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Contains fulltext : 136527.pdf (publisher's version ) (Open Access)

Item does not contain fulltext, OBJECTIVE: The purpose of this study was to develop and validate a generic questionnaire to evaluate experiences and reported outcomes in patients who receive treatment across a range of healthcare sectors. DESIGN: Mixed-methods design including focus groups, pretests and field test. SETTING: The patient questionnaire was developed in the context of a nationwide program in Germany aimed at quality improvements across the healthcare sectors. PARTICIPANTS: For the field test, 589 questionnaires were distributed to patients via 47 general practices. MAIN MEASUREMENTS: Descriptive item analyzes non-responder analysis and factor analysis (PCA). Retest coefficients (r) calculated by correlation of sum scores of PCA factors. Quality gaps were assessed by the proportion of responders choosing a response category defined as indicating shortcomings in quality of care. RESULTS: The conceptual phase showed good content validity. Four hundred and seventy-four patients who received a range of treatment across a range of sectors were included (response rate: 80.5%). Data analysis confirmed the construct, oriented to the patient care journey with a focus on transitions between healthcare sectors. Quality gaps were assessed for the topics 'Indication', including shared-decision-making (6 items, 24.5-62.9%) and 'Discharge and Transition' (10 items; 20.7-48.2%). Retest coefficients ranged from r = 0.671 until r = 0.855 and indicated good reliability. Low ratios of item-non-response (0.8-9.3%) confirmed a high acceptance by patients. CONCLUSIONS: The number of patients with complex healthcare needs is increasing. Initiatives to expand quality assurance across organizational borders and healthcare sectors are therefore urgently needed. A validated questionnaire (called PEACS 1.0) is available to measure patients' experiences across healthcare sectors with a focus on quality improvement.

Item does not contain fulltext, BACKGROUND: Cardiovascular prevention can be provided to patients at different risk levels. The aim of this study was to compare the quality of cardiovascular prevention provided in European primary care between patients with diagnosed coronary heart disease (CHD) and individuals at high risk due to known risk factors but not labelled with a diagnosis of cardiovascular disease (CVD). Additionally, we aimed to identify individual and practice factors to predict risk factor control. METHODS: An international cross-sectional study was conducted in 10 European countries. Clinical record data were abstracted for quality indicators for 8928 patients in 10 countries and patient questionnaires were completed by 7846 patients in nine countries. Information about 320 general practices was assessed using practice questionnaires and interviews. Hierarchical multilevel modelling was used for analyses. RESULTS: Recording of risk factors and advice was higher in the CHD than in the high-risk group. Risk factor control was better in the CHD group: uncontrolled levels of blood pressure (34.2 vs. 49.3%; p < 0.001), cholesterol (32.4 vs. 64.5%; p < 0.001). Predictors of risk factor control were medication adherence (RR 0.97; p = 0.007) and health-related quality of life (RR 0.86; p = 0.005). Being at high risk (RR 1.42; p < 0.001), being single (RR 1.12; p < 0.001), and having lower educational level (RR 1.09; p < 0.001) were associated with poorer risk factor control. Practice factors were not associated with outcomes. CONCLUSIONS: Strategies to improve guidelines adherence in cardiovascular prevention may be stronger focused on individuals at risk before CVD is diagnosed and require organizational and political support to reinforce general practices.

Item does not contain fulltext, BACKGROUND: This study aimed to describe and to analyse the importance of educational level for controlled risk factors and health-related quality of life (HRQoL). METHODS: This observational study was conducted in nine European countries (5632 patients in 249 practices). We compared patients with a low level of education (up to 9 years) with patients with a high level of education (>9 years), with regard to controlled cardiovascular disease risk factors and HRQoL. A multilevel approach was used for statistical analysis. RESULTS: Patients with a low level of education were older (P < 0.001), more often female (P < 0.001), more often single (P < 0.001) and had a higher number of other conditions (e.g. heart failure) (P < 0.001). Significant differences in terms of controlled risk factors were revealed for blood pressure (RR)

