Willeke Kasje. Implementing joint treatment guidelines to improve prescribing in general practice

Implementing joint treatment guidelines to improve prescribing in general practice

Willeke Kasje

Paranimfen: Nynke Schuiling-Veninga Jacoba Greving

Printing of this thesis was generously supported by The Groningen Institute of Drug Exploration (GUIDE), and The Northern Centre for Healthcare research (NCH). The Dutch Ministry of Health, Well-being and Sports by means of the Proeftuin Farmaceutische Zorg Groningen financially supported part of this study.

Cover Willeke Kasje

Kasje, W.N. Implementing joint treatment guidelines to improve prescribing in general practice. Dissertation University of Groningen.-with Dutch summary ISBN 90-77113-12-1

 Copyright W.N. Kasje. All rights reserved. No part of this book maybe reproduced, in any manner or by any means without written permission from the author.

Rijksuniversiteit Groningen

Implementing joint treatment guidelines to improve prescribing in general practice Proefschrift

ter verkrijging van het doctoraat in de Medische Wetenschappen aan de Rijksuniversiteit Groningen op gezag van de Rector Magnificus, dr. F. Zwarts, in het openbaar te verdedigen op woensdag 3 november 2004 om 16:15 uur

door Willeke Nynke Kasje geboren op 27 mei 1974 te Koudum

Promotores

Prof. Dr. F.M. Haaijer-Ruskamp Prof. Dr. P.A. de Graeff

Copromotor

Dr. P. Denig

Beoordelingscommissie

Prof. Dr. R.T.P.M. Grol Prof. Dr. B. Meyboom-de Jong Prof. Dr. D.J. van Veldhuizen Prof. Dr. J.H. Kingma

Contents Chapter 1

Introduction

1

Chapter 2

Specialists’ expectations regarding joint treatment guidelines for primary and secondary care

13

Chapter 3

Physicians’ views on joint treatment guidelines for primary and secondary care

33

Chapter 4

Perceived barriers for treatment of chronic heart failure in general practice. Are they affecting performance?

47

Chapter 5

Current treatment of chronic heart failure: Do physician, organisational and patient characteristics have an impact in general practice?

59

Chapter 6

Physician, organizational and patient factors associated with suboptimal blood pressure management in type 2 diabetes patients in primary care

71

Chapter 7

Evaluating an educational program to improve adherence to joint guidelines in general practice

85

Chapter 8

General discussion

101

Summary

109

Samenvatting

117

Appendix

127 133

Dankwoord

Joint treatment guidelines for chronic heart failure Joint treatment guidelines for hypertension

138

From The Morning Visit …The morning visit-not till sickness falls In the charmed circles of your own safe walls; Till fever's throb and pain's relentless rack Stretch you all helpless on your aching back; Not till you play the patient in your turn, The morning visit's mystery shall you learn. 'Tis a small matter in your neighbor's case, To charge your fee for showing him your face; You skip upstairs, inquire, inspect, and touch, Prescribe, take leave, and off to twenty such. But when at length, by fate's transferred decree, The visitor becomes, the visitee, Oh, then, indeed, it pulls another string; Your ox is gored, and that's a different thing!…. Be gentle, then, though Art's unsparing rules Give you the handling of her sharpest tools; Use them not rashly - sickness is enough; Be always "ready," but be never "rough." But simple kindness, kneeling by the bed To shift the pillow for the sick man's head, Give the fresh draught to cool the lips that burn, Fan the hot brow, the weary frame to turn Kindness, untutored by our grave M.D.'s, But Nature's graduate, when she schools to please, Wins back more sufferers with her voice and smile Than all the trumpery in the druggist's pile. …Once more, be quiet: coming up the stair, Don't be a plantigrade, a human bear.

Oliver Wendell Holmes

Chapter 1 Introduction This thesis focuses on the quality of prescribing, specifically in the field of chronic diseases where general practitioners and hospital specialists both have the responsibility for the same group of patients. Within each medical profession different perspectives, diverse roles and various working environments exist. This may lead to a lack of co-operation or consistency between primary and secondary care, and reduce the quality of care. Guidelines as a means to improve quality of treatment Improving quality of treatment is an important topic in health care. There is growing awareness of large variations in clinical practice and of suboptimal health care. One of the means to reduce variation and improve treatment quality is the development and dissemination of practice guidelines. Guidelines refer to a collection of statements about a defined topic, usually the prevention, diagnosis, and treatment of a health problem 1 . Guidelines are a tool for closing the gap between what clinicians do and what scientific evidence supports 2,3 . Guidelines can improve clinical practice, but this depends on many factors, including the clinical context and the methods of developing, disseminating, and implementing those guidelines 4 . A guideline preferably begins with a thorough review of available scientific evidence by experts who appropriately represent the target group 5 . The acceptance of a guideline depends on this development process. In addition, the properties of the guideline itself affect its adherence in daily practice. Compatibility of the recommendations with existing values is needed for physicians to accept the guideline. The less complex guideline recommendations are, the better they are usually followed. Furthermore, better use of guidelines is associated with situations where no new skills or organisational changes are needed 6,7 . Many different types of guidelines exist and as a result various recommendations are given to health care professionals leading to confusion. In the Netherlands, recommendations in terms of drug choice vary in regional treatment guidelines 8 . In order to improve the quality of guidelines and guideline development, criteria for good quality guidelines have been set up. The Appraisal instrument for Guidelines, Research and Evaluation in Europe (AGREE) has been constructed to 1

General introduction

judge the scope, scientific evidence, as well as the clarity and applicability of guidelines 9 . Practice guidelines developed on the basis of reaching consensus take their evidence usually more from expert panels than from scientific evidence. This may lower the quality of the guideline 2 . In the Netherlands, the Dutch Institute for Health Care Improvement (CBO) uses quality criteria to ensure high-quality development of guidelines. CBO-guidelines include recommendations for specialist care. For primary care, the Dutch College of General practitioners (NHG) develops its own guidelines. In 1998 both organisations made an agreement to adjust their guidelines to one another. General practitioners (GPs) in the Netherlands are rather positive about having guidelines in daily practice. GPs adhere to 70% of the recommendations in the NHGguidelines, although this varies between GPs and between guidelines 10 . Few studies have been conducted to examine the attitudes and use of guidelines in outpatient specialist care. Specialists were found to have a generally positive attitude towards guidelines, but were not using them to a large extent 11,12 . In the Netherlands, half of hospital specialists reported to use CBO-guidelines 13 . An important issue is the collaboration between GPs and hospital specialists. Specialists have a great impact on treatment at the GP level; nevertheless they are often not included in efforts to improve treatment in primary care. In the year 2000, a program has been set up in the Netherlands to improve the quality of treatment care across the primary-secondary care interface 14 . The aim was to improve both quality and efficiency in health care by bringing the therapeutic care provided by GPs and hospital specialists in line with each other on a regional level. In other countries some experience has been gained with joint treatment guidelines. In Scotland, a joint formulary was successfully developed by a group of specialists and interested local GPs 15 . One of the approaches in the Netherlands was to develop joint treatment guidelines to be used by all physicians in one region. In the Groningen region, local committees of specialists, family physicians, and hospital and community pharmacists were involved in development of such regional joint guidelines. Their recommendations were based on existing regional guidelines for primary care, national guidelines, scientific evidence and expert experiences. Such joint guidelines developed by a multidisciplinary team could reduce the lack of consistency and improve collaboration between primary and secondary care, and may lead to more efficient care. Barriers for implementing treatment guidelines Newly developed guidelines need to be disseminated to improve quality of care. Whilst knowledge of a guideline is important, it is rarely, by itself, sufficient to change behaviour. Behavioural change is not easy to accomplish and insight into the factors that prevent change will help to develop better implementation 2

Chapter 1

strategies. A variety of barriers undermine the use of guideline recommendations 7 . Obstacles in practice can arise at different stages in the health care system: at the level of the health care organisation, at the level of the individual physician, and at the level of the patient 6 . Many studies have focussed on the barriers at the physician level to explain the gap between evidence-based medicine and actual daily practice 11,16 -18 . In addition, some studies have shown that available resources and acceptance of a change by patients and colleagues are relevant factors 11,19,20 . Therefore, quality improvement needs to take into account not only the clinical behaviour of individual physicians but also the system within which they work. Several of the problems in health care can be attributed to problems that arise at the interface between primary and secondary care. A specialis t has a major influence on prescriptions of drugs in primary care 21 . In addition, co-operation is scarce and the professions are providing fragmented care 22 . Therefore the setting in which the behavioural change should occur can hamper this process. Legislation and lack of resources are other determinants at the organisational level that influence the behavioural change. For instance, lack of time was felt by GPs as a major influence in every part of practice, as it minimises treatment options being discussed or patients being examined properly 23 . Barriers at the individual physician level can be negative attitudes and views towards guideline recommendations or legislation. These vary from feelings of being tired or stressed to the amount of self-efficacy or competence a physician experiences to perform a certain task 23 . Moreover, motivation to change should be present for the behavioural change to occur 24 . The physician may also need certain skills to enable actual change. Finally, the specialisation is relevant. Specialists, for example, may perceive guidelines developed without their input to contain insufficient expertis e 3 . It will be unlikely for specialists to use such a guideline, whereas for GPs such a guideline might be a useful aid in deciding which therapy to choose 25 . Patients’ demand for treatment that is not recommended, is reported to be a barrier for non-adherence to guidelines 26 . The physicians’ intentions to avoid conflict with their patients and to respect the patients’ views are factors that may affect their decisions 23 . Lack of patient compliance is mentioned as a barrier for adherence to treatment guidelines. Optimal care can only be reached if the patient is willing to cooperate. The complexity of some diseases is another factor that can hinder change. In the case of chronic heart failure, for example, the diagnosis of heart failure is difficult to make in general practice, and the doctor may not provide appropriate treatment due to uncertainty about the diagnosis 27 . Strategies for implementing guidelines Systematic development of interventions and tailoring the strategy and the content to specific features of a target group and setting seems necessary for effective 3


improvement of the quality of patient care 28 . Many different implementation strategies have been developed to change clinical practice and implement guidelines: professional oriented strategies, patient related strategies, financial incentives, organisational strategies and regulatory interventions (Table 1) 20 . Table 1: Overview of the different implementation strategies Strategies Regulatory strategies Financial incentives Patient related strategies Organisational strategies Professional oriented strategies

Approaches Accreditation, licenses, medical responsibility Fee-for-service, incentives, penalties Patient charges, patient-mediated interventions, patient participation & empowerment Structural changes in facilities and resources, multidisciplinary teams, changes in professional roles Educational meetings, academic detailing, feedback, reminders

None of these strategies is superior for all changes in all settings. Combination of strategies seems to be a more effective approach 19 , as obstacles to change may occur within the physician setting, the patient population or the organisation. Regulatory and financial strategies are usually conducted on a national level. The generalisability of studies looking at the effect of these strategies is limited. These strategies may be effective in one setting but not in another. Financial incentives seem to affect physicians’ behaviour, but only a few adequate studies have been conducted 29 . Patient related strategies form another tool in quality improvement. They can enhance patient involvement and improve patient outcomes. Patient mediated interventions seem to have variable effectiveness 17 . A study in the Netherlands examining the effect of feedback of patients’ evaluations of care found no effect. Although the GPs reported to have made changes in their performance, patients’ evaluations of care did not change 30 . A qualitative study examining the impact of patient charges on GPs prescribing behaviour reported that patient charges did not have much influence on prescribing. The GPs were not confronted with patients complaining about out-of-pocket costs or drugs with out-of-pocket costs were not the GPs’ drugs of choice 31 . In diabetes management, the addition of patientoriented interventions has shown to be effective, especially through patient education or facilitating adherence to treatment 32 . Organisational intervention strategies often focus on improving collaboration between teams or changing roles to attain more efficient patient care. There is some evidence on the effect of organisational strategies 6 . Interventions aimed at changing roles and responsibility, such as assigning nurses with medical tasks, have shown mixed results 20 . Organisational interventions targeting regular recall 4

