[Show abstract][Hide abstract] ABSTRACT: General practitioners with more positive role security and therapeutic commitment towards patients with hazardous or harmful alcohol consumption are more involved and manage more alcohol-related problems than others. In this study we evaluated the effects of our tailored multi-faceted improvement implementation programme on GPs' role security and therapeutic commitment and, in addition, which professional related factors influenced the impact of the implementation programme.
In a cluster randomised controlled trial, 124 GPs from 82 Dutch general practices were randomised to either the intervention or control group. The tailored, multi-faceted programme included combined physician, organisation, and patient directed alcohol-specific implementation strategies to increase role security and therapeutic commitment in GPs. The control group was mailed the national guideline and patients received feedback letters. Questionnaires were completed before and 12 months after start of the programme. We performed linear multilevel regression analysis to evaluate effects of the implementation programme.
Participating GPs were predominantly male (63%) and had received very low levels of alcohol related education before start of the study (0.4 h). The programme increased therapeutic commitment (p = 0.005; 95%-CI 0.13 - 0.73) but not role security (p = 0.58; 95%-CI -0.31 - 0.54). How important GPs thought it was to improve their care for problematic alcohol consumption, and the GPs' reported proportion of patients asked about alcohol consumption at baseline, contributed to the effect of the programme on therapeutic commitment.
A tailored, multi-faceted programme aimed at improving GP management of patients with hazardous and harmful alcohol consumption improved GPs' therapeutic commitment towards patients with alcohol-related problems, but failed to improve GPs' role security. How important GPs thought it was to improve their care for problematic alcohol consumption, and the GPs' reported proportion of patients asked about alcohol consumption at baseline, both increased the impact of the programme on therapeutic commitment. It might be worthwhile to monitor proceeding of role security and therapeutic commitment throughout the year after the implementation programme, to see whether the programme is effective on short term but faded out on the longer term.Trial registration: ClinicalTrials.gov Identifier: NCT00298220.
BMC Family Practice 04/2014; 15(1):70. · 1.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background. To define appropriate antibiotic use for patients with a complicated urinary tract infection (UTI), we developed in a previous study a key set of four valid, guideline-based quality indicators (QIs). In the current study, we evaluated the association between appropriate antibiotic use for patients with a complicated UTI, as defined by these QIs, and length of hospital stay (LOS). Methods. A retrospective, observational multicentre study included 1,252 patients with a complicated UTI, hospitalized at Internal Medicine and Urology departments of 19 university and non-university Dutch hospitals. Data from the patients' medical charts were used to calculate QI performance scores. Multilevel mixed model analyses were performed to relate LOS to QI performance (appropriate use or not). We controlled for the potential confounders gender, age, (urological) comorbidity, febrile UTI and ICU admission<24 h. Results. Prescribing therapy in accordance with local hospital guidelines was associated with a shorter LOS (7.3 days vs. 8.7 days; P=0.02), as was early intravenous-oral switching (4.8 days vs. 9.1 days; P<0.001). There was an inverse relationship between the proportion of appropriate use in a patient (QI sumscore/number of applicable QIs) and LOS (9.3 days for lower tertile vs. 7.2 days for upper tertile; overall P<0.05). Conclusion. Appropriate antibiotic use in patients with a complicated UTI seems to reduce length of hospital stay and therefore favours patient outcome and health care costs. In particular, adherence to the total set of QIs showed a significant dose-response relationship with a shorter LOS.
[Show abstract][Hide abstract] ABSTRACT: Quality indicators for the treatment of type 2 diabetes are often retrieved from a chronic disease registry (CDR). This study investigates the quality of recording in a general practitioner's (GP) electronic medical record (EMR) compared to a simple, web-based CDR.
The GPs entered data directly in the CDR and in their own EMR during the study period (2011). We extracted data from 58 general practices (8235 patients) with type 2 diabetes and compared the occurrence and value of seven process indicators and 12 outcome indicators in both systems. The CDR, specifically designed for monitoring type 2 diabetes and reporting to health insurers, was used as the reference standard. For process indicators we examined the presence or absence of recordings on the patient level in both systems, for outcome indicators we examined the number of compliant or non-compliant values of recordings present in both systems. The diagnostic OR (DOR) was calculated for all indicators.