Contains fulltext : 118387.pdf (publisher's version ) (Open Access), BACKGROUND: Colorectal cancer (CRC) has a high prevalence in western countries. Diagnosis and treatment of CRC is complex and requires multidisciplinary collaboration across the interface of health care sectors. In Germany, a new nationwide established program aims to provide quality information of healthcare delivery across different sectors. Within this context, this study describes the development of a set of quality indicators charting the whole pathway of CRC-care including data specifications that are necessary to operationalize these indicators before practice testing. METHODS: Indicators were developed following a systematic 10 step modified 'RAND/UCLA Appropriateness Method' which involved a multidisciplinary panel of thirteen participants. For each indicator in the final set, data specifications relating to sources of quality information, data collection procedures, analysis and feedback were described. RESULTS: The final indicator set included 52 indicators covering diagnostic procedures (11 indicators), therapeutic management (28 indicators) and follow-up (6 indicators). In addition, 7 indicators represented patient perspectives. Primary surgical tumor resection and pre-operative radiation (rectum carcinoma only) were perceived as most useful tracer procedures initiating quality data collection. To assess the quality of CRC care across sectors, various data sources were identified: medical records, administrative inpatient and outpatient data, sickness-funds billing code systems and patient survey. CONCLUSION: In Germany, a set of 52 quality indicators, covering necessary aspects across the interfaces and pathways relevant to CRC-care has been developed. Combining different sectors and sources of health care in quality assessment is an innovative and challenging approach but reflects better the reality of the patient pathway and experience of CRC-care.

Contains fulltext : 117949.pdf (publisher's version ) (Open Access), BACKGROUND: Prevention of cardiovascular diseases (CVD) is a major health issue worldwide. Primary care plays an important role in cardiovascular risk management (CVRM). Guidelines and quality of care measures to assess CVRM in primary care practices are available. In this study, we assessed the relationship between structural and organisational practice characteristics and the quality of care provided in individuals at high risk for developing CVD in European primary care. METHODS: An observational study was conducted in 267 general practices from 9 European countries. Previously developed quality indicators were abstracted from medical records of randomly sampled patients to create a composite quality measure. Practice characteristics were collected by a practice questionnaire and face to face interviews. Data were aggregated using factor analysis to four practice scores representing structural and organisational practice features. A hierarchical multilevel analysis was performed to examine the impact of practice characteristics on quality of CVRM. RESULTS: The final sample included 4223 individuals at high risk for developing CVD (28% female) with a mean age of 66.5 years (SD 9.1). Mean indicator achievement was 59.9% with a greater variation between practices than between countries. Predictors at the patient level (age, gender) had no influence on the outcome. At the practice level, the score 'Preventive Services' (13 items) was positively associated with clinical performance (r = 1.92; p = 0.0058). Sensitivity analyses resulted in a 5-item score (PrevServ_5) that was also positively associated with the outcome (r = 4.28; p < 0.0001). CONCLUSIONS: There was a positive association between the quality of CVRM in individuals at high risk for developing CVD and the availability of preventive services related to risk assessment and lifestyle management supported by information technology.

Contains fulltext : 110491.pdf (publisher's version ) (Open Access), BACKGROUND: Primary care has an important role in cardiovascular risk management (CVRM) and a minimum size of scale of primary care practices may be needed for efficient delivery of CVRM . We examined CVRM in patients with coronary heart disease (CHD) in primary care and explored the impact of practice size. METHODS: In an observational study in 8 countries we sampled CHD patients in primary care practices and collected data from electronic patient records. Practice samples were stratified according to practice size and urbanisation; patients were selected using coded diagnoses when available. CVRM was measured on the basis of internationally validated quality indicators. In the analyses practice size was defined in terms of number of patients registered of visiting the practice. We performed multilevel regression analyses controlling for patient age and sex. RESULTS: We included 181 practices (63% of the number targeted). Two countries included a convenience sample of practices. Data from 2960 CHD patients were available. Some countries used methods supplemental to coded diagnoses or other inclusion methods introducing potential inclusion bias. We found substantial variation on all CVRM indicators across practices and countries. We computed aggregated practice scores as percentage of patients with a positive outcome. Rates of risk factor recording varied from 55% for physical activity as the mean practice score across all practices (sd 32%) to 94% (sd 10%) for blood pressure. Rates for reaching treatment targets for systolic blood pressure, diastolic blood pressure and LDL cholesterol were 46% (sd 21%), 86% (sd 12%) and 48% (sd 22%) respectively. Rates for providing recommended cholesterol lowering and antiplatelet drugs were around 80%, and 70% received influenza vaccination. Practice size was not associated to indicator scores with one exception: in Slovenia larger practices performed better. Variation was more related to differences between practices t

