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Contains fulltext : 305029.pdf (Publisher’s version ) (Open Access), BACKGROUND: Shared decision making (SDM) is considered fundamental to person-centred care. However, applying SDM may be a challenge for residents in general practice, since it is a complex competence that requires the integration of knowledge and skills from several competency domains. OBJECTIVE: To support learning of SDM during medical residency, we aimed to gain insight in Dutch residents' observed and perceived SDM performance in general practice. METHODS: We evaluated residents' SDM performance from an observer, resident, and patient perspective. Consultations of first- and third-year residents were recorded. Trained observers used the validated Observing Patient Involvement (OPTION5) scale to assess observed SDM performance of residents in 98 actual recorded consultations. Perceived SDM performance was evaluated by residents and patients completing validated SDM questionnaires, supplemented with questions about (the context of) the consultation and perceived relevance of SDM immediately after the consultation. The data were analysed using descriptive statistics (mean, SD, minimums, and maximums) and explorative bivariate analyses. RESULTS: The residents' observed mean SDM performance was 19.1 (range, 0-100, SD = 10.9), mean resident self-reported SDM performance was 56.9 (range, 0-100, SD = 18.5), and mean patient-reported SDM performance was 73.3 (range, 0-100, SD = 26.8). We found a significant and positive correlation between observed SDM performance and residents' perceived relevance of SDM for the consultation (t = 4.571, P ≤ 0.001) and the duration of the consultation (r = 0.390, P ≤ 0.001). CONCLUSIONS: This study showed that there is room for increasing awareness of the potential incongruence between observed and perceived SDM performance during medical residency, in order to facilitate the implementation of SDM in clinical practice. THE PROBLEM: Shared decision making is an important process in which healthcare professional and patient work together t

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Contains fulltext : 251417.pdf (Publisher’s version ) (Open Access), BACKGROUND: 'What matters to me' is a five-category preference elicitation tool to assist clients and professionals in choosing long-term care. This study aimed to evaluate the use of and experiences with this tool. METHODS: A mixed-method process evaluation was applied. Participants were 71 clients or relatives, and 12 professionals. They were all involved in decision-making on long-term care. Data collection comprised online user activity logs (N = 71), questionnaires (N = 38) and interviews (N = 20). Descriptive statistics was used for quantitative data, and a thematic analysis for qualitative data. RESULTS: Sixty-nine per cent of participants completed one or more categories in an average time of 6.9 (±0.03) minutes. The tool was rated 6.63 (±0.88) of 7 in the Post-Study System Usability Questionnaire (PSSUQ). Ninety-five per cent experienced the tool as useful in practice. Suggestions for improvement included a separate version for relatives and a non-digital version. Although professionals thought the potentially extended consultation time could be problematic, all participants would recommend the tool to others. CONCLUSION: 'What matters to me' seems useful to assist clients and professionals with preference elicitation in long-term care. Evaluation of the impact on consultations between clients and professionals by using 'What matters to me' is needed.

Contains fulltext : 229849.pdf (publisher's version ) (Open Access), PURPOSE: Although shared decision making (SDM) is considered the preferred approach in medical decision making, it is currently not routinely used in clinical practice. To bridge the transfer gap between SDM training and application, the authors aimed to reach consensus on entrustable professional activities (EPAs) for SDM and associated behavioral indicators as a framework to support self-directed learning during postgraduate medical education. METHOD: Using existing literature on SDM frameworks and competencies; input from an interview study with 17 Dutch experts in SDM, doctor-patient communication, and medical education; and a national SDM expert meeting as a starting point, in 2017, the authors conducted a modified online Delphi study with a multidisciplinary Dutch panel of 32 experts in SDM and medical education. RESULTS: After 3 Delphi rounds, consensus was reached on 4 EPAs-(1) the resident discusses the desirability of SDM with the patient, (2) the resident discusses the options for management with the patient, (3) the resident explores the patient's preferences and deliberations, and (4) the resident takes a well-argued decision together with the patient. Consensus was also reached on 18 associated behavioral indicators. Of the 32 experts, 30 (94%) agreed on this list of SDM EPAs and behavioral indicators. CONCLUSIONS: The authors succeeded in developing EPAs and associated behavioral indicators for SDM for postgraduate medical education to improve the quality of SDM training and the application of SDM in clinical practice. These EPAs are characterized as process EPAs for SDM in contrast with content EPAs related to diverse medical complaints. A next step is the implementation of the SDM EPAs in existing competency-based workplace curricula.

Contains fulltext : 245650.pdf (Publisher’s version ) (Open Access), BACKGROUND AND PURPOSE: In selected breast cancer patients, radiation treatment (RT) lowers the recurrence risk, with minor or no improvement of survival. In these patients, the choice to undergo RT is considered a preference-sensitive decision. To facilitate shared decision-making (SDM) for this choice, a patient decision aid was made. We aimed to evaluate the effect of the PtDA on decisional conflict. MATERIAL AND METHODS: We performed a multi-center pre- and post-intervention study (BRASA-trial). The first 214 patients made a choice without support of the PtDA; the subsequent 189 patients received a link to the PtDA. The primary endpoint was decisional conflict; secondary endpoints were perceived SDM and knowledge on treatment options. Patients filled out questionnaires immediately after, and three months after their decision. Data were analyzed with multi-level regression analysis. RESULTS: After correcting for the difference in age and educational level, the mean (±SD) decisional conflict for the intervention group (27.3 ± 11.4) was similar to the control group (26.8 ± 11.4; difference = 0.86, 95 %CI 1.67,3.36) three months after their decision. This also applied to perceived SDM. Patients exposed to the PtDA pursued additional treatment less often (45% vs 56%, odds ratio 0.59, 95 %CI 0.37,0.95) and scored significantly higher on the knowledge test (7.4 ± 2.5 vs 6.1 ± 2.7, corrected difference = 1.0, 95 %CI 0.50,1.49). There was no significant increase in consultation time. CONCLUSIONS: Handing out the PtDA was not associated with improved scores in decisional conflict or perceived SDM, but it was associated with a choice for less additional treatment and better knowledge about the treatment options.