We found less concordance for process indicators than for outcome indicators. HbA1c testing was the process indicator with the highest DOR. Blood pressure measurement, urine albumin test, BMI recorded and eye assessment showed low DOR. For outcome indicators, the highest DOR was creatinine clearance <30 mL/min or mL/min/1.73 m(2) and the lowest DOR was systolic blood pressure <140 mm Hg.
Clinical items are not always adequately recorded in an EMR for retrieving indicators, but there is good concordance for the values of these items. If the quality of recording improves, indicators can be reported from the EMR, which will reduce the workload of GPs and enable GPs to maintain a good patient overview.
Journal of the American Medical Informatics Association 10/2013; · 3.57 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To establish which cut-off point for the FEV1/FVC (i.e. fixed 0.70 or Lower Limit of Normal cut-off point) best predicts accelerated lung function decline and exacerbations in middle-aged smokers.We performed secondary analyses on the Lung Health Study dataset. 4,045 smokers aged 35 to 60 years with mild to moderate obstructive pulmonary disease were subdivided into categories based on presence or absence of obstruction according to both FEV1/FVC cut-off points. Postbronchodilator FEV1 decline served as primary outcome to compare subjects between the respective categories.583 subjects (14.4%) were non-obstructed and 3,230 subjects (79.8%) were obstructed according to both FEV1/FVC cut-off points. 173 (4.3%) subjects were obstructive according to the fixed but not according to the LLN cut-off point("discordant" subjects). Mean postbronchodilator FEV1 decline was 41.8 (SE 2.0) mL·year(-1) in non-obstructive subjects, 43.8 (3.8) mL·year(-1) in discordant subjects, and 53.5 (0.9) mL·year(-1) in obstructive subjects (p<0.001).Our study showed that FEV1 decline in subjects deemed obstructed according to a fixed criterion (FEV1/FVC<0.70), but non-obstructed by a sex and age-specific criterion (LLN) closely resembles FEV1 decline in subjects designated as non-obstructed by both criteria. Sex and age should be taken into account when assessing airflow obstruction in middle-aged smokers.
European Respiratory Journal 04/2013; · 6.36 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Aim: The evidence on the acute effects of smoking on biomarkers is limited. Our aim was to study the acute effect of smoking on disease-related biomarkers. Methods: The acute effect of smoking on serum high sensitivity CRP (hs-CRP) and plasma fibrinogen and its association with disease severity was studied by challenging 31 chronic obstructive pulmonary disease patients with cigarette smoking and repeatedly measuring these biomarkers before and after smoking. Results: Fibrinogen and hs-CRP increased directly after smoking by 9.4 mg/dl (95% CI: 4.2-14.5) and 0.13 mg/l (95% CI: 0.03-0.23), respectively. Fibrinogen levels remained elevated after 35 min, whereas hs-CRP normalized. Pearson's correlation coefficient between the hs-CRP change and chronic obstructive pulmonary disease severity was 0.25 (p = 0.06). Conclusion: Fibrinogen and hs-CRP increased directly after smoking in the chronic obstructive pulmonary disease patients. Their association with disease risk and/or progression remains to be demonstrated.
Biomarkers in Medicine 04/2013; 7(2):211-9. · 3.22 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: PURPOSE Screening guidelines for type 2 diabetes recommend targeting high-risk individuals. Our objective was to assess whether diagnosis of type 2 diabetes based on opportunistic targeted screening results in lower vascular event rates compared with diagnosis on the basis of clinical signs or symptoms. METHODS In a prospective, nonrandomized, observational study, we enrolled patients aged 45 to 75 years from 10 family practices in the Netherlands with a new diagnosis of type 2 diabetes, detected either by (1) opportunistic targeted screening (n = 359) or (2) clinical signs or symptoms (n = 206). Patients in both groups received the same guideline-concordant diabetes care. The main group outcome measure was a composite of death from cardiovascular disease (CVD), nonfatal myocardial infarction, and nonfatal stroke. RESULTS Baseline vascular disease was more prevalent in the opportunistic targeted screening group, mainly ischemic heart disease (12.3% vs 3.9%, P = .001) and nephropathy (16.9% vs 7.1%, P = .002). After a mean follow-up of 7.7 years (SD = 2.4 years) and 7.1 years (SD = 2.7 years) for the opportunistic targeted screening and clinical diagnosis groups, respectively, composite primary event rates did not differ significantly between the 2 groups (9.5% vs 10.2%, P = .78; adjusted hazard ratio 0.67, 95% confidence interval, 0.36-1.25; P = .21). There were also no significant differences in the separate event rates of deaths from CVD, nonfatal myocardial infarction, and nonfatal strokes. CONCLUSIONS Opportunistic targeted screening for type 2 diabetes detected patients with higher CVD morbidity at baseline when compared with clinical diagnosis but showed similar CVD mortality and major CVD morbidity after 7.7 years. Opportunistic targeted screening and guided care appears to improve vascular outcomes in type 2 diabetes in primary care.