Chapter 1

and review of patients (central computerised systems or nurses who regularly contact the patient) have shown to improve diabetes management 32 . Collaboration between health professionals seems one of the important factors why some changes are effective in health care; however the evidence as yet is too heterogeneous to come to final conclusions 20 . Most research has been done on the effect of professional oriented strategies. The effect of distribution of educational materials seems to be limited but as part of a more comprehensive approach it may have more positive outcomes 6 . Interactive dissemination strategies seem more successful, particularly when the participants are actively involved in the teaching process. Combining distribution of educational material with small group education and active participation proved to be effective for improving prescribing behaviour 33 . Another promising approach is the provision of educational outreach visits, in particular when the aim is to improve prescribing 17,34. Studies demonstrating the effect of feedback have shown mixed results. Concurrent feedback and feedback in combination with reminders or education seem more effective then feedback alone 5,6 . A review aimed at interventions to improve prescribing found that feedback which included specific recommendations was more likely to change behaviour than general feedback 18 . Comparison of one’s own practice with that of immediate colleagues may provide a powerful stimulant for changing behaviour 35 . Behavioural theories suggest that performance is influenced by external stimuli such as feedback and reinforcements 20 . Reminders seems to be one of the most effective single strategies 6 . Implementing treatment guidelines in primary care in the Netherlands For GPs in the Netherlands it is common to discuss the management of patients and drug prescribing in peer review groups. These are small groups of physicians or interdisciplinary groups with other health care professionals aimed at assessing and improving the quality of patient care 36 . They discuss treatment of diseases and make agreements on pharmacotherapy, and are known to use the NHGguidelines 37 . The first peer review groups exist since the 1970s but they have been installed nation-wide since 1991. They are led by the doctors and pharmacists (peers) themselves 38 . Education in terms of sharing knowledge and clinical experience can be successful by discussing in a small group the way in which colleagues approach common problems 39 . Group approaches appear to be a useful and cost effective approach to improve evidence based prescribing 40 . Moreover, social influence theories suggest that it is important to meet the social norms in a group one identifies with. The few controlled studies that have been carried out in this area show some promising results. Veninga et al. found that an educational program in peer review groups improved prescribing behaviour for asthma 41 . Effective meetings attempt not to 5


deviate too much from the current prescribing practice and meetings are in particular successful when the changes concern medication that should be stopped 37 . Changes in chronic treatment are more difficult to achieve by peer review than changes in acute treatment 37,42. Additional activities might be needed, such as providing individual patient specific feedback and reminders 37,43 . The use of feedback data and use of a formulary were two other characteristics that may enhance behavioural change. Feedback on actual patient cases appears to work better than theoretical lectures. Use of a formulary might be seen as an intention to rationalise prescribing 36 . Some characteristics of peer review groups may affect the success of an educational program 36 . The intention of the group, i.e. whether the groups were merely changing information or actually making agreements, influenced the success of the intervention. Large groups may be less effective due to not well-structured meetings 41 . The amount of experience with this kind of ‘group learning’ is probably related to the effect of peer review groups meetings. Dutch GPs, who are used to having regular meetings and discussing pharmacotherapy, improved more using a peer review program than their Norwegian or Swedish colleagues 42 . Educational program to implement joint guidelines in primary care in this study As said before, a national program has started in 2000 to improve the consistency of treatment between primary and secondary care. In Groningen this has resulted in joint treatment guidelines for sixteen diseases developed by local multidisciplinary committees consisting of GPs, specialists, community and hospital pharmacists. An educational program was developed to implement these joint treatment guidelines in primary care in the Groningen region. The program aims to be self-supporting within the context of the existing infrastructure of peer review groups of GPs and pharmacists in the Netherlands. One of the regular meetings of the peer review groups was chosen as the setting to perform the educational implementation. The educational program incorporates several elements described in the previous paragraphs to make it successful. The educational program starts with an update of knowledge by discussing the recommendations in the joint treatment guideline. The idea is to get the physicians acquainted with the evidence-based guideline recommendations. The main part of the program focuses on discussing the treatment of actual patient cases. Discrepancies between current practice and prescribing recommendations in the joint guideline are examined and discussed. Each GP screens five of his own patients regarding their treatment. These patients are presented and discussed in the peer review group offering the opportunity to exchange information or getting advice from peers. The last part of the program deals with the barriers to change prescribing behaviour and possible solutions to 6

Chapter 1

overcome these barriers. Each GP mentioned what the reason was for nonadherence if applicable. All barriers are written down and possible solutions are discussed in the peer review group. Here, the rationale is to improve the awareness of barriers and to learn skills in overcoming barriers. A GP or pharmacist leads the program ensuring active involvement from participants. A local team of the Dutch Institute for Rational Drug Use (DGV) developed two educational packages for the peer review groups. This institute has consultants who support peer review groups in every region with their meetings, co-ordinate projects, provide them with educational material, and teach groups how to use prescribing data for feedback 44 . One package aimed to improve the treatment of hypertension in diabetes mellitus type 2 patients, and the other to improve the treatment of chronic heart failure. These chronic diseases have been chosen because they are common both in primary and secondary care. Although the GP is usually the first who is confronted with the patient, these patients are often referred to a specialist for complications or advice on treatment. Furthermore, there is room for improvement in treatment of both diseases 45,46 . For blood pressure control in patients with diabetes stringent target levels are being recommended in treatment guidelines, since this significantly reduces the risk of developing macrovascular and microvascular diseases. However, suboptimal management in both diagnosis and treatment of hypertension in type 2 diabetes patients has been shown 45 . Despite several landmark studies that showed that appropriate treatment of chronic heart failure can improve morbidity and mortality, management in general practice is still not optimal. Persisting major problems are, among others, underuse and underdosing of angiotensin-converting enzyme (ACE) inhibitors 46-48 . Aims and Objectives Research aims

This thesis focuses on three issues regarding implementing joint treatment guidelines for primary and specialist care. The first issue deals with the attitudes and barriers physicians experience with guidelines in general, and in particular with joint treatment guidelines. The question will be answered as to what type of barriers GPs and specialists perceive with joint treatment guidelines. Insight into these views is needed to tailor an educational program to the wishes of the target group, the physicians. The second issue concentrates on the various determinants that influence prescribing quality. The gap between recommendations and actual prescribing is taken into account regarding the management of heart failure and of hypertension in diabetes mellitus type 2 patients. The relationship between perceived barriers and actual prescribing behaviour is studied. Furthermore, the impact of

7


determinants on different levels (organisational, physician or patient level) on quality of treatment is examined. The third and last issue considers the evaluation of the educational program for implementing joint treatment guidelines in primary care, focussing on the effect on the management of these two chronic diseases . In addition, a process evaluation is conducted to be able to explain why the program was effective or not in changing practice. Outline of thesis

Chapter 2 describes the results of a focus group study among 27 specialists to identify their views on the newly developed joint treatment guidelines. The focus group method was chosen to identify all factors that are relevant in a specific setting or context. The aim of this study was to explore the factors that may limit or facilitate the use of joint treatment guidelines for primary and secondary care as perceived by Dutch specialists. In Chapter 3 the family physicians’ views on joint treatment guidelines for primary and secondary care are addressed in addition to the specialists’ views. A survey was conducted to quantify the extent to which both hospital specialists and general practitioners are motivated to use the newly developed joint guidelines. This study examines three questions, i.e. which type of guidelines are used by both groups of clinicians, what is their support for using joint treatment guidelines, and what are the perceived barriers and facilitators for using a specific joint treatment guideline. A comparison is made between both groups of clinicians to determine whether an implementation program should be tailored for each of the groups separately. Chapter 4 focuses more in detail on the barriers to the joint treatment guideline of chronic heart failure. Barriers are measured by means of a questionnaire including literature -based barriers and self-reported barriers. Little is known about the relevance of these barriers for actual management of chronic heart failure in general practice. In this chapter, we investigate to what extent the number and type of barriers perceived is related to the prescribing behaviour of GPs. In Chapter 5 and 6 the prescribing behaviour is evaluated of GPs who participate in the educational intervention to implement joint treatment guidelines. The extent to which prescribing at baseline is in accordance with guideline recommendations is assessed. In Chapter 5, we identify the influence of organisational, physician and patient characteristics on the quality of chronic heart failure treatment in primary care. Chapter 6 describes the quality of hypertension management in diabetes mellitus type 2 in relation to organisational, physician, and patient factors. The effect of the educational intervention on adherence to joint treatment guidelines in primary care is analysed in Chapter 7. The effects of both educational programs for the treatment of hypertension in diabetes mellitus patients and for the treatment of heart failure are evaluated. 8

Chapter 1

The influence of some physician and patient characteristics is included in the analysis . In addition, the attending physicians evaluated the program itself. The thesis ends in Chapter 8 with a discussion of the major findings and conclusions regarding factors that influence the adherence to these joint treatment guidelines and the impact of the educational program. Implications for the effective implementation of joint guidelines and further approaches to improve joint care between primary and secondary care are discussed. References 1

Thorsen T, Makela M. Changing professional practice. Theory and practice of clinical guidelines implementation. Copenhagen: DSI: Danish Institute for Health Services Research and Development, 1999. 2 Bergman DA. Evidence-based guidelines and critical pathways for quality improvement. Pediatrics 1999; 103: 225-32. 3 Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Potential benefits, limitations, and harms of clinical guidelines. BMJ 1999; 318: 527-30. 4 Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993; 342: 1317-22. 5 Weingarten S. Translating practice guidelines into patient care : guidelines at the bedside. Chest 2000;118: 4S-7S. 6 Grol R,.Grimshaw J. From best evidence to best practice: effective implementation of change in patients' care. Lancet 2003; 362: 1225-30. 7 Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MD, Abboud P-AC et al. Why don't physicians follow clinical practice guidelines? JAMA 1999; 282: 1458-65. 8 Kamps GB, Meyboom-de Jong B. Comparison of regional formularies for general practitioners (in Dutch). Ned.Tijdschr.Geneeskd 1997; 141:1002-7. 9 Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: the AGREE project. Qual Saf Health Care 2003; 12: 18-23. 10 Spies T. H, Mokkink H. Toetsen aan standaarden. Het medisch handelen van huisartsen in de praktijk getoetst. 1999. Nijmegen, Werkgroep Onderzoek Kwaliteit (WOK). 11 Hayward RSA, Guyatt GH, Moore KA, McKibbon KA, Carter AO. Canadian physicians' attitudes about and preferences regarding clinical practice guidelines. CMAJ 1997; 156: 1715-23. 12 Katz DA. Barriers between guidelines and improved patient care: an analysis of AHCPR's unstable angina clinical practice guideline. Agency for health care policy and research. Health Services Research 1999; 34: 377-89.