Contains fulltext : 237587.pdf (Publisher’s version ) (Open Access), INTRODUCTION: Researchers, policy-makers and healthcare professionals often stress the importance of an early dementia diagnosis. Empirical evidence, however, is scarce leading to a lack of consensus on the necessity of diagnosing dementia early. We emphasise the need for a 'timely' diagnosis, that is, one that occurs at the right moment for a person with memory complaints and his/her significant other. As the optimal timing differs between individuals, the implementation of shared decision making (SDM), preferably by the general practitioner (GP), as the start of a diagnostic trajectory, could help to determine this timely moment. SDM, however, is rarely practised with respect to dementia diagnoses. Therefore, in the context of the Shared Decision-Making regarding Dementia Diagnosis project, a patient decision aid (PtDA) for 'timely' dementia diagnosis in general practice will be developed. This protocol will describe the planned before and after evaluation of its implementation. METHODS AND ANALYSIS: In a mixed-methods pilot study, we will investigate decision-making processes and experiences regarding a diagnostic trajectory before and after the introduction of a PtDA for people with memory complaints, their significant others and their GPs. The 'before group' will receive diagnostics as usual from their GPs. The 'after group' will use the PtDA. We expect the PtDA to increase the level of SDM and to contribute to a timely and personalised diagnostic trajectory. Data will be collected using semistructured interviews, questionnaires and information retrieved from people with memory complaints' medical records. ETHICS AND DISSEMINATION: This study protocol was approved by the Medical Review Ethics Committee of the Maastricht University Medical Centre. The findings will be published in peer-reviewed international journals and presented at conferences. This study was funded by the public funded Dutch Research Institute for Care and Medical Sciences (ZonMw). TRIAL REGI

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Contains fulltext : 217668.pdf (publisher's version ) (Open Access)

Contains fulltext : 204219.pdf (publisher's version ) (Open Access)

Contains fulltext : 202231.pdf (publisher's version ) (Open Access), BACKGROUND: Patient-directed knowledge tools such as patient versions of guidelines and patient decision aids are increasingly developed to facilitate shared decision making. In this paper, we report how consensus was reached within the Netherlands on quality criteria for development, content and governance of these tools. METHOD: A 12-month development and consensus study. The consortium worked on four work packages: (a) reviewing existing criteria; (b) drafting the quality criteria; (c) safe-guarding the acceptability and feasibility of the draft criteria by participatory research in on-going tool development projects; and (d) gaining formal support from national stakeholders on the quality criteria. RESULTS: We reached consensus on a 8-step guidance; describing minimal quality criteria for (a) the team composition; (b) setting the scope; (c) identifying needs; (d) the content and format; (e) testing the draft; (f) finalizing and approval; (g) dissemination and application, and (h) ownership and revision. The participants of the on-going tool development projects were positive about the quality criteria in general, but divided as to the degree of detail. Whereas some expressed a clear desire for procedural standards, others felt that it would be sufficient to provide only general directions. Despite the different views as to the degree of detail, consensus was reached in three stakeholder meetings. DISCUSSION: We successfully collaborated with all stakeholders and achieved formal support from national stakeholders on a set of minimum criteria for the development process, content and governance of patient-directed knowledge tools.

Contains fulltext : 174299.pdf (publisher's version ) (Closed access)

Contains fulltext : 174265.pdf (publisher's version ) (Open Access), BACKGROUND: Much research worldwide is focussed on cost containment and better adherence to guidelines in healthcare. The research focussing on professional behaviour is often performed in a well-controlled research setting. In this study a large-scale implementation of a peer review strategy was tested on both test ordering and prescribing behaviour in primary care in the normal quality improvement setting. METHODS: We planned a cluster-RCT in existing local quality improvement collaboratives (LQICs) in primary care. The study ran from January 2008 to January 2011. LQICs were randomly assigned to one of two trial arms, with each arm receiving the same intervention of audit and feedback combined with peer review. Both arms were offered five different clinical topics and acted as blind controls for the other arm. The differences in test ordering rates and prescribing rates between both arms were analysed in an intention-to-treat pre-post analysis and a per-protocol analysis. RESULTS: Twenty-one LQIC groups, including 197 GPs working in 88 practices, entered the trial. The intention-to-treat analysis did not show a difference in the changes in test ordering or prescribing performance between intervention and control groups. The per-protocol analysis showed positive results for half of the clinical topics. The increase in total tests ordered was 3% in the intervention arm and 15% in the control arm. For prescribing the increase in prescriptions was 20% in the intervention arm and 66% in the control group. It was observed that the groups with the highest baseline test ordering and prescription volumes showed the largest improvements. CONCLUSIONS: Our study shows that the results from earlier work could not be confirmed by our attempt to implement the strategy in the field. We did not see a decrease in the volumes of tests ordered or of the drugs prescribed but were able to show a lesser increase instead. Implementing the peer review with audit and feedback proved to be

Contains fulltext : 182286.pdf (Publisher’s version ) (Open Access), To inform the development of recommendations to facilitate learning of skilled doctor-patient communication in the workplace, this qualitative study explores experiences of trainees and supervisors regarding how trainees learn communication and how supervisors support trainees' learning in the workplace. We conducted a qualitative study in a general practice training setting, triangulating various sources of data to obtain a rich understanding of trainees and supervisors' experiences: three focus group discussions, five discussions during training sessions and five individual interviews. Thematic network analysis was performed during an iterative process of data collection and analysis. We identified a communication learning cycle consisting of six phases: impactful experience, change in frame of reference, identification of communication strategies, experimentation with strategies, evaluation of strategies and incorporation into personal repertoire. Supervisors supported trainees throughout this process by creating challenges, confronting trainees with their behaviour and helping them reflect on its underlying mechanisms, exploring and demonstrating communication strategies, giving concrete practice assignments, creating safety, exploring the effect of strategies and facilitating repeated practice and reflection. Based on the experiences of trainees and supervisors, we conclude that skilled communication involves the development of a personal communication repertoire from which learners are able to apply strategies that fit the context and their personal style. After further validation of our findings, it may be recommended to give learners concrete examples, opportunities for repeated practise and reflection on personal frames of reference and the effect of strategies, as well as space for authenticity and flexibility. In the workplace, the clinical supervisor is able to facilitate all these essential conditions to support his/her trainee in becoming a skilled com

Contains fulltext : 189962.pdf (publisher's version ) (Closed access)

Item does not contain fulltext, BACKGROUND: A monitoring-and-feedback tool was developed to stimulate physical activity by giving feedback on physical activity performance to patients and practice nurses. The tool consists of an activity monitor (accelerometer), wirelessly connected to a Smartphone and a web application. Use of this tool is combined with a behaviour change counselling protocol (the Self-management Support Programme) based on the Five A's model (Assess-Advise-Agree-Assist-Arrange). OBJECTIVES: To examine the reach, implementation and satisfaction with the counselling protocol and the tool. DESIGN: A process evaluation was conducted in two intervention groups of a three-armed cluster randomised controlled trial, in which the counselling protocol was evaluated with (group 1, n=65) and without (group 2, n=66) the use of the tool using a mixed methods design. SETTINGS: Sixteen family practices in the South of the Netherlands. PARTICIPANTS: Practice nurses (n=20) and their associated physically inactive patients (n=131), diagnosed with Chronic Obstructive Pulmonary Disease or Type 2 Diabetes, aged between 40 and 70 years old, and having access to a computer with an Internet connection. METHODS: Semi structured interviews about the receipt of the intervention were conducted with the nurses and log files were kept regarding the consultations. After the intervention, questionnaires were presented to patients and nurses regarding compliance to and satisfaction with the interventions. Functioning and use of the tool were also evaluated by system and helpdesk logging. RESULTS: Eighty-six percent of patients (group 1: n=57 and group 2: n=56) and 90% of nurses (group 1: n=10 and group 2: n=9) responded to the questionnaires. The execution of the Self-management Support Programme was adequate; in 83% (group 1: n=52, group 2: n=57) of the patients, the number and planning of the consultations were carried out as intended. Eighty-eight percent (n=50) of the patients in group 1 used the tool until