The Annals of Family Medicine 01/2013; 11(1):20-7. · 4.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND AND OBJECTIVE: We hypothesized that bronchodilation in patients with chronic obstructive pulmonary disease (COPD) increases the smoke-related risk to develop cardiovascular disease and aimed to study the effect of short-acting anticholinergic bronchodilation and smoking on cardiovascular events. METHODS: We performed a secondary analysis on data from the Lung Health Study, a large randomized clinical trial of smokers with mild to moderate pulmonary obstruction, 35 to 60 years old, without cardiovascular co-morbidity. We used Cox proportional survival analysis, controlling for several confounders, to study the effect on 5-year risk of fatal and/or nonfatal cardiovascular events. Secondary outcome encompassed fatal and nonfatal coronary events. RESULTS: Of 2,745 participants, 23 (0.8%) died of cardiovascular disease. One hundred and sixty two participants were hospitalized for a cardiovascular event, and 94 participants due to a coronary event. Survival analysis revealed no effect between smoking and short-acting anticholinergic bronchodilation on fatal and/or nonfatal cardiovascular events, HR=1.12 (0.58-2.19), nor on coronary events: HR=1.46 (0.60-3.56). CONCLUSIONS: Our study results show that short-acting anticholinergic bronchodilation had no detrimental effect on cardiovascular disease in smokers with mild to moderate pulmonary obstruction.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: With increasing age and longevity, the rising number of frail elders with complex and numerous health-related needs demands a coordinated health care delivery system integrating cure, care and welfare. Studies on the effectiveness of such comprehensive chronic care models targeting frail elders show inconclusive results. The CareWell-primary care program is a complex intervention targeting community-dwelling frail elderly people, that aims to prevent functional decline, improve quality of life, and reduce or postpone hospital and nursing home admissions of community dwelling frail elderly.Methods/designThe CareWell-primary care study includes a (cost-) effectiveness study and a comprehensive process evaluation. In a one-year pragmatic, cluster controlled trial, six general practices are non-randomly recruited to adopt the CareWell-primary care program and six control practices will deliver 'care as usual'. Each practice includes a random sample of fifty frail elders aged 70 years or above in the cost-effectiveness study. A sample of patients and informal caregivers and all health care professionals participating in the CareWell-primary care program are included in the process evaluation.In the cost-effectiveness study, the primary outcome is the level of functional abilities as measured with the Katz-15 index. Hierarchical mixed-effects regression models / multilevel modeling approach will be used, since the study participants are nested within the general practices. Furthermore, incremental cost-effectiveness ratios will be calculated as costs per QALY gained and as costs weighed against functional abilities. In the process evaluation, mixed methods will be used to provide insight in the implementation degree of the program, patients' and professionals' approval of the program, and the barriers and facilitators to implementation. DISCUSSION: The CareWell-primary care study will provide new insights into the (cost-) effectiveness, feasibility, and barriers and facilitators for implementation of this complex intervention in primary care.Trial registrationThe CareWell-primary care study is registered in the ClinicalTrials.gov Protocol Registration System: NCT01499797.