9


13 Van Everdingen JJE, Mokkink H, Klazinga NS, Grol R, Koekenbier GJS. De bekendheid en verspreiding van CBO-richtlijnen onder medisch specialisten. Tijdschr Gezondheidswetenschappen 2003; 8: 468-71. 14 Proeftuin Farmaceutische Zorg. The Groningen transmural guidelines ("Op weg naar het Groninger transmuraal formularium"). Groningen: 2000. 15 Garvey G, Jappy B, Stewart D, Williams A, Duffus PR, Maitland JM et al. Grampian Health Board's joint drug formulary. BMJ 1990; 301: 851-2. 16 Cranney M, Warren E, Barton S, Gardner K, Walley T. Why do GPs not implement evidence-based guidelines? A descriptive study. Fam Pract 2001; 18: 359-63. 17 Bero LA, Grilli R, Grimshaw J, Harvey E, Oxman AD, Thomson MA. Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. BMJ 1998; 317: 465-8. 18 NHS. Getting evidence into practice. Effective Health Care 5(1), 1-16. 1999. 19 Wensing M, van der WT, Grol R. Implementing guidelines and innovations in general practice: which interventions are effective? Br J Gen Pract 1998; 48: 991-7. 20 Grol R, Wensing M. Implementatie. Effectieve verandering in de patiëntenzorg. Maarssen: Elsevier, 2001. 21 Bijl D, Van Sonderen E, Haaijer-Ruskamp FM. Prescription changes and drug costs at the interface between primary and specialist care. Eur J Clin Pharmacol 1998; 54: 3336. 22 Kvamme OJ, Olesen F, Samuelsson M. Improving the interface between primary and secondary care: a statement from the European working party on quality in family practice (EQuiP). Qual Health Care 2001; 10: 33-9. 23 Tomlin Z, Humphrey C, Rogers S. General practitioners' perceptions of effective health care. BMJ 1999; 318: 1532-5. 24 Grol R. Implementing guidelines in general practice. Qual Health Care 1992; 1:184-91. 25 Edep ME, Shah NB, Tateo IM, Massie BM. Differences between primary care physicians and cardiologists on management of congestive heart failure: Relation to practice guidelines. J Am College Cardiol 1997; 30: 518-26. 26 Schers H, Wensing M, Huijsmans Z, van Tulder M, Grol R. Implementation barriers for general practice guidelines on low back pain a qualitative study. Spine 2001; 26: E348-E353. 27 Khunti K, Baker R, Grimshaw G. Diagnosis of patients with chronic heart failure in primary care: usefulness of history, examination, and investigations. Br J Gen Pract 2000; 50: 50-4. 28 Van Bokhoven MA, Kok G, Van der Weijden. Designing a quality improvement intervention: a systematic approach. Qual Saf Health Care 2003; 12: 215-20. 29 Gosden T, Forland F, Kristiansen IS, Sutton M, Leese B, Giuffrida A, et al. Capitation, salary, fee-for-service and mixed systems of payment: effects on the behaviour of primary care physicians. Cochrane Database Syst Rev 2000; CD002215.

10

Chapter 1

30 Vingerhoets E, Wensing M, Grol R. Feedback of patients' evaluations of general practice care: a randomised trial. Qual Health Care 2001; 10: 224-8. 31 Kasje WN, Timmer JW, Boendermaker PM, Haaijer-Ruskamp FM. Dutch GPs' perceptions: the influence of out-of-pocket costs on prescribing. Soc Sci Med 2002; 55: 1571-8. 32 Renders CM, Valk GD, Franse LV, Schellevis FG, Van Eijk JT, Van der Wal G. Longterm effectiveness of a quality improvement program for patients with type 2 diabetes in general practice. Diabetes Care 2001; 24: 1365-70. 33 Soumerai SB, McLaughlin TJ, Avorn J. Improving drug prescribing in primary care: a critical analysis of the experimental literature. Milbank Q 1989; 67: 268-317. 34 Grimshaw JM, Shirran L, Thomas R, Mowatt G, Fraser C, Bero L et al. Changing provider behavior: an overview of systematic reviews of interventions. Med Care 2001; 39: II2-45. 35 Johnston G, Crombie IK, Davies HT, Alder EM, Millard A. Reviewing audit: barriers and facilitating factors for effective clinical audit. Qual Health Care 2000; 9: 23-36. 36 Van Eijk, M. E. Effects of outreach strategies in quality of pharmacotherapy. 2001. University of Utrecht. 37 De Vries, C. S. Collaboration in health care: The tango to drug safety. 1998. University of Groningen. 38 Beyer M, Gerlach FM, Flies U, Grol R, Krol Z, Munck A et al. The development of quality circles/peer review groups as a method of quality improvement in Europe: Results of a survey in 26 European countries. Fam Pract 2003; 20: 443-51. 39 Pereles L, Lockyer J, Fidler H. Permanent small groups: group dynamics, learning, and change. J Contin Educ Health Prof 2002; 22: 205-13. 40 Van Eijk ME, Avorn J, Porsius AJ, de Boer A. Reducing prescribing of highly anticholinergic antidepressants for elderly people: randomised trial of group versus individual academic detailing. BMJ 2001; 322: 654-7. 41 Veninga CCM, Denig P, Zwaagstra R, Haaijer-Ruskamp FM. Improving drug treatment in general practice. J Clin Epidemiol 2000; 53: 762-72. 42 Veninga, CCM. Improving prescribing in general practice. 2000. University of Groningen. 43 Smeele IJ, Grol RP, van Schayck CP, van den Bosch WJ, van den Hoogen HJ, Muris JW. Can small group education and peer review improve care for patients with asthma/chronic obstructive pulmonary disease? Qual Health Care 1999; 8: 92-8. 44 De Groot J, Cambach W. Peer review groups; more than noncommittal (De vrijblijvendheid voorbij. Farmacotherapiegroepen kunnen beter functioneren). Medisch Contact 2003; 38: 102-104. 45 Berlowitz DR, Ash AS, Hickey EC, Glickman M, Friedman R, Kader B. Hypertension management in patients with diabetes: the need for more aggressive therapy. Diabetes Care 2003; 26: 355-9.

11


46 Luzier AB, Ditusa L. Underutilization of ACE inhibitors in heart failure. Pharmacotherapy 1999; 19: 1296-307. 47 Houghton AR, Cowley AJ. Why are angiotensin converting enzyme inhibitors underutilised in the treatment of heart failure by general practitioners? Int J Cardiol 1997; 59: 7-10. 48 Pont LG, Sturkenboom MC, Van Gilst WH, Denig P, Haaijer-Ruskamp FM. Trends in prescribing for heart failure in Dutch primary care from 1996 to 2000. Pharmacoepidemiol Drug Saf 2003; 12: 327-34.

12

Chapter 1

Chapter 2 Specialists’ expectations regarding joint treatment guidelines for primary and secondary care W.N. Kasje, P. Denig, F.M. Haaijer-Ruskamp Objective: To identify factors that may hinder or facilitate specialists’ use of joint treatment guidelines for primary and secondary care. Design: Qualitative study using focus group discussions based on a topic guide with openended questions. Main outcome measures: Themes identified by two researchers that specify the specialists’ views on the use and implementation of treatment guidelines in general, and transmural guidelines in particular. Setting: Departments of Cardiology and Internal Medicine in three Dutch hospitals. Study participants: Ten general internists, 11 cardiologists, and six gastroenterologists participating in seven group discussions. Results: Specialists did not perceive the treatment guidelines as useful for their own field of expertise, but expected that joint guidelines might improve integration between primary and secondary care. Furthermore, the guidelines could be useful for areas outside their expertise, for specialists in training, and for general practitioners. Concerns were expressed regarding their content and development process. In addition, specialists feared negative consequences, such as loss of autonomy, extra administrative workload, and organizational and financial barriers such as loss of industry-sponsored research and conferences. Conclusion: The specialists are not very motivated to use the guidelines themselves. This is a major obstacle that should be addressed in an implementation programme. Furthermore, negative outcomes at organisational and financial level must be minimised or compensated for. A joint implementation programme seems worthwhile, making use of the advantage seen by specialists in making agreements with general practitioners.

International Journal for Quality in Health Care, 2002. Vol. 14, 6: 509-518

Introduction Chronic patients often need care from both sides of the primary and secondary interface. Currently, there is little coherence across these sectors regarding treatment guidelines and drug selection 1 . Lack of consistency and cooperation between primary and secondary care can lead to inefficient care and places patients at risk of unnecessary investigations and polypharmacy 2 . Conflicting information or seemingly inconsistent care reduces the patient’s confidence, and may result in non-compliance 3 . The need for improving the integration of care provided by different physicians has recently been stressed by the European Working Party on Quality in Family Practice 2 . One of the recommended actions was that general practitioners and specialists should establish local clinical guidelines together. In the Dutch health care system, this is certainly relevant since it is a gatekeeping system. Patients need a referral from their general practitioner to have access to specialist or hospital care. After discharge, most patients are treated again by their general practitioner. Patients also need a referral for outpatient clinics, where the specialist can decide to treat the patient on an outpatient basis or refer the patient back to the general practitioner for further treatment 4 . This implies that the responsibility for the treatment of a chronic patient may alternate more than once between the general practitioner and a specialist. In the year 2000, several programmes have been set up in The Netherlands to improve the quality of transmural therapeutic care. In other countries, such care has also been called integrated care, shared care, joint care or seamless care 5 . The aim was to improve both quality and efficiency by bringing the therapeutic care provided by general practitioners and hospital specialists in line with each other on a regional level. The approach chosen in several regions was to develop treatment guidelines to be used by all physicians. At the time of this study, 16 guidelines for transmural care were being developed in the province of Groningen in the north of The Netherlands. Local committees of specialists, general practitioners, and pharmacists were involved in the development of these guidelines. They used the available evidence as well as existing national guidelines and local formularies for either primary or secondary care to establish a uniform treatment policy for all patients with specific diseases. For all relevant indications and subpopulations, drugs of first-choice were selected using criteria of efficacy, safety, userfriendliness, and applicability. The resulting transmural treatment guidelines are unique in combining recommendations for general practitioners as well as specialists including the allocation of some treatments between primary and secondary care. To stimulate the adoption and use of the guidelines an implementation programme is needed, because simple distribution usually does not change clinical practice 6 . 14

Chapter 2

There are many possible barriers and facilitators for adopting clinical guidelines 79 , which can be found on different levels (Table 1) 8,9 . Identification of such factors is essential for choosing the best fitting implementation programme. Most studies conducted previously were surveys using close-ended questions, which limits the barriers observed to those selected by the researchers 9 . Furthermore, most studies examined only one or two types of barriers in one setting. The majority of studies have looked at barriers seen in family or general practice, and studies focusing on specialists’ views on treatment guidelines are scarce 8,9 . In The Netherlands one study looked at internists’ perceived barriers to the implementation of diabetes guidelines in hospitals 10 . The most important barriers anticipated were organizational and financial barriers. One study identified barriers for improving transmural pharmacotherapy as perceived by hospital pharmacists and clinical pharmacologists 1 . These health care professionals also considered organizational and financial problems as the most important barriers. No studies could be found on factors related to physician acceptance, or adherence to guidelines for integrated or transmural care. Table 1: Barriers to the use of clinical practice guidelines Content of guideline Recommendations are not based on relevant and reliable scientific evidence Recommendations are not concrete and precise Recommendations are not consistent with current beliefs Development process Lack of feeling of ownership of guideline Lack of authority of the organization or people developing the guideline Lack of trust in people involved in developing guideline Distrust of the objectives underlying the guideline Target population of physicians Negative attitudes towards guidelines in general, such as fear of losing autonomy, belief that they are not applicable to individual patients or that they are too rigid to apply Little or no motivation for using guideline, such as belief they will not improve outcomes, that one can not perform accordingly, and satisfaction with current behavior Organization and setting Lack of time or resources to implement and follow all recommendations Lack of (financial) incentives Negative attitudes in professional environment towards using guidelines Recommendations conflict with other agreements or guidelines Recommendations conflict with patients’ wishes

In this study, our aim was to explore the factors that may limit or facilitate the use of joint treatment guidelines for primary and secondary care as perceived by Dutch specialists in order to develop a suitable implementation programme. Questions 15