Contains fulltext : 172704.pdf (publisher's version ) (Open Access), OBJECTIVE: The research sought to establish validated search filters for retrieval of studies on patients' knowledge and values. SETTING: Two nonprofit organizations in the Netherlands were studied for guideline development. METHODS: An existing filter was adapted to three bibliographic interfaces. After defining the scope, a reference database was built for the development of the new filters. The performance of the new filters was validated in different disease categories. RESULTS: Sensitivity, specificity, precision, negative predictive value, and accuracy were (%): 90.5/98/77/99.2/97 (MEDLINE-Ovid), 90.1/98.8/79.3/99.5/98.3 (PubMed), and 93.1/98.4/81.8/99.6/98.7 (Embase). CONCLUSIONS: The filters provide pragmatic tools for searching for patients' issues. Further optimization and validation is recommended.

Item does not contain fulltext, Currently, there are many diagnostic self-tests on body materials available to consumers. The aim of this study was to assess the effect of an online decision aid on diagnostic self-testing for cholesterol and diabetes on knowledge among consumers with an intention to take these tests. A randomized controlled trial was designed. A total of 1259 consumers with an intention to use a diagnostic cholesterol or diabetes self-test were selected from an existing Dutch Internet panel. The intervention group was invited to view an online decision aid offering general information on self-testing and test-specific information on cholesterol and diabetes self-testing, including indications for testing, how to perform the test and interpreting the result. The placebo condition consisted of a limited information sheet. Multiple regression analysis showed that the knowledge level in the diabetes arm was higher in the intervention group than in the control group (B = 0.657; 95% CI, 0.011-1.303), as was the number of participants with an informed choice (OR, 1.672; 95% CI, 1.134-2.465). No differences were found in the cholesterol arm. Consumers who are considering doing a self-test should have access to independent information on self-testing and be encouraged to read this information. TRIAL REGISTRATION: Dutch Trial Register: NTR 3149.

Item does not contain fulltext, BACKGROUND: Gathering information from talkative patients presents a challenge to clinicians. Empirical evidence on how to effectively deal with this challenge is scant. OBJECTIVE: This study explores communication strategies and their underlying mechanisms that GPs consider effective when gathering information from talkative patients in order to inform the development of best practices. METHODS: We conducted a qualitative study with experienced GPs. We held individual stimulated-recall interviews (SRIs) with six GPs using their videotaped consultations as a stimulus. The transcripts that ensued were triangulated with data from three focus-group discussions (FGs). We performed a thematic network analysis during an iterative process of data collection and analysis. RESULTS: To deal with talkative patients during consultations, GPs first try to pinpoint the cause of patients' talkativeness before deciding on the approach to take. Moreover, they resort to the familiar communication strategies, however, in doing so adopt take a more directive attitude. To prevent such attitude from damaging the relationship, GPs take a stepped approach in which they try not to be overly directive, make the patient co-responsible for efficient time management and make use of empathic interrupting. CONCLUSIONS: In the absence of evidence, this description of GPs' communication strategies can guide clinicians, residents and students in gathering information from talkative patients in an efficient, yet empathic and respectful manner. When developing best practices, heed should be paid to the causes of patients' talkativeness and the tension between taking a directive approach and building a doctor-patient relationship.

Item does not contain fulltext, BACKGROUND: There is a general consensus about the need to define and improve the quality of pain treatment facilities. Although guidelines and recommendations to improve the quality of pain practice management have been launched, provision of appropriate pain treatment is inconsistent and the quality of facilities varies widely. The aim of the study was to develop an expert-agreed list of quality indicators applicable to pain treatment facilities. The list was also intended to be used as the basis for a set of criteria for registered status of pain treatment facilities. METHODS: The University Pain Center Maastricht at the Department of Anesthesiology and Pain Management of the Maastricht University Medical Center conducted a 3-round Delphi study in collaboration with the Board of the Pain Section of the Dutch Society of Anesthesiologists (NVA). RESULTS: Twenty-five quality indicators were selected as relevant to 2 types of pain treatment facilities, pain clinics and pain centers. The final expert-agreed list consisted of 22 quality indicators covering 7 quality domains: supervision, availability of care, staffing level and patient load, quality policy, multidisciplinarity, regionalization, and research and education. CONCLUSIONS: This set of quality indicators may facilitate organizational evaluation and improve insight into service quality from the perspectives of patients, pain specialists, and other healthcare professionals. Recommendations for improvements to the current set of quality indicators are made. In 2014 the process of registering pain treatment facilities in the Netherlands started; facilities can register as a pain clinic or pain center.

Contains fulltext : 172847.pdf (publisher's version ) (Open Access), BACKGROUND: The number of people with multiple chronic conditions demanding primary care services is increasing. To deal with the complex health care demands of these people, professionals from different disciplines collaborate. This study aims to explore influential factors regarding interprofessional collaboration related to care plan development in primary care. METHODS: A qualitative study, including four semi-structured focus group interviews (n = 4). In total, a heterogeneous group of experts (n = 16) and health care professionals (n = 15) participated. Participants discussed viewpoints, barriers, and facilitators regarding interprofessional collaboration related to care plan development. The data were analysed by means of inductive content analysis. RESULTS: The findings show a variety of factors influencing the interprofessional collaboration in developing a care plan. Factors can be divided into 5 key categories: (1) patient-related factors: active role, self-management, goals and wishes, membership of the team; (2) professional-related factors: individual competences, domain thinking, motivation; (3) interpersonal factors: language differences, knowing each other, trust and respect, and motivation; (4) organisational factors: structure, composition, time, shared vision, leadership and administrative support; and (5) external factors: education, culture, hierarchy, domain thinking, law and regulations, finance, technology and ICT. CONCLUSIONS: Improving interprofessional collaboration regarding care plan development calls for an integral approach including patient- and professional related factors, interpersonal, organisational, and external factors. Further, the leader of the team seems to play a key role in watching the patient perspective, organising and coordinating interprofessional collaborations, and guiding the team through developments. The results of this study can be used as input for developing tools and interventions targeted at executing and i

Item does not contain fulltext, The systematic development of a counselling protocol in primary care combined with a monitoring and feedback tool to support chronically ill patients to achieve a more active lifestyle. An iterative user-centred design method was used to develop a counselling protocol: the Self-management Support Programme (SSP). The needs and preferences of future users of this protocol were identified by analysing the literature, through qualitative research, and by consulting an expert panel. The counselling protocol is based on the Five A's model. Practice nurses apply motivational interviewing, risk communication and goal setting to support self-management of patients in planning how to achieve a more active lifestyle. The protocol consists of a limited number of behaviour change consultations intertwined with interaction with and responses from the It's LiFe! monitoring and feedback tool. This tool provides feedback on patients' physical activity levels via an app on their smartphone. A summary of these levels is automatically sent to the general practice so that practice nurses can respond to this information. A SSP to stimulate physical activity was defined based on user requirements of care providers and patients, followed by a review by a panel of experts. By following this user-centred approach, the organization of care was carefully taken into account, which has led to a practical and affordable protocol for physical activity counselling combined with mobile technology.

