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ABSTRACT: PurposeThis study examined the referral process for genetic counseling at a cancer genetics clinic in patients with colorectal cancer
and to search for determinants of variation in this referral process.
MethodsPatients who were recently diagnosed with colorectal cancer at a young age or multiple cancers associated with Lynch syndrome,
hereditary nonpolyposis colorectal cancer, (N = 119) were selected from PALGA, the nationwide network and registry of histopathology
and cytopathology in the Netherlands. In a retrospective analysis, we examined whether these patients visited a cancer genetics
clinic and identified determinants for referral to such a clinic. Factors of patients, professional practice, and hospital
setting were explored with logistic regression modeling.
ResultsThirty-six (30 percent) patients visited a cancer genetics clinic. Seventy percent of patients whom the surgeon referred to
a cancer genetics clinic decided to visit such a clinic. Analysis of determinants showed that patients with whom the surgeon
discussed referral and that were treated in a teaching hospital were more likely to visit a cancer genetics clinic.
ConclusionThe referral process is not optimally carried out. To deliver optimal care for patients suspected of hereditary colorectal
cancer, this process must be improved with interventions focusing on patient referral by surgeons and raising awareness in
nonteaching hospitals.
Diseases of the Colon & Rectum 04/2012; 51(8):1249-1254. · 3.13 Impact Factor
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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. · 1.96 Impact Factor
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ABSTRACT: Despite growing attention to patient-centered care, the needs of cancer patients are not always met.
Using a RAND modified Delphi method, this study aimed to systematically develop evidence-based indicators, to be used to measure the quality of patient-centered cancer care as a first step toward improvement.
First, key recommendations were identified from literature and were distributed over 5 domains of patient-centered cancer care: communication, physical support, psychosocial care, after-care, and organization of care. Generic key recommendations, with best available evidence, were selected from guidelines. A multidisciplinary panel of patients and medical professionals (n = 14) rated and prioritized these recommendations in a written procedure. Subsequently, the panel discussed the recommendations at a consensus meeting.
Key recommendations were identified for communication (n = 32), physical support (n = 13), psychosocial care (n = 25), after-care (n = 11), and organization of care (n = 11). For all domains, recommendations based on high-level evidence were identified except for after-care and physical support. The panel developed 17 indicators concerning criteria for communication and informed consent, evaluation of communication skills, provision of information, examination of emotional health, appointment of a care coordinator, physical complaints, follow-up, rehabilitation, psychosocial effects of waiting times, and self-management.
A set of 17 indicators for patient-centered cancer care resulted from this study. Evidence support was available for most indicators.
This set provides an opportunity to measure and improve the quality of patient-centered cancer care. It is generic and therefore applies to many patients.
Cancer nursing 05/2011; 35(1):29-37. · 1.88 Impact Factor
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ABSTRACT: Guidelines on recurrent miscarriage are poorly implemented in daily clinical practice. To ensure proper implementation, we identified existing barriers and facilitators for guideline adherence according to professionals and patients.
Qualitative research.
Two different regions in the Netherlands.
Forty-two professionals: gynecologists, residents in obstetrics and gynecology, fertility doctors and clinical geneticists. Ten patients with recurrent miscarriage.
Focus group interviews were performed with professionals and individual in-depth interviews with patients. Reports from the interviews were analyzed and barriers were identified.
Identified barriers, categorized in four domains, including characteristics of: (I) the guideline, (II) professionals, (III) patients, (IV) organization.
Ninety-six barriers, at all four domains, were identified among professionals. The most frequently mentioned barriers were: guideline being too complicated in the consultancy room and finding it difficult to refuse demands of insistent patients. Patients mentioned 40 barriers, of which lack of up-to-date patient information and lack of detailed knowledge about family history were most frequently mentioned. Potential facilitators, such as an electronic decision tool and patient questionnaires prior to their first visit, were mentioned by both professionals and patients. All participants agreed that complete adherence to the guideline was theoretically achievable.
Both professionals and patients experienced barriers and facilitators for guideline adherence in recurrent miscarriage. Guideline implementation strategies should take these identified barriers into account.