Contains fulltext : 110205.pdf (publisher's version ) (Open Access), OBJECTIVES: Cardiovascular risk management (CVRM) received by patients shows large variation across countries. In this study we explored the aspects of primary care organisation associated with key components of CVRM in coronary heart disease (CHD) patients. DESIGN: Observational study. SETTING: 273 primary care practices in Austria, Belgium, England, Finland, France, Germany, The Netherlands, Slovenia, Switzerland and Spain. PARTICIPANTS: A random sample of 4563 CHD patients identified by coded diagnoses in eight countries, based on prescription lists and while visiting the practice in one country each. MAIN OUTCOME MEASURE: We performed an audit in primary care practices in 10 European countries. We used six indicators to measure key components of CVRM: risk factor recording, antiplatelet therapy, influenza vaccination, blood pressure levels (systolic <140 and diastolic <90 mm Hg), and low-density lipoprotein cholesterol <2.5 mmol/l. Data from structured questionnaires were used to construct an overall measure and six domain measures of practice organisation based on 39 items. Using multilevel regression analyses we explored the effects of practice organisation on CVRM, controlling for patient characteristics. RESULTS: Better overall organisation of a primary care practice was associated with higher scores on three indicators: risk factor registration (B=0.0307, p<0.0001), antiplatelet therapy (OR 1.05, p=0.0245) and influenza vaccination (OR 1.12, p<0.0001). Overall practice organisation was not found to be related with recorded blood pressure or cholesterol levels. Only the organisational domains 'self-management support' and 'use of clinical information systems' were linked to three CVRM indicators. CONCLUSIONS: A better organisation of a primary care practice was associated with better scores on process indicators of CVRM in CHD patients, but not on intermediate patient outcome measures. Direct support for patients and clinicians seemed most influential.

Contains fulltext : 108501.pdf (publisher's version ) (Open Access), BACKGROUND: Medication adherence can be essential for improving health outcomes. Patients with multiple chronic conditions, often receiving multiple medications, are at higher risk for medication nonadherence. Previous research has focused on concordance between patients and providers about which medication should be taken. However, the question of whether patients and providers are concordant in rating actual medication intake has not been answered as yet. This study aimed to explore the extent and predictors of patient - provider concordance in rating medication adherence in patients with multiple chronic conditions. METHODS: Overall medication adherence was measured by self-report (Medication Adherence Report Scale, MARS-D) in a sample of 92 patients with multiple chronic conditions. Twelve treating primary care physicians were asked to rate medication adherence in these patients using a mirrored version of the MARS-D. Concordance between external rating and self-reported medication adherence was analyzed descriptively. Predictors of concordance in rating medication adherence were explored in a multilevel analysis. RESULTS: Patients rate their medication adherence markedly higher than their general practitioner. Accordingly, the percentage of concordance ranges between 40% (forgot to take medication) and 61% (deliberately omitted a dose). In multilevel analysis, concordance in rating medication adherence was positively associated with being the single primary care provider (beta 2.24, P < 0.0001) and frequent questioning about medication use (beta 0.66, P = 0.0031). At the patient level, "not [being] married" (beta -0.81, P = 0.0064) and "number of prescribed medications" (beta -0.10, P = 0.0203) were negative predictors of patient - provider concordance in rating medication adherence. CONCLUSION: Concordance for rating medication adherence between general practitioners and their patients was low. Talking about medication on a regular basis and better continuity