Specialists’expectations

addressed were: What barriers and facilitators were seen for using treatment guidelines in general, and transmural guidelines in particular? Were there barriers or facilitators that were specific for the type of hospital, for the medical speciality or for one treatment guideline? Methods We chose a qualitative research method enabling identification of all factors that were relevant in a specific setting or context. Focus group discussions were held with several groups of specialists at different hospitals, and discussing different disease topics for which guidelines for transmural care were being developed. We chose three transmural guidelines as cases for this study, i.e. for the treatment of hypertension, heart failure, and gastric diseases 11 . These guidelines affect the practice of a substantial number of physicians in primary and secondary care. They were not yet published at the time of data collection, but all specialists had been informed through news bulletins about their development and also about the goals of the programme for transmural pharmacotherapy in their region. From the hospitals involved in our study, four general internists, four cardiologists and two gastroenterologists were members of the committees responsible for developing the guidelines. Study population

Only specialists commonly dealing with one or more of the selected topics were included, i.e. general internists, cardiologists, and gastroenterologists. Three of the five hospitals in the province of Groningen were included. These hospitals were selected for their difference in organizational structure. One was a large university hospital where specialists were employed by the hospital. The second was a large teaching hospital where specialists work in private group practices. The third was one of the three smaller non-teaching hospitals where specialists also work in private group practices. Since not all specialities were offered in these smaller hospitals, we selected the hospital where at least two of the three specialities were present for our study. We sent introduction letters to all general internists, cardiologists, and gastroenterologists in the selected hospitals. The aim was to conduct separate discussions for each hospital and each medical speciality with groups of four to eight people, but for some groups the maximum number possible was less than four. In the non-teaching hospital, where only two cardiologists and no gastroenterologists worked, one combined focus group was planned. One member from each group was personally asked to set the best time and place for the discussion, and also to encourage specialists with presumably different opinions to participate. For six focus groups, it was possible to find a time and place where five or six

16

Chapter 2

specialists could attend. For one group, the maximum number possible of three specialists was invited to the meeting. Data collection

A topic guide with open-ended questions was used to steer the discussion (see Appendix). We tested this topic guide with a general internist and a cardiologist. The first questions focussed on current use and advantages or disadvantages of guidelines in general. Next, the transmural care aspect of the new guidelines was discussed. The participants were asked to think about possible pros and cons of having a transmural guideline for a specific subject. General internists discussed possible guidelines for hypertension and gastric diseases, gastroenterologists talked about gastric diseases, and cardiologists discussed the subjects heart failure and hypertension. Each discussion lasted approximately one hour. The moderator was a medical doctor who was not part of the study population. On two occasions, one of the authors (P.D.) moderated the discussion. All the discussions were held in meeting rooms in the specialists’ own hospitals during lunchtime or after hours from April to June 2000. Analysis

All discussions were recorded on tape and transcribed verbatim. We conducted a content analysis based on an inductive approach using the constant comparison method 12 . Firstly, one researcher (W.N.K.) identified the main themes running through the data that were related to our research questions. Seven themes were identified after the analysis of the first focus group. A second researcher independently analysed the same data to check the consistency of these themes. Subsequently, both researchers analysed all transcripts independently, manually dividing the texts in parts referring to similar notions, and classifying these segments to one of the themes. Discrepancies were discussed until agreement was reached. The texts from all seven focus groups could be classified according to the identified themes. Separate reports were made for each focus group summarising the statements within each theme. These reports were sent to the participants for checking. Using the reports we searched for factors that were specific for a hospital organization, medical speciality or guideline. Firstly, we compared statements mentioned from the focus groups in the university hospital with those from the non-university teaching hospital and the non-teaching hospital. Secondly, a similar comparison was made looking at statements from general internists, cardiologists, and gastroenterologists. Finally, the reports were checked for statements that were related explicitly to one of the treatment guidelines.

17


Results Of the 35 specialists invited to a focus group discussion, 27 attended, resulting in five meetings with four or five participants, one meeting with three, and one with two participants. The participants were 10 general internists, 11 cardiologists, and six gastroenterologists. All participants were males, and their mean age was 46 years (range 31-62 years). The findings are presented under the seven main themes that emerged from the analysis. These themes are closely related to our research questions, and focus on aspects that may hinder or facilitate the implementation of joint treatment guidelines. 1) Attitudes towards treatment guidelines in general (Table 2)

Most specialists indicated that they do not need treatment guidelines. They believed that most treatment guidelines recommend commonly prescribed drugs with which they are already quite familiar. They were used to working with their personal set of drugs, were guided by international scientific literature, and sometimes had local agreements regarding the treatment of choice within their department or group practice. Most specialists believed that general practitioners need guidelines more than they do, because general practitioners are generalists who have to deal with all diseases. Treatment guidelines were also seen as useful for specialists in training, although some specialists at the university hospital feared that guidelines might lead to ‘prescribing without thinking’. Several specialists expressed that guidelines could be useful for diseases outside their expertise. Guidelines always have their limitations in the specialists’ opinion. Not every individual can be treated according to guidelines, especially in a hospital setting. Many patients have already been treated with the standard treatment by their general practitioner, and have come to the specialist because they want or need something else. Some specialists mentioned that strictly adhering to recommended doses and duration is also not always possible for individual patients. Guidelines limit the specialists in their freedom of choice. The specialists saw the loss of their autonomy as an important disadvantage of treatment guidelines. They believed that guidelines are often out of date, and new drugs are seldom included. By definition, there is always less evidence for new drugs, and evidence from equivalence studies is not as convincing as evidence from placebocontrolled studies. Some specialists described themselves as keen to prescribe new medications. Many specialists said they needed the freedom to try other treatments. 2) Positive beliefs about the new guidelines for transmural care (Table 3)

Many specialists expressed that a more harmonized prescribing policy could emerge with transmural guidelines. Such guidelines can show what are the drugs of first choice, which is helpful for physicians not specialized in those areas. 18

Chapter 2

Table 2: Examples of attitudes towards guidelines in general “I never felt the need to consult guidelines. It doesn’t have any additional value. We have our own list of drugs that we use.” “We look consciously at the literature and statements of the American Heart Association…” “Specialists, like you and me, know everything about cardiovascular drugs, but a general practitioner has to know something about every disease and he doesn’t know all. For them a guideline is very useful.” “I think that specialists in training will use such a guideline more often than people who work here for a longer time. We know the drugs that are available for this department, we don’t need a guideline. But…for example for antibiotics, I think we fall back on guidelines.” “...that is because of our patient population. We have to do something else, they usually had the standard treatment. They also expect that.” “Especially in a university hospital, you want to get a feeling for a new drug, you want to try it to see how it works .. what your experience is with that drug. You will lose that aspect.” “..the danger we are afraid of is that we lose our autonomy. I just want to have the possibility to prescribe a third, fourth or fifth option. Not that I do that, but I find the idea that somebody else decides that I am not allowed to do so very disturbing”

A regional policy was considered useful when taking over patients from another physician. As one specialist put it: “When patients are referred to you by a general practitioner, it is an advantage if they have been treated with drugs you are familiar with and would consider as first line treatment yourself”. Another positive aspect attributed to a regional policy was that all physicians become familiar with the same drugs, which makes it easier to recognize and deal with possible adverse effects and interactions. A uniform policy could also make a better impression on patients. Several specialists saw it as an advantage that the transmural guidelines can be cost saving. A few medical speciality and disease-specific issues emerged when comparing the data from different focus groups. Cardiologists and general internists mentioned that reduction of the number of different drugs prescribed, especially me -too’s, could be an advantage of transmural guidelines. Gastroenterologists never mentioned this as a possible advantage. Regarding the guideline for gastric diseases, both gastroenterologists and general internists mentioned that it could help with rationalizing the use of proton-pump inhibitors. Such possible improvements in rational drug use were not mentioned for the other two treatment guidelines. 3) Negative beliefs about the new guidelines for transmural care (Table 3)

Many specialists feared that the new guidelines would be too restrictive. They feared that they would have to account for not following the guidelines. 19


Table 3: Examples of beliefs about new transmural treatment guidelines Positive beliefs “It would be nice if the northern region could have a consensus. Better cohesion among us, between physicians, between departments, and it makes a better impression on patients.” “If you can make agreements about prescribing not always proton pump inhibitors… that there is also room for H2-antagonists, than we are doing well in this region.” “When I get a patient from a general practitioner with a whole lot of drugs that I am not so familiar with, then I may not recognize all possible interaction problems. .. If some of these problems are excluded by these regional guidelines, it would be an improvement.” Negative beliefs “I foresee you have to fill in 80 forms to show that this patient needed that drug. Do I have to justify, personally… well, big brother is watching you. “You create that the industry will do less research. What can they do with a drug they won’t sell? That is going to be a problem.” “You give one drug, and thus one manufacturer, a monopoly position. I think you’ll become the toy of the industry. I don’t think that is good.” “We are not taking part in a committee. There is danger that we are not heard and the committee might force their own preferences through.” “You can bet on it. It will be used politically, that it is no longer a guideline, but that it tells you what you must prescribe” “..it is the intention of the government that health insurance companies will point out to the doctors that they have guidelines … that they should prescribe according to these guidelines.”

This idea of personal justification and the extra work needed to explain why they have to deviate from the guidelines were considered a significant problem. Some specialists believed that these new guidelines are superfluous, because many treatment guidelines already exist. According to most specialists, the aim of the new guidelines was mainly to reduce costs, which they saw as a negative aspect. They distrusted the involvement and intentions of the Ministry of Health and Health Insurance Companies. Most specialists did not feel involved, because their own department was not adequately represented in the committees developing the guidelines. Some felt that pharmacists were too much involved in the development of these new guidelines. Other specialists voiced their concerns about the influence of the pharmaceutical industry and the possibility of the development of a monopoly. They feared that the industries would try to influence the people developing the guidelines. Furthermore, some felt that the time set for developing the treatment guidelines (6 months) was too short. Another negative aspect seen by several specialists was that industries might lose interest in doing research in this region and will no longer sponsor courses and conferences when certain drugs are not included in the guidelines.

20

Chapter 2

4) Integration with primary care

Some specialists expressed that developing transmural guidelines has the advantage that there is more communication about drug treatments with general practitioners. Most specialists believed that guidelines for transmural care could be useful to bring primary and secondary care more in line with each other, although they als o believed that not much fine-tuning was needed. A few specialists reported they were sometimes confronted with a patient receiving an unfamiliar drug from a general practitioner. In The Netherlands, it is common practice that specialists explain their treatment or give advice in referral letters to the general practitioners. According to the specialists, the general practitioners usually follow their recommendations. Some specialists reported that occasionally a treatment intended for long-term use was not continued long enough in primary care. It seldom happened that a general practitioner or a pharmacist substituted a drug advised by a specialist. Several specialists said they may leave the specific drug choice to the general practitioner, giving advice to start treatment with, for instance, an angiotensin converting enzyme (ACE) inhibitor. In some cases, the general practitioner was regarded as the central person who can prevent undesirable combinations of drugs prescribed by different specialists to one patient. 5) Preconditions

A trustworthy representative from each group of specialists should be involved in the development of the guidelines. These specialists should be aware of representing their group, and not try to force their own preferences or those of certain pharmaceutical industries on others. Some specialists mentioned that there should be the possibility to react on the choices made in the guidelines. Others said that the choices should be well motivated, and this motivation should be clear to everyone. Furthermore, the guidelines have to be updated regularly: some say every 6 months, others think every 1 or 2 years is adequate. Guidelines should not be too restrictive and must include more than one drug per drug group according to many specialists. This allows them to choose from several options, which are seldom fully equivalent. In addition, this prevents one industry getting a monopoly. The specialists said that guidelines should guide and not dictate practice. It must be possible to deviate. There should be room for a specialist to try new drugs or one specific drug for an individual patient who can not be treated according to guideline recommendations. Some specialists indicated that it is essential that specialists at all hospitals in the region, including the university hospital, accept the guidelines and will prescribe the same drugs. 6) Organizational factors

Specialists at one hospital expressed concerns regarding the new guidelines referring back to negative experiences with their hospital formulary. Others