Contains fulltext : 172292.pdf (publisher's version ) (Open Access), BACKGROUND: The number of people suffering from one or more chronic conditions is rising, resulting in an increase in patients with complex health care demands. Interprofessional collaboration and the use of shared care plans support the management of complex health care demands of patients with chronic illnesses. This study aims to get an overview of the scientific literature on developing interprofessional shared care plans. METHODS: We conducted a scoping review of the scientific literature regarding the development of interprofessional shared care plans. A systematic database search resulted in 45 articles being included, 5 of which were empirical studies concentrating purely on the care plan. Findings were synthesised using directed content analysis. RESULTS: This review revealed three themes. The first theme was the format of the shared care plan, with the following elements: patient's current state; goals and concerns; actions and interventions; and evaluation. The second theme concerned the development of shared care plans, and can be categorised as interpersonal, organisational and patient-related factors. The third theme covered tools, whose main function is to support professionals in sharing patient information without personal contact. Such tools relate to documentation of and communication about patient information. CONCLUSION: Care plan development is not a free-standing concept, but should be seen as the result of an underlying process of interprofessional collaboration between team members, including the patient. To integrate the patients' perspectives into the care plans, their needs and values need careful consideration. This review indicates a need for new empirical studies examining the development and use of shared care plans and evaluating their effects.

Item does not contain fulltext, PURPOSE: Although physical activity and exercise for stroke patients is highly recommended for fast recovery, patients in hospitals and rehabilitation centres are insufficiently encouraged to be physically active. In this study, we investigated the impact of knowledge brokers (KBs), enterprising nurses and therapists, on health professionals' (HP) performance to encourage stroke inpatients to be physically active. METHOD: This multicenter intervention study used a pre-post test design. Two or three KBs were trained in each stroke unit of 12 hospitals and 10 rehabilitation centres in The Netherlands. Questionnaires were completed by patients and HPs before and after the KB-intervention. The primary outcome was encouragement given by HPs to their patients to be physically active, as reported by patients and HPs. RESULTS: After the KB-intervention, many more patients (48%; N=217) reported at least some encouragement by HPs to be physically active than before (26%; N=243, p<0.000). HPs (N=288) on an average reported encouraging patients more often after the intervention, but this difference was significant only for occupational therapists and KBs. CONCLUSIONS: Based on patient's reports of HP behaviour, the KB-intervention appears effective since more patients felt encouraged to be physically active after the intervention compared to before. Replication of this study in an experimental design is needed to allow causal inferences. Implications for rehabilitation We advise rehabilitation teams to make use of knowledge brokers (KBs), since the KB-intervention was shown to increase the encouragement felt by stroke patients to be physically active. It seems worthwhile to involve physicians, nurses and patients' families more frequently in efforts to encourage stroke patients to be physically active.

Contains fulltext : 168224.pdf (publisher's version ) (Open Access), BACKGROUND: Patient participation in goal setting is important to deliver client-centered care. In daily practice, however, patient involvement in goal setting is not optimal. Patient-specific instruments, such as the Patient Specific Complaints (PSC) instrument, can support the goal-setting process because patients can identify and rate their own problems. The aim of this study is to explore patients' experiences with the feasibility of the PSC, in the physiotherapy goal setting. METHOD: We performed a qualitative study. Data were collected by observations of physiotherapy sessions (n=23) and through interviews with patients (n=23) with chronic conditions in physiotherapy practices. Data were analyzed using directed content analysis. RESULTS: The PSC was used at different moments and in different ways. Two feasibility themes were analyzed. First was the perceived ambiguity with the process of administration: patients perceived a broad range of experiences, such as emotional and supportive, as well as feeling a type of uncomfortableness. The second was the perceived usefulness: patients found the PSC useful for themselves - to increase awareness and motivation and to inform the physiotherapist - as well as being useful for the physiotherapist - to determine appropriate treatment for their personal needs. Some patients did not perceive any usefulness and were not aware of any relation with their treatment. Patients with a more positive attitude toward questionnaires, patients with an active role, and health-literate patients appreciated the PSC and felt facilitated by it. Patients who lacked these attributes did not fully understand the PSC's process or purpose and let the physiotherapist take the lead. CONCLUSION: The PSC is a feasible tool to support patient participation in the physiotherapy goal setting. However, in the daily use of the PSC, patients are not always fully involved and informed. Patients reported varied experiences related to their personal attribu

Item does not contain fulltext, Consultations with talkative patients present a challenge to doctors. It is difficult to gather all the necessary information within the available time, without damaging the doctor-patient relationship. Based on the listed existing literature and doctors' experiences, we present ten tips for gathering information from talkative patients in an effective manner whilst maintaining a good therapeutic alliance. In consultations with talkative patients, it is important to explore the cause of patients' talkativeness and to adapt one's communication approach accordingly.- Familiar communication strategies such as 'summarizing' can still be applied. When taking this route, a more directive communication approach--e.g. by means of a 'closed-ended summary'--can prevent the patient interrupting the doctor or departing from his subject. There are strategies aimed at avoiding a damaging effect to the doctor-patient relationship when applying this approach: don't be overly directive, make the patient co-responsible for efficient time management in the consultation, and make use of empathic interrupting and humour.