01 april 2012, Item does not contain fulltext, BACKGROUND: Detection and registration of high risk for cardiovascular diseases (CVD) by assessing individual's absolute cardiovascular risk is recommended in clinical guidelines. Effective interventions to reduce cardiovascular risk are available, but not optimally implemented. The aim of this study was to assess the quality of cardiovascular risk-factor recording and lifestyle counselling in high-risk patients in European primary care and to identify factors related to these clinical processes. METHODS: An international cross-sectional observational study was conducted in stratified samples of primary care practices in nine European countries. Patient records were audited, using a structured data-abstraction tool based on internationally developed quality indicators. To identify factors associated with the recording, additional data were collected in a patient survey. Descriptive and multilevel data analyses were conducted. RESULTS: In 268 general practices across Europe, 3723 records of individuals at high risk for cardiovascular diseases were audited. We found important variations in the quality of documentation of risk factors and lifestyle interventions. Recording of risk factors was best for blood pressure (92.5% of audited records, 95% CI 0.89-0.96). Lifestyle advice was recorded best for smoking cessation (65.6%, 95% CI 0.58-0.73) and worst for physical activity (38.8%, 95% CI 0.31-0.47). Of the study population, 50.6% (0.42-0.59) had elevated blood pressure levels, 59.8% (0.51-0.69) had total cholesterol >5 mmol/l, and 30.5% (0.22-0.39) were smokers. Multivariate analyses showed that recording of risk factors and counselling were related to specific patient characteristics more than to country effects. CONCLUSIONS: Analysis of different country results can be helpful for developing quality-improvement strategies.

Objectives: A clinical practice guideline (CPG) contains specifically developed recommendations that can serve physicians as a decision aid in evidence-based practice. The implementation of heart failure (HF) CPGs represents a challenge in general practice. As part of the development of a tailored curriculum, aim of this study was to identify barriers of guideline adherence and needs for medical education (CME) in HF care.Methods: We conducted a modified focus group with elements of a workshop of three hours duration. Thirteen GPs collected and discussed together and parallel in smaller groups barriers of guideline implementation. Afterwards they performed a needs assessment for a tailored CME curriculum for chronic HF. The content of the discussions was analysed qualitatively according to Mayring and categorised thematically.Results: Barriers of guideline adherence were found in the following areas: doctor: procedural knowledge (knowledge gaps), communicative and organisational skills (e.g. time management) and attitude (dissatisfaction with time-money-relation). Patients: individual case-related problems (multimorbidity, psychiatric comorbidity, expectations and beliefs). Doctor and patient: Adherence and barriers of communication. Main measures for improvement of care concerned the areas of the identified barriers of guideline adherence with the focus on application-oriented training of the abovementioned procedural knowledge and skills, but also the supply of tools (like patient information leaflets) and patient education. Conclusion: For a CME-curriculum for HF tailored to the needs of GPs, a comprehensive educational approach seems necessary. It should be broad-based and include elements of knowledge and skills to be addressed and trained case-related. Additional elements should include support in the implementation of organisational processes in the practice and patient education., Zielsetzung: Leitlinien zur Herzinsuffizienz (HI) enthalten systematisch entwickelte Empfehlungen, deren Umsetzung speziell in der hausärztlichen Praxis eine bekannte Herausforderung darstellt. Ziel der vorliegenden Studie war es, Barrieren bei der Umsetzung der Leitlinienempfehlungen zu identifizieren, Vorschläge zu Verbesserungsmaßnahmen der hausärztlichen Versorgung und für die Entwicklung einer bedarfsgerechten Fortbildung zu gewinnen.Methodik: Es wurde eine modifizierte Fokusgruppe mit Workshopcharakter durchgeführt. In drei parallelen Kleingruppen erarbeiteten 13 Hausärzte Barrieren bei der Leitlinienumsetzung zur HI. Darauf aufbauend wurde eine Bedarfsanalyse bzgl. der Lernziele und der spezifischen Verbesserungsmaßnahmen für eine hausärztliche Fortbildung zur HI durchgeführt. Die protokollierten Aussagen der Ärzte wurden mittels Inhaltsanalyse nach Mayring ausgewertet und anschließend thematisch kategorisiert.Ergebnisse: Als Barrieren der Umsetzung vorhandener Leitlinien nannten die teilnehmenden Ärzte arztseitige Defizite und Unterstützungsbedarf in den Dimensionen Wissen, kommunikativen und organisatorischen Fähigkeiten (z. B. Zeitmangel/-management) und der Haltung gegenüber Leitlinien (z.B. Faulheit). Den Patienten wurden individuelle, patientenbezogene Probleme (z.B. Komplexität des Einzelfalles bei Multimorbidität, psychische Komorbidität) sowie ablehnende Einstellungen (z.B. gegenüber "Schulmedizin") zugeschrieben. Im Bereich der Arzt-Patient-Interaktion wurden u.a. mangelnde medikamentöse Adhärenz und Kommunikationsprobleme als Barrieren genannt. Vorschläge zu Verbesserungs- bzw. Schulungsmaßnahmen umfassten breit angelegte Schulungskonzepte (z.B. in interdisziplinären Qualitätszirkeln mit Fall-Audit), die neben der Vermittlung von Wissensaspekten aus einer (idealerweise einheitlichen) Leitlinie auch praktische Fertigkeiten hinsichtlich Arzt-Patienten-Kommunikation und Praxis-Organisation einschlossen. Die Bereitstellung praktikabler Arbeitsmateriali