Acta Obstetricia Et Gynecologica Scandinavica 02/2011; 90(2):186-91. · 1.77 Impact Factor
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ABSTRACT: To identify organizational determinants of positive patient experiences with fertility care, with the goal of improving patient centeredness of care.
Cross-sectional survey.
One large university clinic and 12 medium-sized fertility clinics in the Netherlands.
Three hundred and sixty-nine couples receiving medically assisted reproduction in one of the participating clinics between March and May 2008.
None.
Organizational determinants of patients' experiences with patient centeredness in fertility care.
Of the patients during the relevant period, 78% of the women and 76% of their partners participated in the study. Infertile couples who have a lead physician, have access to an electronic personal health record, or see trained fertility nurses have more positive experiences with aspects of patient-centered care, like continuity of care and partner involvement. Moreover, receiving a treatment other than in vitro fertilization was negatively associated with the perceived patient centeredness of care. The identified determinants explained 5.1% to 22.4% of the total variance.
This study provides organizational determinants of patients' experiences with fertility care on numerous facets of patient centeredness. These organizational determinants can be used as valuable tools to enable clinics to provide a more positive patient experience.
Fertility and sterility 02/2011; 95(2):513-9. · 3.97 Impact Factor
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ABSTRACT: BACKGROUND Proper use of clinical practice guidelines can decrease variation in care between settings. However, actual use of fertility guidelines is suboptimal and in need of improvement. Hence, a cluster-randomized controlled trial was designed to study the effects of two strategies to implement national Dutch guidelines on comprehensive fertility care. METHODS Sixteen fertility clinics participated in the trial. A minimal, professional-oriented implementation strategy of audit and feedback was tested versus a maximal multi-faceted strategy that was both professional and patient oriented. The extent of adherence to guideline recommendations, reflected in quality indicator scores, was the primary outcome measure. To gain an insight into unwanted side effects, patient anxiety and depression scores were gathered as secondary outcomes. Data collection encompassed medical record search, patient and professional questionnaires. RESULTS A total of 1499 couples were included at baseline and 1396 at the after-measurement. No overall significant improvement in indicator scores was found for either strategy [odds ratios ranging from 0.23 (95% confidence interval (CI): 0.06-0.95) to 6.66 (95% CI: 0.33-132.8]. Secondary outcomes did not differ significantly for both groups, although selected anxiety scores appeared lower in the maximal intervention group. Process evaluation of the trial revealed positive patient experiences with the intervention material [e.g. an increased understanding of their doctor's treatment policy (61%), an increased ability to ask questions about the treatment (61%)]. Professionals' appreciation of intervention elements varied, and execution of the multi-faceted strategy appeared incomplete. DISCUSSION Absence of an intervention effect may be due to the nature of the strategies, incomplete execution or flaws in study design. Process evaluation data raise the question of whether professionals should be the only stakeholder responsible for guideline implementation. This study therefore contributes to an increased understanding of fertility guideline implementation in general, and the role of patients in particular.
Human Reproduction 12/2010; 26(4):817-26. · 4.47 Impact Factor
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ABSTRACT: Health-care delivery according to clinical practice guidelines is thought to be critical in achieving optimal outcomes. This study aimed to assess the extent to which practice performance in intrauterine insemination (IUI) care is consistent with guideline recommendations and to evaluate the association between guideline adherence and outcome of IUI care. In a retrospective cohort study, 1100 infertile couples who underwent IUI treatment at 10 Dutch hospitals were asked to grant access to their medical record for assessment of guideline adherence using 25 systematically developed guideline-based performance indicators. A total of 558 couples who started 2334 IUI cycles participated. Guideline adherence regarding 20 process and five structure aspects of IUI care was often substandard and varied considerably between hospitals. Out of 10 possible associations investigated, guideline adherence regarding sperm quality and guideline adherence regarding the total number of IUI cycles were associated with improved ongoing pregnancy rates after IUI. Thus, guideline adherence in IUI care is far from optimal and varies substantially between hospitals. As associations between guideline adherence and ongoing pregnancy after IUI were mainly non-significant, further research is needed to evaluate associations between guideline adherence and other outcomes of IUI care besides ongoing pregnancy, such as patient safety and cost effectiveness.