Contains fulltext : 172725.PDF (publisher's version ) (Open Access), OBJECTIVES: Understanding the preferences of patients with multiple sclerosis (MS) for disease-modifying drugs and involving these patients in clinical decision making can improve the concordance between medical decisions and patient values and may, subsequently, improve adherence to disease-modifying drugs. This study aims first to identify which characteristics-or attributes-of disease-modifying drugs influence patients decisions about these treatments and second to quantify the attributes' relative importance among patients. METHODS: First, three focus groups of relapsing-remitting MS patients were formed to compile a preliminary list of attributes using a nominal group technique. Based on this qualitative research, a survey with several choice tasks (best-worst scaling) was developed to prioritize attributes, asking a larger patient group to choose the most and least important attributes. The attributes' mean relative importance scores (RIS) were calculated. RESULTS: Nineteen patients reported 34 attributes during the focus groups and 185 patients evaluated the importance of the attributes in the survey. The effect on disease progression received the highest RIS (RIS = 9.64, 95% confidence interval: [9.48-9.81]), followed by quality of life (RIS = 9.21 [9.00-9.42]), relapse rate (RIS = 7.76 [7.39-8.13]), severity of side effects (RIS = 7.63 [7.33-7.94]) and relapse severity (RIS = 7.39 [7.06-7.73]). Subgroup analyses showed heterogeneity in preference of patients. For example, side effect-related attributes were statistically more important for patients who had no experience in using disease-modifying drugs compared to experienced patients (p < .001). CONCLUSIONS: This study shows that, on average, patients valued effectiveness and unwanted effects as most important. Clinicians should be aware of the average preferences but also that attributes of disease-modifying drugs are valued differently by different patients. Person-centred clinical decision making would

Item does not contain fulltext, A patient's values and preferences are one of the three 'pillars' of evidence-based medicine (EBM). How can we explain that this one pillar has hardly been elaborated in the EBM-literature?? Were the EBM pioneers really committed to the patient's preferences, were they not ready yet, or were they not committed at all? In key international EBM publications dated between 1985 and 2000, we only found sympathetic, yet vague, statements lacking concrete content. In the Netherlands, a Health Council report set the tone with a sense of fear for 'consumer medicine'. In addition to an overly optimistic view of the past, in 2014 Greenhalgh sketched a vision of the future of EBM in which the sympathetic comments about patient preferences are finally made concrete. The EBM movement has already successfully adapted to social developments in the past; therefore, there is reason for optimism.

Contains fulltext : 171708.pdf (publisher's version ) (Open Access), A personalized patient education tool for decision making (PET) for postmenopausal women with osteoporosis was developed by means of a systematic development approach. A prototype was constructed and refined by involving various professionals and patients. Professionals and patients expressed a positive attitude towards the use of the PET. INTRODUCTION: The purpose was to systematically develop a paper-based personalized PET to assist postmenopausal women with osteoporosis in selecting a treatment in line with their personal values and preferences. METHODS: The development of the PET was based on a systematic process including scope, design, development of a prototype, and alpha testing among professionals and patients by semi-structured interviews. RESULTS: The design and development resulted in a four-page PET prototype together with a one-page fact sheet of the different drug options. The prototype PET provided the personal risk factors, the estimated individualized risk for a future major osteoporotic fracture and potential reduction with drugs, and a summary of advantages and disadvantages whether or not to start drugs. The drug fact sheet presents five attributes of seven drugs in a tabular format. The alpha testing with professionals resulted in some adaptations, e.g., inclusion of the possibility to calculate fracture risk based on various individual risk scoring methods. Important results from the alpha testing with patients were differences in the fracture risk percentage which was seen as worthwhile to start drugs, the importance of an overview of side effects, and of the timing of the PET into the patient pathway. All women indicated that the PET could be helpful for their decision to select a treatment. CONCLUSION: Physicians and patients expressed a positive attitude towards the use of the proposed PET. Further research would be needed to test the effects of the PET on feasibility in clinical workflow and on patient outcomes.

Item does not contain fulltext, BACKGROUND: Patients with type 2 diabetes mellitus face several emotional and social consequences of their chronic illness in their everyday life. Symptoms of distress and depression are prevalent. For providing psychosocial self-management support, nurses in primary care were trained to identify patients with psychosocial problems during routine medically-shaped diabetes consultations. However, detection rates appeared to be strikingly low. OBJECTIVES: Our study aimed to examine patients' readiness to discuss psychosocial problems with nurses during diabetes consultations. DESIGN: A mixed methods design was used in which qualitative data collection was followed up by quantitative data collection. SETTING: Diabetes care in a regional group of family practices in the south of the Netherlands. PARTICIPANTS: Type 2 diabetes patients with psychosocial problems, determined by a self-administered questionnaire. METHODS: First, in-depth interviews (n=12) were conducted about patients' experiences with routine diabetes consultations and their perspective on a biopsychosocial care approach. Based on a qualitative content analysis, a structured questionnaire was designed to further explore the findings among a larger group of patients. This questionnaire was completed by 205 patients. The questionnaire included 14 items measuring patients' agreement with statements about diabetes care and the role of the nurse to focus on patients' emotional and social functioning. RESULTS: The interviews showed that patients view a diabetes consultation primarily as a biomedical check-up, and do not perceive discussion of psychosocial well-being as an integral part of diabetes management. More than 90% of the sample showed a positive attitude towards current diabetes consultations. Patients' intentions and perceived needs regarding a biopsychosocial care approach of the nurse were variable. Younger patients seemed more open to discussing psychosocial problems with the nurse than patients ove

Item does not contain fulltext, Despite the increasing number of research publications on patient preferences, their use in healthcare policy-making is limited. Integrating research evidence on patient preferences in policy-making is advocated by some, but several issues are put forward as well. There has been no systematic investigation of the stakeholders' view on this matter so far. Objective is to explore the opinions of Dutch stakeholders on how to integrate evidence on patient preferences in pharmaceutical coverage decisions and clinical practice guideline (CPG) development, and which issues may be encountered. METHODS: Qualitative study with semi-structured interviews with Dutch researchers (N=7), policy-makers and CPG developers (N=4) and patient representatives (N=4) involved in pharmaceutical coverage decisions and/or CPG development. The interview scheme focused on the definition of patient preferences; how to integrate evidence on patient preferences in decision-making; and barriers and facilitators. RESULTS: Respondents mentioned various barriers and facilitators for integration, of conceptual, normative, procedural, methodological and practical nature. There is also variety in the terms and definitions used for preferences, complicating searching and synthesising evidence. It is not clear how to integrate evidence on patient preferences in different decision contexts, and what weight preferences should have in relation to other decision criteria. CONCLUSIONS: This study revealed important issues that need guidance when integrating evidence on patient preferences in healthcare policy decisions.

Item does not contain fulltext, BACKGROUND: To ensure true patient-centered care, the urgency of patient participation in research is increasingly recognized. This study takes this one step further and reports on patient participation in describing patients' needs for improving quality of care in the context of research priorities - a challenging partnership with patients in research as we yet lack experience in the Netherlands. OBJECTIVES: 1) To illustrate the process of describing patients' needs in the context of research priorities for patients with blood cancer (multiple myeloma or Waldenstrom's disease) with the purpose to improve the quality of health care. 2) To describe the experienced needs in the context of research priorities in the patients. METHODS: Following the Dialogue Model, we first established a balanced project group and agreed on the study protocol, followed by the actual data collection of which the most important steps included: individual interviews and focus groups with purposeful samples of patients, a questionnaire that was sent to all members of the patient organization (n=1,782), and a dialogue meeting with patients to prioritize the final issues. RESULTS: 1) Ten interviews and two focus groups were successfully conducted. Response rate on the questionnaire averaged 44%. 2) Main research topics: improved information on all aspects of disease and treatment, involving patients in decision making, organization of care and the burden of neuropathy. DISCUSSION: Given the process of data collection we believe that the patients' needs for quality of care improvements in the context of research priorities that were described are valid and representative. The novelty of this approach was that patients themselves contacted researchers to assess the patients' priorities in a scientific and reliable way.