BMC Family Practice 12/2012; 13(1):115. · 1.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: INTRODUCTION: Bronchodilators are the cornerstone for symptomatic treatment of chronic obstructive pulmonary disease (COPD). Many patients use these agents while persisting in their habit of cigarette smoking. We hypothesized that bronchodilators increase pulmonary retention of cigarette smoke and hence the risk of smoking-related (cardiovascular) disease. Our aim was to investigate if bronchodilation causes increased pulmonary retention of cigarette smoke in patients with COPD. METHODS: A double-blinded, placebo-controlled, randomized crossover trial, in which COPD patients smoked cigarettes during undilated conditions at one session and maximal bronchodilated conditions at the other session. Co-primary outcomes were pulmonary tar and nicotine retention. We performed a secondary analysis that excludes errors due to possible contamination. Secondary outcomes included the biomarkers C-reactive protein and fibrinogen, and smoke inhalation patterns. RESULTS: Of 39 randomized patients, 35 patients completed the experiment and were included in the final analysis. Bronchodilation did not significantly increase tar retention (-4.5%, p = 0.20) or nicotine retention (-2.6%, p = 0.11). Secondary analysis revealed a potential reduction of retention due to bronchodilation: tar retention (-3.8%, p = 0.13), and nicotine retention (-3.4%, p = 0.01). Bronchodilation did not modify our secondary outcomes. CONCLUSIONS: Our results do not support the hypothesis that cigarette tar and nicotine retention in COPD patients is increased by bronchodilation, whereas we observed a possibility towards less retention. TRIAL REGISTRATION: www.clinicaltrials.gov: NCT00981851.
Respiratory medicine 10/2012; · 2.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Evidence for pay-for-performance (P4P) has been searched for in the last decade as financial incentives increased to influence behaviour of health care professionals to improve quality of care. The effectiveness of P4P is inconclusive, though some reviews reported significant effects. OBJECTIVE: To assess changes in performance after introducing a participatory P4P program. DESIGN: An observational study with a pre- and post-measurement.Setting and subjects.Sixty-five general practices in the south of the Netherlands.Intervention.A P4P program designed by target users containing indicators for chronic care, prevention, practice management and patient experience (general practitioner's [GP] functioning and organization of care). Quality indicators were calculated for each practice. A bonus with a maximum of 6890 Euros per 1000 patients was determined by comparing practice performance with a benchmark. MAIN OUTCOME MEASURES: Quality indicators for clinical care (process and outcome) and patient experience. RESULTS: We included 60 practices. After 1 year, significant improvement was shown for the process indicators for all chronic conditions ranging from +7.9% improvement for cardiovascular risk management to +11.5% for asthma. Five outcome indicators significantly improved as well as patients' experiences with GP's functioning and organization of care. No significant improvements were seen for influenza vaccination rate and the cervical cancer screening uptake. The clinical process and outcome indicators, as well as patient experience indicators were affected by baseline measures. Smaller practices showed more improvement. CONCLUSIONS: A participatory P4P program might stimulate quality improvement in clinical care and improve patient experiences with GP's functioning and the organization of care.
[Show abstract][Hide abstract] ABSTRACT: Although childhood vaccination programmes have been very successful, there are some hard to reach minority groups that object to vaccination. The Netherlands has experienced several epidemics of vaccine-preventable diseases, confined to the orthodox Protestant minority. However, vaccination coverage in this minority is still unknown and this hampers prevention and control of epidemics.
We estimated vaccination coverage among the orthodox Protestant minority and its various subgroups (denominations), using two sub-studies with different design and study population. For both sub-studies separately, we determined overall vaccination coverage and vaccination coverage per denomination. The results were compared and discussed.
An online survey was filled out by 1778 orthodox Protestant youngsters, invited via orthodox Protestant media using a snowball method. Next to that, results of a national sample study on vaccination were used, of which only orthodox Protestant respondents were included in our analyses (N = 2129). Overall vaccination coverage among orthodox Protestants in The Netherlands was estimated to be at minimum 60%. Moreover, in both sub-studies three clusters of denominations could be identified, with high (>85%), intermediate (50-75%) and low (<25%) vaccination coverage.
The integration of both sub-studies, with their own specific strengths and weaknesses, added to our insight in the vaccination coverage in this minority. Based on these results, we recommend to focus prevention and control of vaccine-preventable diseases on the orthodox Protestant subgroups with intermediate and low vaccination coverage.