Contains fulltext : 98245.pdf (publisher's version ) (Closed access), BACKGROUND: The number of patients with chronic diseases is increasing which poses a challenge to healthcare organisations. A proactive, structured, and population-orientated approach is needed: the chronic care model (CCM) provides such a framework. AIM: To assess organisational conditions for providing structured chronic care according to the CCM across different healthcare systems. DESIGN OF STUDY: International observational study. SETTING: A stratified sample of 315 primary care practices in 10 European countries and Israel in 2008 and 2009. METHOD: Practice questionnaires and interviews. Outcome measures were mean practice scores on CCM domains per country, as a percentage of the maximum score, and the influence of practice size and urbanisation on these scores. RESULTS: Practice size showed large differences with the largest practices in Spain, England, Finland, and Israel. These countries, with a strong primary care orientation, had most physicians and staff involved per practice. The CCM domains 'clinical information systems' and 'decision support' had total practice means of 90%; other domains scored about 50%. Spain and England scored above average on almost all domains. Practice size and urbanisation had little impact. CONCLUSION: Characteristics for chronic care delivery differed for most CCM domains. The most common characteristics related to computerisation, providing a good starting point and high potential everywhere. All countries showed room for improvement. Further research should focus on relations between practice characteristics, organisational features, including health system and primary care orientation, and outcomes. Primary care seems suited for chronic care delivery; however, a stronger primary care was associated with better scores.

Contains fulltext : 96207.pdf (publisher's version ) (Open Access), BACKGROUND: Cardiovascular risk management plays an important role in primary care. In patients at high risk for cardiovascular diseases (CVD) lifestyle and, where appropriate, medical interventions are recommended in guidelines. Health-related quality of life (HRQoL) is an important outcome in clinical practice. This study aimed to assess the HRQoL of this patient group and to investigate the impact of both patients' characteristics and practice quality scores on their assessments of HRQoL. METHODS AND FINDINGS: An observational study in 218 general practices from 8 European countries was conducted. 2142 patients at risk for CVD (33.5% female) with a mean age of 66.3 (SD 9.1) years completed a questionnaire including the EQ-5D instrument and provided data from medical record. Validated quality indicators of general practices were assessed using practice questionnaires and face-to-face interviews. A hierarchical multilevel analysis was performed to identify predictors of EQ-5D scores at patient and practice level. The mean EQ-5D score was 0.78 (SD 0.19). Female gender (r = -0.03, p<0.0016), age (r = -0.01, p = 0.0387) and lower educational level (r = -0.03, p<0.0001) were correlated negatively with EQ-5D scores. Clinically more important was the correlation of HRQoL with the frequency of practice contacts (r = -0.12, p<0.0001) and the number of uncontrolled risk factors (r = -0.01, p<0.0039). Medication adherence (r = 0.032, p<0.0001), and physical activity (r = 0.02, p<0.0001) were identified as positive predictors of HRQoL. The EUPROPEP-score category 'organization' (r = 0.02, p<0.0001) was positively related to EQ-5D scores, whereas other practice scores were not correlated to EQ-5D-scores. CONCLUSIONS: In patients at risk for CVD, good medication adherence, regular physical activity, controlling of biomedical risk factor levels and patient-centered practice organization have been shown to be positively correlated to HRQoL and should therefore be targeted in inte