Reproductive biomedicine online 04/2010; 20(4):533-42. · 2.04 Impact Factor
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ABSTRACT: To assess determinants of patients' experiences and satisfaction with fertility care.
Cross-sectional questionnaire study.
Sixteen fertility clinics in The Netherlands.
A total of 1,499 infertile women in The Netherlands who visited a participating clinic in April-June 2005 for diagnostics or treatment.
Patients experiences and satisfaction with several aspects of fertility care, and the patient and clinic characteristics that are determinants of those two concepts.
In general, patients' satisfaction with care was high (94%). Waiting times, information provision and emotional support were experienced the least positive aspects of care. Determinants of all care aspects were found to be significant at four different domains: three at patient level, i.e., demographic characteristics, type of received treatment and both general and mental health status, and one at clinic level, i.e., organization of care.
This study provides an increased understanding of the determinants of patients' experiences and satisfaction with fertility care. This enables professionals to tailor their care to specific subgroups of patients and adjust their organization of fertility care where needed. Moreover, the study underlines the need to investigate whether case-mix correction is necessary whenever interpreting patient-surveys on care experiences, because both the patient's and the clinic's characteristics can influence the way that health care delivery is experienced. Demographic background of this regional patient sample was rather homogeneous, which should be taken into account when interpreting results.
Fertility and sterility 10/2009; 94(4):1254-60. · 3.97 Impact Factor
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ABSTRACT: When deciding how many embryos to transfer during in vitro fertilisation (IVF), clinicians and patients have to balance optimizing the chance of pregnancy against preventing multiple pregnancies and the associated complications. This paper describes the development and pilot test of a patient decision aid (DA) for this purpose.
The development of the DA consisted of a literature search, establishment of the format, and a pilot test among IVF patients. The DA development was supervised by a panel of experts in the fields of subfertility, obstetrics and DA-research and it was based on the criteria of the International Patient Decision Aid Standards.
One Cochrane review and 34 articles were selected for the DA content. The DA presents information in text, summaries, tables, figures and through an interactive worksheet. The DA was reviewed positively and as acceptable for use in clinical practice by patients and professionals.
The DA was thoroughly developed and is likely to be helpful for the decision-making process for the number of embryos transferred after IVF.
Physicians and researchers can use the DA without restriction in clinical practice or research related to decision-making.
Patient Education and Counseling 06/2009; 78(1):124-9. · 2.31 Impact Factor
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ABSTRACT: To assess patients' views on the care provided by nurse practitioners compared with that provided by general practitioners and to determine factors influencing these views.
Many countries have sought to shift aspects of primary care provision from doctors to nurses. It is unclear how patients view these skill mix changes.
Cross-sectional survey.
Patients (n = 235) who received care from both nurse and doctor were sent a self-administered questionnaire. The main outcome measures were patient preferences, satisfaction with the nurses and doctors and factors influencing patients' preference and satisfaction.
Patients preferred the doctor for medical aspects of care, whereas for educational and routine aspects of care half of the patients preferred the nurse or had no preference for either the nurse or doctor. Patients were generally very satisfied with both nurse and doctor. Patients were significantly more satisfied with the nurse for those aspects of care related to the support provided to patients and families and to the time made available to patients. However, variations in preference and satisfaction were mostly attributable to variation in individual patient characteristics, not doctor, nurse or practice characteristics. Conclusion: Patient preference for nurse or doctor and patient satisfaction both vary with the type of care required and reflect usual work demarcations between nurses and doctors. In general, patients are very satisfied with the care they receive.
In many countries, different aspects of primary care provision have shifted from doctors to nurses. Our study suggests that these skill mix changes meet the needs of patients and that patients are very satisfied with the care they receive. However, to implement skill mix change in general practice it is important to consider usual work demarcations between nurses and doctors.