21


mentioned that these new guidelines might be in conflict with existing treatment recommendations within their department or with guidelines from professional organizations. Some specialists said that they used their freedom of choice in the outpatient clinic to work with drugs that they were not allowed to prescribe within the hospital. A few had concerns that drugs not listed in the guidelines will not be easily available in the future, because pharmacies may not keep them in stock. Specialists at both teaching hospitals said that the standard treatments usually recommended in guidelines were not sufficient in their setting and that they needed other drugs for their patient population. Specialists at the university hospital in part icular, focused on ways in which the guidelines could be used and misused when training residents. Specialists at the regional hospital said they tried to limit the number of different drugs they prescribed, because there were a lot of dispensing general practitioners in their region. For the same reason, they tried not to change their preferences too quickly. 7) Incentives and reinforcements

Specialists at the non-university hospitals mentioned the need for financial incentives. They felt they should get some reward for using the guidelines. As one specialist put it: “One way is to impose the guideline, the other way is to make it tempting”. Incentives could be, for instance, paying for conferences or for an extra assistant at their department. One specialist however, commented that he could not be bribed to use a guideline he did not support. Many specialists said that savings from using the guidelines should be shared with all people involved. Some specialists believed that feedback on performance might be useful for stimulating change. For instance, a specialist who always prescribes the most expensive drug, should receive some feedback on that. Others explicitly rejected the idea of being audited. Discussion This qualitative study revealed a large number of specialists’ attitudes and beliefs regarding treatment guidelines, some of which have not been identified in other studies. In particular, beliefs regarding joint guidelines for primary and secondary care were previously unknown. The specific guidelines were not yet available at the time of the study, limiting the possibility to discuss barriers and facilitators for specific recommendations. However, most specialists were aware of the goals of the programme for transmural pharmacotherapy and of the development of joint treatment guidelines in their region. Early identification of possible barriers and facilitators to the use of such guidelines may help to focus the implementation process. A possible weakness of this study is the small number of participants in some focus groups. Although more than 75% of the invited specialists participated in the 22

Chapter 2

discussions, there were two groups with less than four participants. In all groups, however, negative attitudes as well as positive attitudes were expressed, resulting in lively discussions between participants. Barriers could be identified at all four levels described in the literature. In Figure 1, the seven themes found are considered in relation to the different levels of barriers as shown in Table 1. With regard to the content of the guideline, only negative beliefs such as guidelines are too restrictive, were identified. Concerning preconditions for both the content and development of the guideline, the request for involvement in developing guidelines played an important role. The barriers identified were consistent with the literature 8-10,13,14 and will not be discussed extensively. At the level of the target population, positive and negative consequences for themselves were expressed as well as the advantage of integration with primary care (see Figure 1). Several of the concerns expressed towards guidelines in general, such as the fear of losing autonomy and the belief that guidelines are not applicable to all patients, have also been reported previously 8-10,13,14. Other barriers concerning the target population are rather new and will be discussed in more detail. Regarding using guidelines themselves in general, the specialists are fairly negative. This is in contrast to general practitioners in The Netherlands who usually see clinical guidelines as a useful tool 15-17 . It is possible that the specialists’ attitudes towards a specific treatment guideline will be more positive than towards guidelines in general 9 . It seems, however, that the specialists in our study did not endorse the frequently advocated belief that evidence-based guidelines will improve the quality of the care they provide to their patients 13 . There are two underlying grounds for this. Firstly, the feeling of having expertise on a specific subject appears to be an important barrier for accepting recommendations from others. For diseases outside their own field of expertise, some specialists were more willing to use guidelines. Secondly, several specialists believed that their patients could not or did not want to be treated with the standard treatments recommended in guidelines. The need for guidelines to be evidencebased seems to conflict with the need felt by some specialists that they have to experiment with drugs in situations for which evidence may be incomplete. In particular, specialists from teaching hospitals mentioned that guidelines were not suitable for many individual patients. Both patient characteristics and clinical setting may limit the generalisability of guideline recommendations 18 . One could expect that ‘problematic’ patients are more often referred to the teaching hospitals. Apparently, dealing more frequently with patients for whom the guideline recommendations may not be valid, can have a large impact on the specialists’ views on the utility of treatment guidelines in general. Although the specialists did not perceive a need for using the guidelines themselves, they did expect several benefits from a uniform regional treatment 23


policy. It has been suggested that one of the barriers for implementing transmural guidelines is the difference in expertise and focus between primary and secondary care 1 . It seems, however, that the specialists did not object to the idea of developing joint treatment guidelines, but they saw these guidelines mostly as useful tools for general practitioners. In addition, a more general advantage was seen by some specialists with regard to a possible reduction in the number of different drugs used and cost savings. These advantages seem to be related to the therapeutic area. Reduction of the number of drugs was mentioned as an advantage when discussing treatment of cardiovascular diseases, but not when discussing treatment of gastric diseases. This is not surprising given the fact that in The Netherlands there are currently 14 betablocking agents, 13 calcium antagonists, 10 ACE inhibitors, and 6 ACE-II-inhibitors on the market, whereas there are only 5 H2 -antagonists and 4 proton-pump inhibitors available. At the level of organization and setting, organizational barriers, preconditions, incentives and reinforcements were identified (see Figure 1). Barriers such as fear of increased work-load, fear of possible conflicts with existing agreements or guidelines, and conflicts with patients’ wishes were known from the literature 9,13,14,19,20 . This was not the case for the expected negative consequences on research and conference opportunities sponsored by the industry. This may in part be due to the fact that many surveys have been carried out among general practitioners, whose personal involvement in such research is less common. In addition, physicians may have been reluctant in the past to acknowledge the importance of sponsoring by pharmaceutical industries. In our study, the specialists emphasized that nowadays much high quality research and many conferences depend on such sponsoring. Financial incentives, which were identified previously as a possible relevant facilitator in The Netherlands 1,10 , were only mentioned by specialists working in private group practices who may receive a more direct benefit from such incentives. One of the barriers for implementing transmural treatment guidelines identified in a study among Dutch hospital pharmacists, i.e. different systems of drug reimbursement in primary and secondary care 1 , was not seen as a barrier by the specialists in our study. Apparently, the specialists were not aware or concerned by such reimbursement problems. Many of the concerns expressed are general barriers for using guidelines developed by others, and not specific for the newly developed guidelines for transmural care. Most barriers were not specific for the type of hospital, the medical speciality or the treatment subject. Implications

Our research was explorative and focused on identifying possible barriers and facilitators for specialists to use transmural treatment guidelines. 24

Chapter 2

Figure 1: Relationship between levels of known barriers to guideline implementation from literature and the seven themes found in this study. The numbers in the Figure correspond to the numbers of the seven themes in the results section.

3 Content of guideline 1) attitudes in general 2) positive beliefs about guidelines for transmural care 3) negative beliefs about guidelines for transmural care

3

Development process

5) preconditions

Target population of physicians 1, 2, 3

4) integration with primary care

6) organizational factors

Organization and setting

7) incentives and reinforcement

Further research is needed to assess the views of general practitioners regarding their use of such guidelines. Based on the results from our study, a number of recommendations can be given regarding the implementation of transmural guidelines (Table 4). The actions suggested tie in with the preconditions and possible incentives or reinforcements mentioned by the specialists themselves to stimulate the use of these guidelines. Regarding the content and development process, the strategies are somewhat limited once the guidelines have been developed. Focusing on the target population, a variety of actions is possible 21 . According to theories of behavior and behavioral change, doctors should have a positive attitude towards guidelines before they are willing to adopt them. Beliefs that the recommended practice will lead to improvements, i.e. positive outcome 25


expectancies, are important for this attitude 22 . Doctors must learn about and agree with the guidelines, see the need to change, and feel able to change 9,23,24 . The specialists’ concerns regarding the content of the guidelines should be considered in the perspective that they were not yet able to evaluate the actual guidelines. Inclusion of more than one drug per drug group and regular updates of the guidelines can remove some of the concerns expressed. To improve the involvement of specialists, trustworthy representatives should be chosen who confer with their colleagues. All physicians should have an opportunity to react on a draft of the guidelines. To counter the belief that the major aim of the developed guidelines is to reduce costs, the choices made in the guidelines should be clearly motivated using the evidence available. The guidelines should include explicit statements of its objectives and also give declarations of all possible conflicts of interest before and during guideline development. It is e xpected that the specialists will not be very motivated to learn about the new guidelines or to accept any changes suggested, because they are satisfied with their current practice 25,26 . Audit and feedback can counter this problem by giving information about the current treatment provided to patients visiting both specialists and general practitioners. In addition, feedback on a regional level regarding the numbers and costs of drugs prescribed every year could be of some use. Most specialists do not consider guidelines as innovative and do not perceive that they contain new information for them, which may negatively affect their own active use of the guidelines 27 . Given the finding that the specialists were more positive about guidelines outside their own field of expertise, one could start with implementing those guidelines. Exposure to the guidelines in the context of clinical practice may lead to a more positive attitude towards the use of such guidelines 9 . Using the guidelines in education and training could contribute to this exposure. To avoid misuse, this training should focus on teaching students about the motivations underlying the guidelines. Furthermore, specialists may support the active use of the guidelines in general practice. An implementation programme with joint meetings of specialists and general practitioners may be worthwhile. This focuses on an aspect of the guidelines that is considered new, and ma kes use of the advantage seen by specialists of making joint agreements with general practitioners. Finally, it is important to try to minimize or compensate for expected negative outcomes at organizational and financial level. For instance, motivated deviations from the guidelines should be possible without introducing an increase in administrative work. Non-recommended drugs should be supplied in specific cases. Savings from using the guidelines could be used to counter expected losses from industry-sponsored activities. It has been suggested before that supportive changes at economic and organizational levels are needed for successful implementation of transmural guidelines 1 . 26

Chapter 2

27

Table 4: Possible actions addressing identified barriers and facilitators for transmural guideline implementation Level Content of guideline

Barriers and facilitators identified a. Expecting the guideline to be too restrictive b. Expecting that the guideline will be outdated rapidly

Possible actions suggested a. Include more than one drug per drug group b. Update the guideline every year

Development process

a. Inadequate representation or involvement in developing the guideline

a1. Involve credible representatives who confer with their colleagues a2. Present guidelines as draft and give all doctors the opportunity to react b. Clearly state objectives and motivate choices made in the guidelines with evidence c. Declare all possible conflicts of interest before and during guideline development

b. Fearing that the major aim of the guideline is to reduce costs c. Being concerned with influence of other parties, such as pharmaceutical industries and health insurance companies


Target population of doctors

a. Not believing that patient care will improve in own field of expertise b. Expecting reduction of the number of drugs and saving of costs c. Willing to use guidelines outside own field of expertise d. Believing that guidelines could be useful for specialists in training, but also fearing their misuse e. Believing that guidelines are useful for general practitioners f. Expecting positive effects from making joint agreements with general practitioners g. Believing that not all patients can be treated with standard treatment h. Fearing limitations in personal freedom of prescribing

a. Give audit and feedback on suboptimal current practice b. Give feedback on regional level regarding number and costs of drugs c. Start implementation of guidelines outside own field of expertise d. Use guidelines in a constructive way in education and training e. Involve specialists to support implementation in general practice f. Organize joint implementation meetings with specialists and general practitioners g. Allow for motivated deviations from the guidelines h. No action possible that ties in with suggestions made by the specialists

28

Table 4 (continued): Possible actions addressing identified barriers and facilitators for transmural guideline implementation Level Organization and setting

Barriers and facilitators identified a. Expecting increased bureaucracy regarding nonadherent prescribing b. Expecting a limited availability of non-recommended drugs c. Expecting loss of industry-sponsored activities d. Expecting cost savings for insurance companies e. Expecting that recommendations conflict with what patients want f. Expecting that recommendations may conflict with existing policies

Possible actions suggested a. Limit administrative workload needed to deviate from guideline recommendations b. Guarantee fast supply of non-recommended drugs for specific cases c/d. Use savings from adherence to guidelines to compensate for financial losses e/f. No action possible that ties in with suggestions made by the specialists.