Contains fulltext : 152095.pdf (publisher's version ) (Open Access), BACKGROUND: Despite the increased attention for assessing the effectiveness of implementation strategies, most implementation studies provide little or no information on its associated costs. The focus of the current study was to provide a detailed report of the resource use and costs associated with implementation of a short stay programme for breast cancer surgery in four Dutch hospitals. METHODS: The analysis was performed alongside a multi-centre implementation study. The process of identification, measurement and valuation of the implementation activities was based on recommendations for the design, analysis and reporting of health technology assessments. A scoring form was developed to prospectively determine the implementation activities at professional and implementation expert level. A time horizon of 5 years was used to calculate the implementation costs per patient. Results : Identified activities were consisted of development and execution of the implementation strategy during the implementation project. Total implementation costs over the four hospitals were euro83.293. Mean implementation costs, calculated for 660 patients treated over a period of 5 years, were euro25 per patient. Subgroup analyses showed that the implementation costs ranged from euro3.942 to euro32.000 on hospital level. From a local hospital perspective, overall implementation costs were euro21 per patient, after exclusion of the costs made by the expert centre. CONCLUSIONS: We provided a detailed case description of how implementation costs can be determined. Notable differences in implementation costs between hospitals were observed. TRIAL REGISTRATION: ISRCTN: ISRCTN77253391.

Contains fulltext : 152218.pdf (publisher's version ) (Open Access), BACKGROUND: Trials evaluating the effects of interventions usually provide little insight into the factors responsible for (lack of) changes in desired outcomes. A process evaluation alongside a trial can shed light on the mechanisms responsible for the outcomes of a trial. The aim of this study was to investigate exposure to and experiences with a computerized decision support system (CDSS) intervention, in order to gain insight into the intervention's impact and to provide suggestions for improvement. METHODS: A process evaluation was conducted as part of a large-scale cluster-randomized controlled trial investigating the effects of the CDSS NHGDoc on quality of care. Data on exposure to and experiences with the intervention were collected during the trial period among participants in both the intervention and control group - whenever applicable - by means of the NHGDoc server and an electronic questionnaire. Multiple data were analyzed using descriptive statistics. RESULTS: Ninety-nine percent (n = 229) of the included practices generated data for the NHGDoc server and 50 % (n = 116) responded to the questionnaire: both general practitioners (GPs; n = 112; 49 %) and practice nurses (PNs; n = 52; 37 %) participated. The actual exposure to the NHGDoc system and specific heart failure module was limited with 52 % of the GPs and 42 % of the PNs reporting to either never or rarely use the system. Overall, users had a positive attitude towards CDSSs. The most perceived barriers to using NHGDoc were a lack of learning capacity of the system, the additional time and work it requires to use the CDSS, irrelevant alerts, too high intensity of alerts and insufficient knowledge regarding the system. CONCLUSIONS: Several types of barriers may have negatively affected the impact of the intervention. Although users are generally positive about CDSSs, a large share of them is insufficiently aware of the functions of NHGDoc and, finds the decision support not always useful or rele

Contains fulltext : 152403.pdf (publisher's version ) (Open Access), BACKGROUND: Physical inactivity is a major public health problem. The It's LiFe! monitoring and feedback tool embedded in the Self-Management Support Program (SSP) is an attempt to stimulate physical activity in people with chronic obstructive pulmonary disease or type 2 diabetes treated in primary care. OBJECTIVE: Our aim was to evaluate whether the SSP combined with the use of the monitoring and feedback tool leads to more physical activity compared to usual care and to evaluate the additional effect of using this tool on top of the SSP. METHODS: This was a three-armed cluster randomised controlled trial. Twenty four family practices were randomly assigned to one of three groups in which participants received the tool + SSP (group 1), the SSP (group 2), or care as usual (group 3). The primary outcome measure was minutes of physical activity per day. The secondary outcomes were general and exercise self-efficacy and quality of life. Outcomes were measured at baseline after the intervention (4-6 months), and 3 months thereafter. RESULTS: The group that received the entire intervention (tool + SSP) showed more physical activity directly after the intervention than Group 3 (mean difference 11.73, 95% CI 6.21-17.25; P<.001), and Group 2 (mean difference 7.86, 95% CI 2.18-13.54; P=.003). Three months after the intervention, this effect was still present and significant (compared to Group 3: mean difference 10.59, 95% CI 4.94-16.25; P<.001; compared to Group 2: mean difference 9.41, 95% CI 3.70-15.11; P<.001). There was no significant difference in effect between Groups 2 and 3 on both time points. There was no interaction effect for disease type. CONCLUSIONS: The combination of counseling with the tool proved an effective way to stimulate physical activity. Counseling without the tool was not effective. Future research about the cost-effectiveness and application under more tailored conditions and in other target groups is recommended. TRIAL REGISTRATION: ClinicalTrials

Contains fulltext : 152217.pdf (publisher's version ) (Open Access), INTRODUCTION: COPD is a leading cause of morbidity and mortality. Self-management interventions are considered important in order to limit the progression of the disease. Computer-tailored interventions could be an effective tool to facilitate self-management. METHODS: This randomized controlled trial tested the effectiveness of a web-based, computer-tailored COPD self-management intervention on physical activity and smoking behavior. Participants were recruited from an online panel and through primary care practices. Those at risk for or diagnosed with COPD, between 40 and 70 years of age, proficient in Dutch, with access to the Internet, and with basic computer skills (n=1,325), were randomly assigned to either the intervention group (n=662) or control group (n=663). The intervention group received the web-based self-management application, while the control group received no intervention. Participants were not blinded to group assignment. After 6 months, the effect of the intervention was assessed for the primary outcomes, smoking cessation and physical activity, by self-reported 7-day point prevalence abstinence and the International Physical Activity Questionnaire - Short Form. RESULTS: Of the 1,325 participants, 1,071 (80.8%) completed the 6-month follow-up questionnaire. No significant treatment effect was found on either outcome. The application however, was used by only 36% of the participants in the experimental group. CONCLUSION: A possible explanation for the nonsignificant effect on the primary outcomes, smoking cessation and physical activity, could be the low exposure to the application as engagement with the program has been shown to be crucial for the effectiveness of computer-tailored interventions. (Netherlands Trial Registry number: NTR3421.).