The European Journal of Public Health 03/2012; 22(3):359-64. · 2.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Current COPD guidelines advocate a fixed < 0.70 FEV1/FVC cutpoint to define airflow obstruction. We compared rate of lung function decline in respiratory symptomatic 40+ subjects who were 'obstructive' or 'non-obstructive' according to the fixed and/or age and gender specific lower limit of normal (LLN) FEV1/FVC cutpoints.
We studied 3,324 respiratory symptomatic subjects referred to primary care diagnostic centres for spirometry. The cohort was subdivided into four categories based on presence or absence of obstruction according to the fixed and LLN FEV1/FVC cutpoints. Postbronchodilator FEV1 decline served as primary outcome to compare subjects between the respective categories.
918 subjects were obstructive according to the fixed FEV1/FVC cutpoint; 389 (42%) of them were non-obstructive according to the LLN cutpoint. In smokers, postbronchodilator FEV1 decline was 21 (SE 3) ml/year in those non-obstructive according to both cutpoints, 21 (7) ml/year in those obstructive according to the fixed but not according to the LLN cutpoint, and 50 (5) ml/year in those obstructive according to both cutpoints (p = 0.004).
This study showed that respiratory symptomatic 40+ smokers and non-smokers who show FEV1/FVC values below the fixed 0.70 cutpoint but above their age/gender specific LLN value did not show accelerated FEV1 decline, in contrast with those showing FEV1/FVC values below their LLN cutpoint.
BMC Pulmonary Medicine 03/2012; 12:12. · 2.76 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To assess the effect of a tailored multi-faceted improvement programme on general practitioners' (GPs') behaviour towards prevention of hazardous and harmful alcohol consumption. The improvement programme consisted of activities aimed at the GP, organization and patient. Educational training sessions and visits by a facilitator were tailored to the GPs' needs and attitudes.
Cluster randomized controlled trial.
General practices in the Netherlands.
Seventy-seven general practices; 119 GPs participated. Data from 6318 patients were available, of whom 765 (12.1%) were at risk. A total of 1502 patients' electronic medical records were reviewed.
The primary outcome was the number of eligible patients who received screening and advice.
Difficulties in recruiting GPs and in motivating GPs for participation in the tailored parts of the programme impeded optimal implementation of the programme. Although GPs in both groups became more involved after enrolment, this improvement waned during the trial. The quality improvement programme enhanced the initial improvement in behaviour and it tempered waning (intervention group), compared to our control condition, resulting in average improvement rates of 5% (screening) and 2% (advice-giving) at 12-month follow-up (not significant).
A tailored, multi-faceted programme aimed at improving general practitioner management of alcohol consumption in their patients failed to show an effect and proved difficult to implement. There remains little evidence to support the use of such an intensive implementation programme to improve the management of harmful and hazardous alcohol consumption in primary care.
[Show abstract][Hide abstract] ABSTRACT: To assess the long term effects of two different modes of disease management (comprehensive self management and routine monitoring) on quality of life (primary objective), frequency and patients' management of exacerbations, and self efficacy (secondary objectives) in patients with chronic obstructive pulmonary disease (COPD) in general practice.
24 month, multicentre, investigator blinded, three arm, pragmatic, randomised controlled trial.
15 general practices in the eastern part of the Netherlands.
Patients with COPD confirmed by spirometry and treated in general practice. Patients with very severe COPD or treated by a respiratory physician were excluded.
A comprehensive self management programme as an adjunct to usual care, consisting of four tailored sessions with ongoing telephone support by a practice nurse; routine monitoring as an adjunct to usual care, consisting of 2-4 structured consultations a year with a practice nurse; or usual care alone (contacts with the general practitioner at the patients' own initiative).
The primary outcome was the change in COPD specific quality of life at 24 months as measured with the chronic respiratory questionnaire total score. Secondary outcomes were chronic respiratory questionnaire domain scores, frequency and patients' management of exacerbations measured with the Nijmegen telephonic exacerbation assessment system, and self efficacy measured with the COPD self-efficacy scale.
