its perceived importance. Moreover, we related these data to attitudes as measured by a postal survey. GPs varied considerably in their attitudes towards personal continuity. Continuity was valued for serious and psychosocial issues and also for routine checks for a chronic illness. There was no relation whatsoever between the importance that individual GPs attached to continuity after consultations, and their scores on the postal survey.
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Papers by Henk Schers