Contains fulltext : 152767.pdf (publisher's version ) (Closed access), BACKGROUND: Between 2006 and 2008 the enhanced recovery after surgery (ERAS) program was implemented in colonic surgery in one-third of all hospitals in the Netherlands (n = 33). This resulted in enhanced recovery and a decrease in hospital length of stay (LOS) from a median of 9 days at baseline to 6 days at one-year follow-up. The present study assessed the sustainability of the ERAS program 3-5 years after its implementation. MATERIALS AND METHODS: From the 33 ERAS hospitals, 10 initially successful hospitals were selected, with success defined as a median LOS of 6 days or lower and protocol adherence rates above 70 %. In 2012 a retrospective audit of 30 consecutive patients was performed in each of these hospitals. Sustainability of the ERAS program was assessed on hospital level, using median hospital LOS, protocol adherence rates and time to functional recovery. Data were compared with the implementation phase data. RESULTS: Overall median LOS in the selected hospitals increased from 5.25 days (interquartile range [IQR] 4.75-6.00; min, 4.00-max, 6.00) to 6 days (IQR 5.00-7.00; min, 5.00-max, 8.00), but this change was not significant (p = 0.052). Time to functional recovery was equal in both phases: median 3.00 days (p = 0.26). Protocol adherence decreased from 75 to 67 % (p = 0.32). Especially adherence to postoperative care elements dropped considerably. CONCLUSIONS: Despite a slight decrease in protocol adherence, the ERAS program was sustained reasonably well in the 10 selected hospitals, although there was quite some variation between the hospitals.

Item does not contain fulltext, In the decision-making environment of evidence-based practice, the following three sources of information must be integrated: research evidence of the intervention, clinical expertise, and the patient's values. In reality, evidence-based practice usually focuses on research evidence (which may be translated into clinical practice guidelines) and clinical expertise without considering the individual patient's values. The shared decision-making model seems to be helpful in the integration of the individual patient's values in evidence-based practice. We aim to discuss the relevance of shared decision making in chronic care and to suggest how it can be integrated with evidence-based practice in nursing. We start by describing the following three possible approaches to guide the decision-making process: the paternalistic approach, the informed approach, and the shared decision-making approach. Implementation of shared decision making has gained considerable interest in cases lacking a strong best-treatment recommendation, and when the available treatment options are equivalent to some extent. We discuss that in chronic care it is important to always invite the patient to participate in the decision-making process. We delineate the following six attributes of health care interventions in chronic care that influence the degree of shared decision making: the level of research evidence, the number of available intervention options, the burden of side effects, the impact on lifestyle, the patient group values, and the impact on resources. Furthermore, the patient's willingness to participate in shared decision making, the clinical expertise of the nurse, and the context in which the decision making takes place affect the shared decision-making process. A knowledgeable and skilled nurse with a positive attitude towards shared decision making-integrated with evidence-based practice-can facilitate the shared decision-making process. We conclude that nurses as well as other heal

Contains fulltext : 152421.pdf (publisher's version ) (Open Access), OBJECTIVE: To evaluate the effectiveness of biopsychosocial Self-Management Support (SMS) delivered by practice nurses in routine diabetes care. DESIGN: A pragmatic cluster-randomised controlled trial within a hybrid effectiveness-implementation study design. Practice nurses were cluster-randomised. SETTING: A regional care group in the Netherlands consisting of 77 family practices. The study involved practice nurses (n=40) providing care to approximately 4000 patients with diabetes. PARTICIPANTS: Patients with type 2 diabetes (n=264) selected by a self-administered questionnaire aimed at measuring emotional distress and diabetes-related reduced daily functioning. INTERVENTION: Practice nurses in the intervention arm (n=19) were trained to integrate SMS into their routine consultations. SMS included detection of patients with emotional distress and reduced daily functioning, and supporting them when needed through problem solving and reattribution techniques. Practice nurses in the control arm (n=21) provided usual care. MAIN OUTCOME MEASURES: The primary outcome measure was a dichotomised score on a Visual Analogue Scale that measured the perceived effect of diabetes on daily functioning. Secondary measures included patients' diabetes-related distress, quality of life, autonomy and participation, self-efficacy, self-management and glycaemic control. Outcomes were measured at baseline and at 4-month and 12-month follow-ups. RESULTS: Only 16 of the 117 patients in the intervention arm (14%) who were found eligible by the posted research-driven screening questionnaire were detected by their practice nurses. Extra consultations for the self-management support were delivered to only 11 study participants. In the control arm, 147 patients received usual care. Multilevel analyses showed no significant differences in outcomes between the intervention and control arms. CONCLUSIONS: SMS in its present form was not effective. The research-driven screening to select trial part

Contains fulltext : 152718.pdf (Publisher’s version ) (Closed access), INTRODUCTION: Self-management is considered a potential answer to the increasing demand for family medicine by people suffering from a chronic condition or multi-morbidity. A key element of self-management is goal setting. Goal setting is often defined as a moment of agreement between a professional and a patient. In the self-management literature, however, goal setting is regarded as a circular process. Still, it is unclear how professionals working in family medicine can put it into practice. This background paper aims to contribute to the understanding of goal setting within self-management and to identify elements that need further development for practical use. Debate: Four questions for debate emerge in this article: (1) What are self-management goals? (2) What is necessary to accomplish the process of goal setting within self-management? (3) How can professionals decide on the degree of support needed for goal setting within self-management? (4) How can patients set their goals and how can they be supported? IMPLICATIONS: Self-management goals can be set for different (life) domains. Using a holistic framework will help in creating an overview of patients' goals that do not merely focus on medical issues. It is a challenge for professionals to coach their patients to think about and set their goals themselves. More insight in patients' willingness and ability to set self-management goals is desirable. Moreover, as goal setting is a circular process, professionals need to be supported to go through this process with their patients.

Item does not contain fulltext, OBJECTIVE: Collecting information during patient encounters is essential for the delivery of patient-centered care. To obtain insight into areas that require more attention in medical communication training, this study explores what difficulties GP trainees encounter when gathering information. METHODS: In this phenomenological study, we observed a morning clinic of 15 GP trainees. To explore trainees' experiences with information-gathering, we held brief interviews after every consultation and a lengthier interview directly after the morning clinic. The resulting data were analyzed using template analysis. RESULTS: From trainees' reflections, we distilled five difficulties that trainees experience when gathering information: (1) Goal conflicts; (2) Ineffectiveness of trained communication skills in specific situations; (3) Trainees' distress hampers open communication; (4) Untrustworthy information; (5) Tunnel vision. CONCLUSION: Information-gathering is difficult for GP trainees. Current generic communication skills training does not seem to support trainees sufficiently to handle effectively the challenges they encounter during consultations. PRACTICE IMPLICATIONS: Medical communication training needs to support trainees in handling their goal-conflicts and feelings that hamper information-gathering, while also providing them with communication strategies adapted to handling specific challenging situations.