Chapter 2

References 1 2

3 4 5 6

7 8 9 10

11 12

13 14

15 16 17

29

Fijn R, Brouwers RBJ, de Jong-van den Berg LTW. Cross-sectional pharmacotherapeutic coherence in the Netherlands. Int Pharm Pract 1999; 7: 159-166 Kvamme OJ, Olesen F, Samuelsson M. Improving the interface between primary and secondary care: a statement from the European working party on quality in family practice (EQuiP). Qual Health Care 2001; 10: 33-39. Presont C, Cheater F, Baker R, Hearnshaw H. Left in limbo: Patients' views on care across the primary/secondary interface. Qual Health Care 1999; 8:16-21. Schrijvers AJP. Health and Health Care in the Netherlands. Utrecht: De Tijdstroom, 1997. Sprague KL, Jarry PD, Fish L. Insight in outpatient formulary management in a vertically integrated health care system. Formulary 1997; 32: 500-514. Bero LA, Grilli R, Grimshaw J, et al. Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. BMJ 1999; 317: 465-468. Grol RDJ, Thomas S, in 't Veld C, et al. Attributes of clinical guidelines that influence use of guidelines in general practice: observational study. BMJ 1998; 317: 858-861. NHS. Getting evidence into practice. Effective Health Care 1999; 5[1]: 1-16. Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice guidelines? JAMA 1999; 282(15): 1458-1465. Dijkstra RF, Braspenning JCC, Uiters E, Ballegooie Ev, Grol R. Perceived barriers to the implementation of diabetes guidelines in hospitals in The Netherlands. Neth J Med 2000; 56: 80-85. Proeftuin Farmaceutische Zorg. The transmural Groningen guidelines; first edition (in Dutch). Groningen: 2000. Dye JF, Schatz IM, Rosenberg, BA, et al. Constant comparison method: A kaleidoscope of data. The Qualitative Report. http://www.nova.edu/ssss/QR/QR34/dye.htmlaccessed 2000. Woolf SH, Grol R, Hutchinson A, et al. Potential benefits, limitations, and harms of clinical guidelines. BMJ 1999; 318: 527-530. Wilkinson EK, Bosanquet A, Salisbury C, Hasler J, Bosanquet N. Barriers and facilitators to the implementation of evidence-based medicine in general practice: a qualitative study. Eur J Gen Pract 1999; 5: 66-70. Veninga CCM, Denig P, Heyink JW, Haaijer-Ruskamp FM. General practitioners' views on the treatment of asthma. Huisarts Wet 1998; 41: 236-240. Grol R. Successes and failures in the implementation of evidence-based guidelines for clinical practice. Med Care 2001; 39(suppl.): 46-54. Hoogvliet G. Decubitis' guideline of the Dutch College of Family Practice; response from family practice. Ned Tijdschr Geneesk 2000; 144(14): 644-645. Specialists’expectations

18 Graham RP, James PA, Cowan TM. Are clinical practice guidelines valid for primary care? J Clin Epi 1999; 53: 949-954. 19 Van de Weijden T, Grol R, Schouten BJ, Knottnerus JA. Barriers to working according to cholesterol guidelines. Eur J Publ Health 1998; 8: 113-118. 20 Thorsen T, Makela M. Changing professional practice. Theory and practice of clinical guidelines implementation. DSI Rapport 99.05 ed. Copenhagen: DSI: Danish Institute for Health Services Research and Development, 1999. 21 Fijn R, Brouwers RBJ, Timmer JW, de Jong-Van den Berg LTW. Rational pharmacotherapy and clinical practice guidelines. Pharmaceutical treatment guidelines. Pharm World Sci 2000; 22(4): 152-158. 22 Kok G. Behavioral Theories. In: Damoiseaux V, Van der Molen HT, Kok G, editors. Health education and behavioral change (in Dutch). Assen: Van Gorcum, 1998. 23 Grol R. Implementing guidelines in general practice. Qual Health care 1992; 1: 184191. 24 Bashook PG, Parboosingh J. Continuing medical education: Recertification and the maintenance of competence. BMJ 1998; 316: 545-548. 25 Knowles M. The adult learner: a neglected species. 4 ed. Houston: Gulf Publishing, 1990. 26 De Vries H. Diffusion of interventions. In: Damoiseaux V, Van der Molen HT, Kok G, editors. Health education and behavioral change (in Dutch). Assen: Van Gorcum, 1998. 27 Rogers EM. The innovation-decision process. In Diffusion of innovations. New York: The Free Press, 1995.

30

Chapter 2

Topic guide for discussing hypertension guideline What is the current situation? Do you have guidelines? Are they treatment guidelines? What is your opinion of those guidelines? Do you use those guidelines? Are there other specific guidelines for the treatment of hypertension? What is your opinion of treatment guidelines in general? What do you think is good of treatment guidelines? What is not good? Can treatment guidelines give you support for prescribing medications for hypertension? Is the use of treatment guidelines different for outpatient care? Treatment guidelines are being developed in the region of Groningen intended for specialists and general practitioners. What do you think of these guidelines? What do you think is good regarding treatment guidelines for transmural care? What is not good? What do you think of a transmural guideline for treatment of hypertension? Which characteristics of such guidelines are relevant for your consideration of using them? What could be done in the organization or financially to encourage you to use the transmural guidelines? Who might influence your use of transmural guidelines?

31


32

Chapter 2

Chapter 3 Physicians’ views on joint treatment guidelines for primary and secondary care W.N. Kasje, P. Denig, P.A. de Graeff, and F.M. Haaijer-Ruskamp Objectives: Joint drug formularies and treatment guidelines have been developed to reduce problems arising at the interface between primary and secondary care. The aim is to compare the willingness of hospital specialists and general practitioners to use joint treatment guidelines, and to determine the most relevant barriers and facilitators. Design of study: A structured survey which consisted of questions about the use of guidelines and formularies in general, and possible barriers and facilitators for using a specific joint guideline. These specific guidelines concerned the treatment of hypertension, heart failure or diabetes mellitus. Setting and study participants: 197 general practitioners and 34 general internists and cardiologists from the North of the Netherlands. Results: Most hospital specialists relied for their prescribing on international guidelines and agreements within their own department, while general practitioners relied more on national and regional guidelines. General practitioners were more supportive than specialists of the initiative to develop joint treatment guidelines, although both groups had concerns regarding the development process. An important barrier for specialists was that they did not perceive a need for these guidelines. As enabling factors, physicians stated that these joint guidelines can lead to harmonisation between specialists and general practitioners, and that they can be useful as an educational tool. Conclusion: Specialists are less ready to adopt joint treatment guidelines than general practitioners, indicating the need for a different approach to implement such guidelines in the two sectors.

International Journal for Quality in Health Care, 2004. Vol.16, 3: 1-8

Introduction Clinical practice guidelines are intended to support health care professionals, but too many different guidelines may be confusing rather than guiding. Despite the application of the same scientific evidence, guidelines issued by different organisations or in various countries do not always give consistent recommendations.1-3 This can be a problem for the health care professional, who may become uncertain about which guideline to follow. It can also lead to confusion in patients who move between different levels of health care, in particular at the primary-secondary care interface.4 This is especially relevant in health care systems such as the Dutch where the general practitioner (GP) acts as a gatekeeper, so that patients can only visit a specialist after referral by their GP. In many cases, the specialist can give advice and send the patient back to the GP for follow-up care. To enhance seamless and efficient health care, a number of researchers have recommended the development of joint formularies or treatment guidelines for primary and secondary care.4,5 In the Netherlands, a programme was set up by the Ministry of Health, Well-being and Sports and supported by Health Insurance Funds to form joint treatment guidelines. Local committees of hospital specialists, GPs, and hospital and community pharmacists developed the guidelines.6 At the time of our study, 16 guidelines for shared care had been developed as part of a regional joint formulary in the province of Groningen.7 An implementation project was planned focussing on two issues, i.e. the treatment of chronic heart failure and the treatment of hypertension in diabetic patients. To develop an effective implementation strategy, it is important to know to what extent the target population opposes or supports the use of these guidelines.8,9 In general, the motivation for using guidelines is related to the quality and reliability of the guideline and its development process, and a variety of barriers and facilitators at the level of the professional and the working environment.10-12 Qualitative research among a small group of Dutch hospital specialists showed that potential barriers for using joint treatment guidelines can be found in all these domains.6 The imp ortance of the revealed barriers is not clear yet, nor is it known whether specialists and GPs have similar views and attitudes. There might be differences in attitude and culture that are important for implementing changes.13 The aim of this study is to assess the willingness of both hospital specialists and GPs to use joint treatment guidelines, and to determine the most relevant barriers and facilitators. A comparison will be made between both groups of physicians to determine whether an implementation programme should be tailored to each group separately. The questions addressed focus on the physicians’ current guideline use, their satisfaction with current practice, their support for the development of joint treatment guidelines in general, and perceived barriers and facilitators towards using one specific guideline. 34

Chapter 3

Methods Study population

We set out to administer a structured questionnaire to all physicians for whom the specific joint treatment guidelines were relevant. These were all 260 GPs, 36 general internists and 24 cardiologists working in Groningen, a province in the North of the Netherlands. The questionnaire was distributed in two waves. The first wave took place in the autumn of 2000 at a series of educational meetings held yearly for both hospital specialists and GPs in this region. One of the topics during these meetings was to inform the physicians about the transmural project in general, and present one specific guideline in particular. We distributed and collected our questionnaire during these meetings. Since not all physicians attended the meetings and therefore had not received the questionnaire, the questionnaire was sent or handed out in a second wave between December 2000 and April 2001 to each of the remaining 97 GPs and 19 specialists who did not attend the educational meetings. Questionnaire

The structured questionnaire consisted of a general and a guideline specific part. The general part included questions regarding background characteristics, current use of clinical treatment guidelines, followed by 3 statements regarding satisfaction with current practice and 3 statements regarding support for the project of developing joint guidelines. Regarding current use of guidelines, respondents could indicate how often they used specific guidelines, formularies or agreements. There are two sets of national guidelines in the Netherlands. For primary care, there are the NHG-guidelines developed by the Dutch College of General practitioners. For specialists, there are the CBO-guidelines developed by the Dutch Institute for Health Care Improvement. On a regional level, a drug formulary exists for GPs, and some regional specialists’ societies have a written agreement on some treatments. Small peer review groups in general practice may develop their own recommendations locally, as may specialists organised in partnerships and departments. The second part of the questionnaire included statements of possible barriers and facilitators for using one specific joint treatment guideline. The guidelines for chronic heart failure, hypertension and diabetes were used as examples, since the implementation programme would focus on these guidelines. The statements were phrased to specify one guideline, for example “I do not need this guideline (for chronic heart failure)”. The specific guideline was presented to the respondents before they were asked to complete the questionnaire. The list of statements involved the four domains identified in previous research, focussing on (1) content of the guideline, (2) development process, (3) usefulness and value for practitioners, and (4) aspects of organisation and setting.6,11,12

35

Physicians’views

Statements from existing instruments, such as the Attitudes towards Guidelines Scale,14 were supplemented with statements derived from an earlier qualitative study.6 A questionnaire with 42 statements was pre-tested by three physicians for clarity and comprehensiveness. Two statements were excluded for being ambiguous or irrelevant. Agreement with all statements was quantified on a 7-point Likert scale, ranging from “Strongly agree” to “Strongly disagree”. Analysis

Mann-Whitney tests were used to test for differences in agreement between specialists and GPs, and between responders to the first and second wave of data collection. Kruskal-Wallis tests were used to test for differences between responders confronted with different specific guidelines. Differences in guideline use were tested with Chi2 -tests. The statements dealing with attitudes towards a specific guideline were re -coded so that low scores (1-3) were negative, the median score (4) was neutral and high scores (5-7) were positive towards guideline use. Numbers of specialists and GPs with negative, neutral or positive attitudes were compared with Chi2 -tests. Cronbach’s a was calculated to determine internal consistency between the items within each domain. For internally consistent domains, sum-scores were computed by calculating the mean score per item adjusting for missing values on individual items resulting in a scale from 1 (negative) to 7 (positive). Results More than half of all cardiologists (16 out of 24) and internists (18 out of 36), and three-quarters of all GPs (197 out of 261) in the region completed the general part of the questionnaire (Table 1). There were fewer respondents to the specific part of the questionnaire in the first wave, because at one meeting the participants did not receive one of the specific guidelines included in our study. The 197 GPs were on average 48 years old (SD 6.7), and 37 (19%) of the GPs were women. The mean age of the 34 specialists was 47 years (SD 7.5), and 3 (9%) of them were women. Responses to only 3 of the 40 items differed for physicians who answered the questionnaire during the educational meetings (wave 1) and physicians who did not attend these meetings (wave 2). Physicians from the first wave more often agreed that medical practice was oversimplified in the guideline (p=.005). On the other hand, they considered the guideline less often as being too restrictive (p=.027), or containing too many equivalent drugs (p=.042). For all further analyses, no distinction is made between data collected in wave 1 or wave 2.