Journal of Clinical Nursing 10/2008; 17(20):2690-8. · 1.12 Impact Factor
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Lucia I H Overbeek,
Marjolijn J L Ligtenberg,
Riki W Willems, Rosella P M G Hermens,
Willeke A M Blokx,
Stefan V Dubois,
Hans van der Linden,
Jos W R Meijer,
Maria L Mlynek-Kersjes,
Nicoline Hoogerbrugge,
Konnie M Hebeda,
Joannes H J M van Krieken
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ABSTRACT: We examined the validity of immunohistochemistry for mismatch repair (MMR) proteins in colorectal cancer specimens to identify patients at risk for Lynch syndrome (hereditary nonpolyposis colorectal cancer) and patients with sporadic microsatellite instable colorectal cancer. This was assessed by observer agreement for and accuracy of interpretation of immunohistochemistry. Seven pathologists from 5 different pathology laboratories evaluated 100 molecularly defined colorectal cancers stained for MLH1, PMS2, MSH2, and MSH6. Two of the pathologists were experienced in interpretation of immunohistochemistry for MMR proteins. After evaluation of a subset of 20 cases, a discussion meeting was organized, after which pathologists evaluated all 100 cases. Staining patterns were interpreted as aberrant, normal, or indefinite. In 82% of tumors, 5 or more pathologists reached the same interpretation, which was considered the consensus diagnosis. Consensus was reached slightly less frequently in microsatellite instable than in stable tumors, and interobserver variation was moderate to substantial (kappa: 0.49-0.79). More microsatellite instable tumors showed an indefinite staining pattern compared with microsatellite stable tumors. Three out of 7 pathologists, including the 2 experienced pathologists, did not miss a microsatellite instable tumor. Each pathologist found at least 1 tumor with an aberrant staining pattern, whereas consensus was a normal staining pattern and the tumor was microsatellite stable. We conclude that, if restricted to experienced pathologists, immunohistochemistry is a valid tool to identify patients at risk for Lynch syndrome and patients with sporadic microsatellite instable colorectal cancer. An indefinite or aberrant staining result has to be followed by molecular microsatellite instability analysis to confirm the presence of a defective DNA MMR system.
The American journal of surgical pathology 09/2008; 32(8):1246-51. · 4.06 Impact Factor
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ABSTRACT: The concept of 'patient-friendly' medically assisted reproduction includes a robust set of clinical practice principles, to improve the quality of subfertility care. This concept is an important move away from the sole focus on effectiveness and high pregnancy rates in assisted reproduction technology (ART). Although the concept of 'patient-friendly ART' has several strong points, we feel it is incomplete. For achieving true high-quality ART, the concept should be extended to two more dimensions: timeliness and patient centredness. Moreover, we propose a change in the concept's name to the less ambiguous 'high-quality ART'.
Human Reproduction 07/2008; 23(6):1242-5. · 4.47 Impact Factor
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ABSTRACT: This study aims to examine the impact of women's characteristics (demographics, risk behaviour, and beliefs) on the uptake of cervical cancer screening, taking practice characteristics (demographic and organizational) into account.
Routinely collected data of screening status were sampled from electronic medical records of 32 Dutch general practices. Additionally, a questionnaire was sent to a sample of 2224 listed women-1204 screened, 1020 unscreened. We used a step-by-step, logistic, multilevel approach to examine determinants of the screening uptake.
Analyses of data for 1392 women (968 screened and 424 unscreened) showed that women's beliefs about cervical screening and attendance are the best predictors of screening uptake, even when demographic and organizational aspects are taken into account. Women aged 40-50 years who felt high personal moral obligation, who had only one sexual partner ever, and who were invited and reminded by their own general practice had the greatest likelihood of screening uptake. A non-response study was performed; the non-responders to the questionnaire (mainly unscreened) thought they had less risk of cervical cancer, were less motivated, less often intended to get future screening, and were more convinced that cervical cancer cannot be cured.
To improve the uptake rate, we should focus on the personal moral obligation of eligible women, beliefs about the risks of cervical cancer, and available cures. Invitations and reminders within general practices enhance the uptake rate.