Item does not contain fulltext, OBJECTIVE: To compare different interventions used to communicate cardiovascular risk and assess their impact on patient related outcomes. METHODS: A systematic search of six electronic data sources from January 1980 to November 2008. Data was extracted from the included studies and a narrative synthesis of the results was conducted. RESULTS: Fifteen studies were included. Only four studies assessed individuals' actual cardiovascular risk; the rest were analogue studies using hypothetical risk profiles. Heterogeneity in study design and outcomes was found. The results from individual studies suggest that presenting patients with their cardiovascular risk in percentages or frequencies, using graphical representation and short timeframes, is best for achieving risk reduction through behaviour change. However, this summary is tentative and needs further exploration. CONCLUSION: Better quality trials are needed that compare different risk presentation formats, before conclusions can be drawn as to the most effective ways to communicate cardiovascular risk to patients. PRACTICE IMPLICATIONS: Instead of directing attention to the accuracy of cardiovascular risk prediction, more should be paid to the effective presentation of risk, to help patients reduce risk by lifestyle change or active treatment.

Contains fulltext : 97806.pdf (publisher's version ) (Open Access), BACKGROUND: Primary care can play an important role in providing cardiovascular risk management in patients with established Cardiovascular Diseases (CVD), patients with a known high risk of developing CVD, and potentially for individuals with a low risk of developing CVD, but who have unhealthy lifestyles. To describe and compare cardiovascular risk management, internationally valid quality indicators and standardized measures are needed. As part of a large project in 9 European countries (EPA-Cardio), we have developed and tested a set of standardized measures, linked to previously developed quality indicators. METHODS: A structured stepwise procedure was followed to develop measures. First, the research team allocated 106 validated quality indicators to one of the three target populations (established CVD, at high risk, at low risk) and to different data-collection methods (data abstraction from the medical records, a patient survey, an interview with lead practice GP/a practice survey). Secondly, we selected a number of other validated measures to enrich the assessment. A pilot study was performed to test the feasibility. Finally, we revised the measures based on the findings. RESULTS: The EPA-Cardio measures consisted of abstraction forms from the medical-records data of established Coronary Heart Disease (CHD)-patients--and high-risk groups, a patient questionnaire for each of the 3 groups, an interview questionnaire for the lead GP and a questionnaire for practice teams. The measures were feasible and accepted by general practices from different countries. CONCLUSIONS: An internationally standardized measure of cardiovascular risk management, linked to validated quality indicators and tested for feasibility in general practice, is now available. Careful development and pilot testing of the measures are crucial in international studies of quality of healthcare.

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Contains fulltext : 71279.pdf (publisher's version ) (Closed access), BACKGROUND: With free movement of labour in Europe, European guidelines on cardiovascular care and the enlargement of the European Union to include countries with disparate health care systems, it is important to develop common quality standards for cardiovascular prevention and risk management across Europe. METHODS: Panels from nine European countries (Austria, Belgium, Finland, France, Germany, Netherlands, Slovenia, United Kingdom and Switzerland) developed quality indicators for the prevention and management of cardiovascular disease in primary care. A two-stage modified Delphi process was used to identify indicators that were judged valid for necessary care. RESULTS: Forty-four out of 202 indicators (22%) were rated as valid. These focused predominantly on secondary prevention and management of established cardiovascular disease and diabetes. Less agreement on indicators of preventive care or on indicators for the management of hypertension and hypercholesterolaemia in patients without established disease was observed. Although 85% of the 202 potential indicators assessed were rated valid by at least one panel, lack of consensus among panels meant that the set that could be agreed upon among all panels was much smaller. CONCLUSION: Indicators for the management of established cardiovascular disease have been developed, which can be used to measure the quality of cardiovascular care across a wide range of countries. Less agreement on how the quality of preventive care should be assessed was observed, probably caused by differences in health systems, culture and attitudes to prevention.