36

Chapter 3

Table 1: Numbers of specialists and general practitioners responding to the questionnaire N (response rate)

Specialists 34 (57%)

General practitioners 197 (76%)

34 25 9

197 145 52

General statements Wave 11 Wave 22

Specific statements 31 147 Wave 1 22 95 Wave 2 9 52 1 questionnaire was distributed and collected during educational meetings for specialists and general practitioners 2 questionnaire was sent to general practitioners and handed out to specialists who were not present at the educational meetings

Figure 1. Current use of treatment guidelines

hospital

local

type of guideline

local

regional regional

national national

international international

0

10

20

30

40

50

60

response percentages

specialists reporting regular use of guideline specialists reporting constant use of guideline GPs reporting regular use of guideline GPs reporting constant use of guideline

37

Physicians’views

70

80

Current situation and general views

Almost all specialists and GPs reported that they used some kind of treatment guideline regularly or always (Figure 1). Significantly more specialists than GPs reported frequent use of international guidelines and local agreements or recommendations, whereas significantly more GPs than specialists reported use of the national and regional guidelines (p<.001). A small majority of the physicians endorsed the view that primary and secondary care were well harmonised, but at the same time most physicians saw room for improvement (Table 2). Almost all physicians agreed that it was worthwhile to make joint treatment agreements, and many considered it not in the patient’s best interest to switch drugs at the primary-secondary care interface. GPs supported the aim and importance of this specific project more than specialists. Table 2: General views of specialists and general practitioners on the current situation at the primary secondary care interface; percentages of physicians agreeing with the questionnaire statements General statement Concerning the treatment of patients there is good harmonisation between primary and secondary care

Agree with statement Specialists GPs (n=34) % (n=197) % 64.7

59.4

20.6

5.1

82.4

82.2

I subscribe to the project’s aim and importance

61.8

72.1

It is not in the patients’ best interest to switch drugs when crossing the primary-secondary care interface.

58.8

71.1

The quality of pharmacotherapy cannot further be improved Communication with specialists/general practitioners about patient treatment can be improved

Chi2 -test* (df=2)

p=.005

p=.028

To make joint agreements on 91.2 92.9 pharmacotherapy is worthwhile * comparing numbers of specialists and GPs agreeing, disagreeing or having a neutral opinion. Only p-values <.05 are reported

Specific barriers and facilitators

Regarding most barriers and facilitators, there were no significant differences between responses to the guideline on hypertension, heart failure or diabetes (data not shown). Only in the case of the diabetes guideline, d id a significantly greater number of respondents agree that its implementation is too time consuming and expensive (p=.004), and that it limits their professional autonomy (p=.005).

38

Chapter 3

Therefore, the answers for the three guidelines were taken together, and presented as such in Table 3. The domains ‘content’, ‘usefulness and value’, and ‘organisation and setting’ had acceptable reliability scores for calculating sum-scores (alpha’s 0.69, 0.76, and 0.64). On average, both groups of physicians were moderately positive regarding all domains (table 3), and there were no significant differences between the two groups. The reliability of the domain ‘development process’ was too low (alpha = 0.42) to calculate sum-scores. Within the domain ‘content’, most physicians agreed that the recommendations in the joint treatment guideline were congruent with their daily practice, although not all agreed that good choices had been made within drug classes. Specialists in particular believed that recommendations should only be given on drug class level. Despite a high level of confidence that the guideline was evidence-based, some specialists considered the guideline to be too conservative. Some barriers were seen in the domain ‘development process’ regarding the dominance of financial interests, and the distance between developers and practitioners. On the other hand, most physicians agreed that the guidelines were developed by experts. In the domain ‘usefulness and value’, both groups of physicians believed that the joint treatment guideline was useful as educational tool, was appropriately applicable in practice, could facilitate communication and improve harmonisation between primary and secondary care. Most GPs and a majority of the specialists agreed that the joint guideline was a good source of advice and could improve quality of care. There was less confidence that it would lead to cost savings. A clear barrier was the fear that the guideline could be misused by government and insurance companies. For at least half of the specialists, lack of need for the guideline, negative influence on innovation, and oversimplification of medical practice were identified as barriers. Some barriers were observed in the domain ‘organisation and setting’. A third of the specialists expected to lose industry support for conferences and research. In addition, specialists considered their practice organisation as less supportive of the guidelines than the GPs. On the other hand, GPs more than specialists saw a problem with patients not wanting to be treated according to the guideline. Discussion Our study showed that the specialists and the GPs in this study use different treatment guidelines, indicating a potential problem for the continuity of care. Most specialists relied on international guidelines and on agreements within their department. International guidelines often provide a detailed review of the evidence, whereas local agreements usually focus more on reducing drug variability or costs.

39

Physicians’views

40

Table 3: Percentages of physicians agreeing and disagreeing with specific statements about joint treatment guidelines Specialists (n=31) Agree

Chapter 3

Guideline content This guideline is based on scientific evidence This guideline recommends what I already do in practice Within drug classes good choices have been made in this guideline This guideline is outdated This guideline is too restrictive This guideline is too conservative Too many equivalent drugs are included in this guideline This guideline should have given recommendations on drug class level only Average of sum-score for domain ‘content’ (scale 1-7)2 Guideline development process 3 The people in the developing committees were appropriate representatives of my professional group This guideline is made by experts This guideline development initiative is too much dominated by financial interests The distance between the developers of these guidelines and practitioners is too big Usefulness and value of guideline This guideline is useful as an educational tool This guideline is a convenient source of advice This guideline can facilitate communication with specialists / GPs This guideline can facilitate communication with patients and families This guideline can improve the quality of pharmacotherapeutic care This guideline can lead to better harmony between primary and secondary care

Disagree1

GPs (n=147) Agree

Disagree

90.3 3.2 90.3 3.2 64.5 19.4 32.3 48.4 38.7 48.4 25.8 58.1 6.5 77.4 48.4 41.9 4.2 (s.d. 1.0)

65.3 3.4 83.7 6.1 64.6 6.1 17.0 52.4 19.7 55.1 8.8 61.9 4.8 60.5 23.1 51.0 4.5 (s.d. 0.7)

64.5

16.1

48.3

4.8

90.3 61.3 45.2

3.2 9.7 16.1

71.4 40.8 24.5

2.7 15.0 23.1

87.1 77.4 83.9 51.6 67.7 87.1

9.7 12.9 12.9 32.3 9.7 6.5

83.7 88.4 85.0 56.5 85.7 83.7

4.1 2.7 2.0 17.7 3.4 1.4

Chi2 -test 1 (df=2)

p=.017 p=.031

p=.019 p=.010 p=.004

p=.043 p=.007

41

Table 3 (continued): Percentages of physicians agreeing and disagreeing with specific statements about joint treatment guidelines Specialists (n=31) Disagree1 Agree

GPs (n=147) Agree Disagree 46.3 15.6 78.9 3.4 52.4 19.7 65.3 15.6 40.8 34.0 27.9 58.5 27.2 58.5 31.3 49.7 14.3 68.0 4.5 (s.d. 0.6)

Chi2 -test 1 (df=2)

Physicians’views

This guideline can lead to cost savings 58.1 19.4 This guideline is well-applicable in practice 74.2 6.5 This guideline facilitates taking over patients from colleagues 54.8 29.0 This guideline can be misused by government and insurance companies 74.2 12.9 This guideline limits innovation 61.3 35.5 p=.016 I do not need this guideline 58.1 32.3 p=.005 This guideline challenges my professional autonomy 45.2 41.9 This guideline oversimplifies medical practice 54.8 32.3 p=.045 Many of my patients can not be treated according to this guideline 9.7 64.5 Average of sum-score for domain ‘usefulness/value’ (scale 1-7) 4.3 (s.d. 0.0) Organisation and setting Most of my colleagues have disapproving attitudes about this guideline 22.6 51.6 12.2 53.7 This guideline is not valued in my practice organisation 16.1 41.9 11.6 68.7 p=.013 To implement this guideline is too time consuming and expensive 29.0 51.6 27.2 44.9 With this guideline I lose industry support for conducting research 35.5 61.3 13.6 51.7 p<.001 With this guideline I lose industry support for conferences and educational meetings 35.5 54.8 17.0 50.3 p=.010 Some of my patients do not want to be treated according to this guideline 32.3 51.6 52.4 25.2 p=.013 This guideline thwarts local guidelines and agreements 12.2 63.9 9.7 71.0 Average of sum-score for domain ‘organisation/setting’ (scale 1-7) 4.5 (s.d. 1.1) 4.6 (s.d. 0.9) 1 scores for neutral responses have been omitted; chi-2 comparing of specialists and GPs agreeing, disagreeing or having a neutral opinion. Only pvalues <.05 are reported 2 sum-scores were computed by calculating the mean score per item adjusting for missing values. Scale 1-7 refers to a negative score (1) and to a positive score (7) 3 reliability score of this domain was too low (α=0.42) to calculate sum-scores

Most GPs reported use of a regional formulary or national guidelines for their prescribing, which both aim at stimulating rational and cost-effective prescribing. This preference of GPs in the Netherlands for national and local guidelines over international ones is similar to preferences found in other countries.15 The finding that both specialists and GPs reported frequent use of local or regional guidelines may be related to feelings of ownership. Moreover, peer pressure may be an additional factor facilitating implementation of local guidelines. Joint treatment guidelines could enable the harmonisation of pharmacotherapy at the primary-secondary care interface.4,5 There are only a few examples of joint drug formularies, such as in the Lothian and Grampian regions in Scotland. Their implementation may have been stimulated by the fact that budget responsibilities for hospital and primary care in Scotland were held by one authority,4 which differs from many other countries including the Netherlands. Organisational policies and procedures, as well as enforcement can increase adherence to guidelines.16,17 When there are no external pressures, the motivation to use guidelines has to come from the physicians themselves. The perceived need to use a new guideline depends on the physician’s satisfaction with the current situation and the perceived efficacy of the recommended change.11,18 The change should ‘make sense’, and people involved must be trusted and respected.19 Both specialists and GPs in our study believed that improvements could be made in communication, harmonisation and quality of pharmacotherapy by making and using joint treatment guidelines. However, GPs seemed more supportive of the project than specialists, and more motivated to use the newly developed guidelines. Problems associated with switching drugs may be more noticeable in general practice. GPs sometimes feel unable to take responsibility for certain treatments started by specialists, and reluctant to make changes.20,21 This poses problems given the current policy debate in primary health care where GPs are given more responsibility in the treatment of chronic patients. Specialists were more critical regarding the conservative and limiting nature of guidelines, and expected more negative consequences, such as loss of industry support. These barriers for specialists were already identified in an earlier exploratory study, but their relevance was not clear.6 This current study shows that more than a third of the specialists worried about losing good research opportunities provided by the industry. In addition, more than half of the specialists particularly stated that they did not need these guidelines. Guidelines are especially appropriate in situations where physicians are uncertain about the most effective way of treating a disease.22 A surplus of self-efficacy, however, could form a barrier. Although most physicians were positive regarding the content of the guidelines, they were concerned about the development and implementation process. They were afraid that the guidelines could be misused by government and insurance companies, and distrusted the financial interests. This distrust is probably linked to 42