Contains fulltext : 152306.pdf (publisher's version ) (Open Access), BACKGROUND: Enhanced Recovery After Surgery (ERAS) programmes aim at an early recovery after surgical trauma and consequently at a reduced length of hospitalisation. This paper presents the protocol for a study that focuses on large-scale implementation of the ERAS programme in major gynaecological surgery in the Netherlands. The trial will evaluate effectiveness and costs of a stepped implementation approach that is characterised by tailoring the intensity of implementation activities to the needs of organisations and local barriers for change, in comparison with the generic breakthrough strategy that is usually applied in large-scale improvement projects in the Netherlands. METHODS: All Dutch hospitals authorised to perform major abdominal surgery in gynaecological oncology patients are eligible for inclusion in this cluster randomised controlled trial. The hospitals that already fully implemented the ERAS programme in their local perioperative management or those who predominantly admit gynaecological surgery patients to an external hospital replacement care facility will be excluded. Cluster randomisation will be applied at the hospital level and will be stratified based on tertiary status. Hospitals will be randomly assigned to the stepped implementation strategy or the breakthrough strategy. The control group will receive the traditional breakthrough strategy with three educational sessions and the use of plan-do-study-act cycles for planning and executing local improvement activities. The intervention group will receive an innovative stepped strategy comprising four levels of intensity of support. Implementation starts with generic low-cost activities and may build up to the highest level of tailored and labour-intensive activities. The decision for a stepwise increase in intensive support will be based on the success of implementation so far. Both implementation strategies will be completed within 1 year and evaluated on effect, process, and cost-effectivene

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Contains fulltext : 152143.PDF (publisher's version ) (Open Access), PURPOSE: The SDM-Q-9 and SDM-Q-Doc measure patient and physician perception of the extent of shared decision making (SDM) during a physician-patient consultation. So far, no self-report instrument for SDM was available in Dutch, and validation of the scales in other languages has been limited. The aim of this study was to translate both scales into Dutch and assess their psychometric characteristics. METHODS: Participants were patients and their treating physicians (general practitioners and medical specialists). Patients (N = 182) rated their consultation using the SDM-Q-9, 43 physicians rated their consultations using the SDM-Q-Doc (N = 201). Acceptability, reliability (internal consistency), and the factorial structure of the instruments were determined. For convergent validity the CPSpost was used. RESULTS: Reliabilities of both scales were high (alpha SDM-Q-9 0.88; SDM-Q-Doc 0.87). The SDM-Q-9 and SDM-Q-Doc total scores correlated as expected with the CPSpost (SDM-Q-9: r = 0.29; SDM-Q-Doc: r = 0.48) and were significantly different between the CPSpost categories, with lowest mean scores when the physician made the decision alone. Principal Component Analyses showed a two-component model for each scale. A confirmatory factor analysis yielded a mediocre, but acceptable, one-factor model, if Item 1 was excluded; for both scales the best indices of fit were obtained for a one-factor solution, if both Items 1 and 9 were excluded. CONCLUSION: The Dutch SDM-Q-9 and SDM-Q-Doc demonstrate good acceptance and reliability; they correlated as expected with the CPSpost and are suitable for use in Dutch primary and specialised care. Although the best model fit was found when excluding Items 1 and 9, we believe these items address important aspects of SDM. Therefore, also based on the coherence with theory and comparability with other studies, we suggest keeping all nine items of the scale. Further research on the SDM-concept in patients and physicians, in different clinical

Contains fulltext : 152301.pdf (Publisher’s version ) (Open Access), Diagnostic reasoning is considered to be based on the interaction between analytical and non-analytical cognitive processes. Gut feelings, a specific form of non-analytical reasoning, play a substantial role in diagnostic reasoning by general practitioners (GPs) and may activate analytical reasoning. In GP traineeships in the Netherlands, trainees mostly see patients alone but regularly consult with their supervisors to discuss patients and problems, receive feedback, and improve their competencies. In the present study, we examined the discussions of supervisors and their trainees about diagnostic reasoning in these so-called tutorial dialogues and how gut feelings feature in these discussions. 17 tutorial dialogues focussing on diagnostic reasoning were video-recorded and transcribed and the protocols were analysed using a detailed bottom-up and iterative content analysis and coding procedure. The dialogues were segmented into quotes. Each quote received a content code and a participant code. The number of words per code was used as a unit of analysis to quantitatively compare the contributions to the dialogues made by supervisors and trainees, and the attention given to different topics. The dialogues were usually analytical reflections on a trainee's diagnostic reasoning. A hypothetico-deductive strategy was often used, by listing differential diagnoses and discussing what information guided the reasoning process and might confirm or exclude provisional hypotheses. Gut feelings were discussed in seven dialogues. They were used as a tool in diagnostic reasoning, inducing analytical reflection, sometimes on the entire diagnostic reasoning process. The emphasis in these tutorial dialogues was on analytical components of diagnostic reasoning. Discussing gut feelings in tutorial dialogues seems to be a good educational method to familiarize trainees with non-analytical reasoning. Supervisors need specialised knowledge about these aspects of diagnostic reasoning and h

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Contains fulltext : 137596.pdf (publisher's version ) (Open Access), BACKGROUND: Many patients who consult their GP are worried about their health, but there is little empirical data on strategies for effective reassurance. To gain a better understanding of mechanisms for effective patient reassurance, we explored cognitions underlying patients' worries, cognitions underlying reassurance and factors supporting patients' reassuring cognitions. METHODS: In a qualitative study, we conducted stimulated recall interviews with 21 patients of 12 different GPs shortly after their consultation. We selected consultations in which the GPs aimed to reassure worried patients and used their videotaped consultation as a stimulus for the interview. The interviews were analysed with thematic coding and by writing interpretive summaries. RESULTS: Patients expressed four different core cognitions underlying their concerns: 'I have a serious illness', 'my health problem will have adverse physical effects', 'my treatment will have adverse effects' and 'my health problem will negatively impact my life'. Patients mentioned a range of person-specific and context-specific cognitions as reasons for these core cognitions. Patients described five core reassuring cognitions: 'I trust my doctor's expertise', 'I have a trusting and supporting relationship with my doctor', 'I do not have a serious disease', 'my health problem is harmless' and 'my health problem will disappear.' Factors expressed as reasons for these reassuring cognitions were GPs' actions during the consultation as well as patients' pre-existing cognitions about their GP, the doctor-patient relationship and previous events. Patients' worrying cognitions were counterbalanced by specific reassuring cognitions, i.e. worrying and reassuring cognitions seemed to be interrelated. CONCLUSIONS: Patients described a wide range of worrying cognitions, some of which were not expressed during the consultation. Gaining a thorough understanding of the specific cognitions and tailoring reassuring strategies to th