165 patients were allocated to self management (n=55), routine monitoring (n=55), or usual care alone (n=55). At 24 months, adjusted treatment differences between the three groups in mean chronic respiratory questionnaire total score were not significant. Secondary outcomes did not differ, except for exacerbation management. Compared with usual care, more exacerbations in the self management group were managed with bronchodilators (odds ratio 2.81, 95% confidence interval 1.16 to 6.82) and with prednisolone, antibiotics, or both (3.98, 1.10 to 15.58).
Comprehensive self management or routine monitoring did not show long term benefits in terms of quality of life or self efficacy over usual care alone in COPD patients in general practice. Patients in the self management group seemed to be more capable of appropriately managing exacerbations than did those in the usual care group.
Clinical trials NCT00128765.
[Show abstract][Hide abstract] ABSTRACT: Current tools for recording chronic obstructive pulmonary disease (COPD) exacerbations are limited and often lack validity testing. We assessed the validity of an automated telephonic exacerbation assessment system (TEXAS) and compared its outcomes with existing tools. Over 12 months, 86 COPD patients (22.1% females; mean age 66.5 yrs; mean post-bronchodilator forced expiratory volume in 1 s 53.4% predicted) were called once every 2 weeks by TEXAS to record changes in respiratory symptoms, unscheduled healthcare utilisation and use of respiratory medication. The responses to TEXAS were validated against exacerbation-related information collected by observations made by trained research assistants during home visits. No care assistance was provided in any way. Diagnostic test characteristics were estimated using commonly used definitions of exacerbation. Detection rates, compliance and patient preference were assessed, and compared with paper diary cards and medical record review. A total of 1,824 successful calls were recorded, of which 292 were verified by home visits (median four calls per patient, interquartile range three to five calls per patient). Independent of the exacerbation definition used, validity was high, with sensitivities and specificities between 66% and 98%. Detection rates and compliance differed extensively between the different tools, but were highest with TEXAS. Patient preference did not differ. TEXAS is a valid tool to assess COPD exacerbation rates in prospective clinical studies. Using different tools to record exacerbations strongly affects exacerbation occurrence rates.
European Respiratory Journal 09/2011; 39(5):1090-6. · 6.36 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In the Netherlands, epidemics of vaccine preventable diseases are largely confined to an orthodox protestant minority with religious objections to vaccination. The clustering of unvaccinated children in orthodox protestant schools can foster the spread of epidemics. School closure has nevertheless not been practiced up until now. A mumps epidemic in 2007-2008 gave us an opportunity to study the role of schools in the spread of a vaccine preventable disease in a village with low vaccination coverage.
A retrospective cohort study was conducted among the students in four elementary schools and their siblings. The following information was collected for each child: having had the mumps or not and when, school, age, MMR vaccination status, household size, presence of high school students in the household, religious denomination, and home village. The spread of mumps among unvaccinated children was compared for the four schools in a Kaplan-Meier analysis using a log-rank test. Cox proportional hazard analyses were performed to test for the influence of other factors. To correct for confounding, a univariate Cox regression model with only school included as a determinant was compared to a multivariate regression model containing all possible confounders.
Out of 650 households with children at the schools, 54% completed a questionnaire, which provided information on 1191 children. For the unvaccinated children (N = 769), the Kaplan-Meier curves showed significant differences among the schools in their cumulative attack rates. After correction for confounding, the Cox regression analysis showed the hazard of mumps to be higher in one orthodox protestant school compared to the other (hazard ratio 1.43, p < 0.001). Household size independently influenced the hazard of mumps (hazard ratio 1.44, p < 0.005) with children in larger households running a greater risk.
If and when unvaccinated children got mumps was determined by the particular school the children and their siblings attended, and by the household size. This finding suggests that school closure can influence the spread of an epidemic among orthodox protestant populations, provided that social distancing is adhered to as well. Further research on the effects of school closure on the final attack rate is nevertheless recommended.
[Show abstract][Hide abstract] ABSTRACT: To assess the association of patient and hospital characteristics with adherence to guidelines for intrauterine insemination (IUI) care.