The European Journal of Public Health 05/2007; 17(2):178-85. · 2.73 Impact Factor
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ABSTRACT: To examine the impact on general practitioners' workload of adding nurse practitioners to the general practice team.
Randomised controlled trial with measurements before and after the introduction of nurse practitioners.
34 general practices in a southern region of the Netherlands.
48 general practitioners.
Five nurses were randomly allocated to general practitioners to undertake specific elements of care according to agreed guidelines. The control group received no nurse.
Objective workload, derived from 28 day diaries, included the number of contacts per day for each of three conditions (chronic obstructive pulmonary disease or asthma, dementia, cancer), by type of consultation (in practice, telephone, home visit), and by time of day (surgery hours, out of hours). Subjective workload was measured by using a validated questionnaire. Outcomes were measured six months before and 18 months after the intervention.
The number of contacts during surgery hours increased in the intervention group compared with the control group (P < 0.06), particularly for patients with chronic obstructive pulmonary disease or asthma (P < 0.01). The number of consultations out of hours declined slightly in the intervention group compared with the control group, but this difference did not reach significance. No significant changes became apparent in subjective workload.
Adding nurse practitioners to general practice teams did not reduce the workload of general practitioners, at least in the short term. This implies that nurse practitioners are used as supplements, rather than substitutes, for care given by general practitioners.
BMJ (Clinical research ed.). 04/2004; 328(7445):927.
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ABSTRACT: To improve follow-up compliance after an initial inadequate or abnormal cervical smear, two follow-up guidance systems were tested for effectiveness. A comprehensive system (cytopathology laboratory monitored the follow-up of all abnormal and inadequate smears) was compared to a selective system (monitoring was left to the smear taker; laboratory acted as a safety net).
In an RCT on all family practices (N = 171) in the catchment areas of two cytopathology laboratories (Nijmegen region, The Netherlands, 1998-2000), practices were allocated at random to one of the follow-up guidance systems. All women included were registered at the practices, invited to the national screening program and had abnormal or inadequate smears. Measurements comprised of (1) follow-up compliance at baseline and 1 year after the initial smear and (2) diagnostic outcome of the follow-up smear.
During the study period, 132 practices sent their cervical smears to the laboratories. The comprehensive system covered 1226 women, the selective 1034. In the comprehensive system, the increase in follow-up compliance for initial inadequate and slightly abnormal smears was significantly higher (8.9%) than in the selective one, which implied an extra detection of eleven, more serious, abnormalities per 1000 women.
The comprehensive system was more effective than the selective and is suitable for use on a larger scale.
Preventive Medicine 41(5-6):809-14. · 3.22 Impact Factor
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ABSTRACT: Background. The effectiveness of three different organizational approaches to cervical cancer screening (community based, family practice based, and a combination) was evaluated in nationally representative family practices.Method. We selected 122 family practices with a computerized sex–age register from a database of 1,251 family practices, representative of all 4,758 family practices in The Netherlands. Approximately 40 practices were linked with each approach. We measured the attendance, the reasons for nonattendance, and the influence of a reminder on the attendance of women invited for cervical screening in September, October, and November 1996. The patients were grouped according to age. A cross-sectional design was used for the study.Results. For younger women, the total attendance rate, coverage (percentage of women “protected” against cervical cancer), and control rate (percentage of women with medical reasons for nonattendance or postponement of the smear) were highest in practices using the family practice-based approach (68, 77, and 90%, respectively) and lowest in practices with the community-based approach (53, 62, and 68%, respectively). For older women, the family practice-based approach and the combination approach were associated with attendance rates significantly higher than those for the community-based approach (approximately 60, 80, and 80% vs 47, 67, and 70%, respectively). A reminder sent by the family physician to women not responding to an initial invitation increased the attendance rate by 7 to 11% in both age categories, depending on who had sent the first invitation.Conclusion. A family practice-based cervical screening approach appeared to be the most effective at a national level, achieving the highest attendance rate, coverage, and control rate.
Preventive Medicine.