Retrospective cohort study using multilevel regression analysis. Characteristics studied at the patient level were female age, type and duration of subfertility, diagnosis and number of started IUI cycles. At the hospital level, the characteristics studied were hospital size, teaching hospital, in vitro fertilization (IVF) licence and number of physicians involved in the IUI programme. Data were obtained from medical records and questionnaires for gynaecologists.
Five hundred and fifty-eight subfertile couples who underwent IUI treatment at 10 Dutch hospitals.
Adherence to systematically developed guideline-based performance indicators describing 20 processes of IUI care.
A total of 558 couples who started 2,334 IUI cycles participated. Guideline adherence in IUI care was often substandard and varied considerably between hospitals. Variation in guideline adherence in IUI care was associated with the patient characteristics 'diagnosis' and 'female age'. Only adherence to the guideline recommendation regarding 'screening for tubal occlusion' was associated with hospital characteristics ('hospital size' and 'IVF licence'). Large explained variances up to 39% were found for the different models.
A number of patient and hospital characteristics were associated with variation in guideline adherence in IUI care, particularly the patient characteristics 'diagnosis' and 'female age'. The identification of different subgroups in the patient population and different types of hospitals with regard to the extent of guideline adherence in IUI care is important for the tailoring of interventions to improve IUI care.
International Journal for Quality in Health Care 06/2011; 23(5):574-82. · 1.79 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Smoking and bronchodilator treatment are both extensively studied as key elements in patients with chronic obstructive pulmonary disease. However, little is known about whether or not these elements interact in terms of developing cardiovascular diseases in patients with COPD.
To explore to what extent the risk of developing ischemic cardiovascular disease in COPD patients is mediated by smoking status, use of bronchodilators and--specifically--their interaction.
We performed an observational pilot study on a relatively healthy Dutch COPD cohort from a primary care diagnostic center database with full information on spirometry tests, smoking status, bronchodilator use and other prescribed medication. We defined first ischemic cardiovascular events as primary outcome, measured by first prescription of antiplatelet drugs and/or nitrates. Unadjusted analyses by Kaplan-Meier were followed by adjusted Cox' proportional hazards.
845 COPD patients, totaling 2,169 observation years, were included in the analyses. We observed an increased risk for nonfatal ischemic cardiovascular events by smoking (adjusted HR=3.58, p=0.001) and a protective effect of bronchodilators (adjusted HR=0.43, p=0.01). Although the protective effect of bronchodilators appears to be substantially minimized in patients that persist in smoking, we could not statistically confirm a hazardous interaction between bronchodilators and smoking (HR 2.50, p=0.21).
Our study reveals bronchodilators may protect from ischemic cardiovascular events in a relatively 'healthy' COPD population. We did not confirm a hazardous interaction between bronchodilators and smoking, although we observed current smokers benefit substantially less from the protective effect of bronchodilators.
[Show abstract][Hide abstract] ABSTRACT: Preterm birth increases the risk for neurologic and developmental disabilities and therefore long-term follow-up is important. This prospective follow-up study aims to describe longitudinal motor performance in preterm infants from 6 to 24 months and to detect the influence of risk factors on motor performance trajectories. We included preterm infants (n=348) with a gestational age of ≤32 weeks. The Bayley Scales of Infant Development, 2nd edition (BSID-II) Motor Scale and the Behaviour Rating Scale were recorded at the corrected ages of 6, 12 and 24 months. The Motor Scale raw score was the dependent variable in random coefficient analysis for risk factors in the cohort if infants with cerebral damage were in- and excluded. The raw score increased, showed the highest correlation (rp=0.48-0.67) and was more stable than the PDI and its classification. Fifteen percent of the infants had a stable classification, while 45% changed one class. Male sex and intra-ventricular haemorrhage (IVH) lowered the raw scores. Higher motor quality scores and height increased the raw scores, while the influence of maternal education varied at different time points. Removal of infants with cerebral damage from the cohort did not change the risk factors. The results showed that the raw score trajectories were more stable, but after corrections for norm data, the measurements became highly unstable. This is clinically important when reporting results to parents, guiding intervention and in randomised trials. The risk factors predominantly influenced the level of motor performance raw scores. Maternal education additionally influenced the trajectory and should be included in randomisation procedures.
Research in developmental disabilities 2011;32(5):1902-9. 05/2011;