Chapter 3

the fact that one of the goals of these guidelines is reduction of clinical variability and costs. The feeling of suspicion and a government ploy to discipline physicians has been seen before and is associated with a negative attitude of the physicians.23 Limitations

Using a questionnaire is an efficient way to examine beliefs and barriers in a structured way. Our questionnaire was based on the validated Attitudes towards Guidelines Scale.14 The four domains included coincide with previously suggested theoretical domains.11 Socially desirable answers are a common problem in this type of research. We have tried to limit this by using positive as well as negative statements, and by emphasizing that the data would be processed anonymously. The response rate was relatively high, but somewhat lower among specialists than GPs, which could be due to the fact that specialists were less interested in this subject of joint treatment guidelines. The diffe rent ways of data collection could be considered a limitation of our study. However, we found no differences in the majority of responses between the two waves of data collection, allowing us to analyse the data together. Another limitation is that the physicians had not yet worked with these joint treatment guidelines. We did present them with an example of one guideline, so that they could form an opinion on that specific guideline. We used three different examples, but found that there were no major differences in opinion. Only regarding the diabetes guideline, physicians were more concerned about their autonomy and the efforts needed for implementation. It is possible that a guideline on a completely different (non-cardiovascular) subject might elicit different barriers and facilitators. Implications

Improving continuity of healthcare has been put on the agenda by governments as well as professional general practitioner organisations in Europe. In several regions, joint drug formularies or guidelines have been developed and new initiatives are being taken, but little is known about the physicians’ motivation to use joint guidelines. Our results indicate that specialists have a different readiness for implementing these guidelines than GPs. The specialists in our study do not see many problems in the current situation, nor do they see much need to use such guidelines themselves, which implies that they are still at the stage Prochaska has termed the “precontemplation stage” of behavioural change.18 This stage represents those individuals who have no desire to change their behaviours in the immediate future. For them, joint guidelines are not needed as review of the evidence. This might be a universal problem, as specialists by definition should have extensive knowledge within their specialty. An implementation programme for specialists should focus on the objective of harmonisation between primary and

43

Physicians’views

secondary care, starting with making them aware of the extent and nature of the current problems at the interface. The GPs in our study seem to be in the contemplation stage, aware of the problem and having a positive attitude towards using joint guidelines. For them it is important to focus on how to apply the recommendations in practice, addressing some specific barriers perceived, for instance, how to deal with uncooperative patients. The GPs’ awareness and positive attitude towards joint guidelines may be related to a health care system where patients frequently switch between primary and secondary care. For both groups of physicians, it seems necessary to address the distrust regarding financial objectives, and focus more on quality of care than on cost savings. References 1

Burgers JS, Bailey JV, Klazinga NS, Van Der Bij AK, Grol R, Feder G. Inside guidelines: comparative analysis of recommendations and evidence in diabetes guidelines from 13 countries. Diabetes Care 2002; 25(11): 1933-1939. 2 Iqbal A, Schloss S, George D, Isonaka S . Worldwide guidelines for chronic obstructive pulmonary disease: a comparison of diagnosis and treatment recommendations. Respirology 2002; 7(3): 233-239. 3 Koes BW, Van Tulder MW, Ostelo R, Kim BA, Waddell G. Clinical guidelines for the management of low back pain in primary care: an international comparison. Spine 2001; 26(22): 2504-2513. 4 Duerden M, Walley T. Prescribing at the interface between primary and secondary care in the UK. Towards joint formularies? Pharmacoeconomics 1999; 15(5): 435-443. 5 Kvamme OJ, Olesen F, Samuelsson M. Improving the interface between primary and secondary care: a statement from the European working party on quality in family practice (EQuiP). Qual Health Care 2001; 10(1): 33-39. 6 Kasje WN, Denig P, Haaijer-Ruskamp FM. Specialists' expectations regarding joint treatment guidelines for primary and secondary care. Int J Qual Health Care 2002; 14(6): 509-518. 7 Proeftuin Farmaceutische Zorg. Towards the Groningen joint formulary (in Dutch). Groningen, 2000. http://www.proeftuinfarmaciegroningen.nl. 8 Grol R, Jones R. Twenty years of implementation research. Fam Pract 2000; 17 (Suppl 1): S32-S35. 9 Wensing M, Van der Weijden T, Grol R. Implementing guidelines and innovations in general practice: which interventions are effective? Br J Gen Pract 1998; 48(427): 991997. 10 Thorsen T, Makela M. Changing professional practice. Theory and practice of clinical guidelines implementation. Copenhagen, DSI: Danish Institute for Health Services Research and Development, 1999. http://www.dsi.dk.

44

Chapter 3

11 Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MD, Abboud PA, et al. Why don't physicians follow clinical practice guidelines? JAMA 1999; 282(15): 1458-1465. 12 Langley C, Faulkner A, Watkins C, Gray S, Harvey I. Use of guidelines in primary care-practitioners' perspective. Fam Pract 1998; 15(2): 105-111. 13 Evans D. A stakeholder analysis of developments at the primary and secondary care interface. Br J Gen Pract 1996; 46(412): 675-677. 14 Elovainio M, Eccles M, Makela M. Attitudes towards guidelines and a scale for measuring them. In Changing professional practice. Copenhagen, DSI: Danish Institute for Health Services, 1999. http://www.dsi.dk. 15 Hobbs FR, Erhardt L. Acceptance of guideline recommendations and perceived implementation of coronary heart disease prevention among primary care physicians in five European countries: the Reassessing European Attitudes about Cardiovascular Treatment (REACT) survey. Fam Pract 2002; 19(6): 596-604. 16 Ward MM, Vaughn TE, Uden-Holman T, Doebbeling BN, Clarke WR, Woolson RF. Physician knowledge, attitudes and practices regarding a widely implemented guideline. J Eval Clin Pract 2002; 8(2): 155-162. 17 Pathman DE, Konrad TR, Freed GL, Freeman VA, Koch GG. The awareness-toadherence model of the steps to clinical guideline compliance. The case of pediatric vaccine recommendations. Med Care 1996; 34(9): 873-889. 18 Prochaska JO. Systems of psychotherapy: a transtheoretical analysis, 2nd ed. Dorsey: Homewood, Ill., 1984. 19 Armstrong D, Reyburn H, Jones R. A study of general practitioners' reasons for changing their prescribing behaviour. BMJ 1996; 312(7036): 949-952. 20 Sibbald B, Wilkie P, Raftery J, Anderson S, Freeling P. Prescribing at the hospitalgeneral practice interface. II: Impact of hospital outpatient dispensing policies in England on general practitioners and hospital consultants. BMJ 1992; 304(6818): 3134. 21 Horne R, Mailey E, Frost S, Lea R. Shared care: a qualitative study of GPs’ and hospital doctors’ views on prescribing specialist medicines. Br J Gen Pract 2001; 51(464): 187-193. 22 Hurwitz B. Guidelines, judgement, opinion, and clinical experience. Qual Health Care 2001; 10(4): 202-203. 23 Johnston G, Crombie IK, Davies HT, Alder EM, Millard A. Reviewing audit: barriers and facilitating factors for effective clinical audit. Qual Health Care 2000; 9(1): 23-36.

45

Physicians’views

46

Chapter 3

Chapter 4 Perceived barriers for treatment of chronic heart failure in general practice. Are they affecting performance? W.N. Kasje, P. Denig, P.A. de Graeff, and F.M. Haaijer-Ruskamp. Objective: The aim of this study is to determine to what extent barriers perceived by general practitioners (GPs) for prescribing angiotensin-converting enzyme inhibitors (ACE) inhibitors in chronic heart failure (CHF) patients are related to underuse and underdosing of these drugs in actual practice. Methods: Barriers were assessed with a semi-structured questionnaire. Prescribing data were extracted from GPs’ computerised medical records for a random sample of their CHF patients. Relations between barriers and prescribing behaviour were assessed by means of Spearman rank correlation and multivariate regression modelling at GP level. Results: GPs perceived on average four barriers in prescribing ACE inhibitors or optimising ACE inhibitor dose. They prescribed ACE inhibitors to 45% and had previously initiated such treatment in an additional 3.5% of their patients, in an average standardised dose of 13.5 mg. Many GPs found it difficult to change treatment initiated by a cardiologist. Furthermore, initiating ACE inhibitors in patients already using a diuretic or stable on their current medication was perceived as a barrier. Titrating the ACE inhibitors dose was also seen as difficult by more than half of the GPs. No significant relationships could be found between the barriers perceived and ACE inhibitors prescribing. Regarding ACE inhibitors dosing, the few GPs who did not agree that the ACE inhibitor should be dosed as high as possible prescribed higher ACE inhibitor doses, and those that believed it is not useful to prescribe ACE inhibitors to very old CHF patients were prescribing lower ACE inhibitor doses. Conclusion: Variation between GPs in prescribing ACE inhibitors for CHF can not be explained by differences in the barriers they perceive. Tailor-made interventions targeting only those doctors that perceive a specific barrier will therefore not be an efficient approach to improve quality of care.

Quality and Safety in Health Care (submitted)

Introduction The prevalence of chronic heart failure (CHF) is increasing with the ageing of the population and leads to high mortality. Despite several landmark studies that showed that appropriate treatment can improve morbidity and mortality, management in general practice is still not optimal. Persisting major problems are underuse and underdosing of angiotensin-converting enzyme (ACE) inhibitors 1 . General practitioners (GPs) perceive certain problems that could explain why they do not treat their CHF patients optimally. These problems can be classified as internal or external barriers. Internal barriers include lack of knowledge, e.g. not knowing the target dose of ACE inhibitors or lack of awareness of new recommendations, as well as certain attitudes, such as lack of confidence, doubts about benefits for very old patients, fear for adverse effects or reluctance to change the treatment when a patient is stable. External barriers may be related to organisational factors, including difficulties at the primary-secondary care interface 2-5 . It is often suggested that intervention programs for improving performance need to be targeted at the perceived barriers 6 . However, it is not clear whether all such barriers are as relevant for not achieving optimal management. Lack of knowledge appears not to be very pertinent, since many GPs have adequate knowledge about ACE inhibitors but are still reluctant to prescribe them for their patients 7 . Selfinsight of doctors in their treatment decisions is limited, and they may not be fully aware of the factors influencing their performance 8 . To our knowledge, no study has tried to assess the relationship between the GPs’ self-reported problems and their actual prescribing for heart failure. Better understanding of this relation may help to indicate areas in which an intervention could be most beneficial. The aim of our study is to determine to what extent barriers that GPs perceive for prescribing ACE inhibitors in CHF patients are related to their actual prescribing. Methods Study population

This study was part of the baseline of a larger study conducted from September 2001 to May 2002 in the north of the Netherlands, evaluating two audit programs for peer review groups focussing on the treatment of CHF and treatment of hypertension in diabetic patients. A total of 95 GPs participated in the chronic heart failure program. Prescribing data were extracted from GPs’ computerised medical records for a random sample of their CHF patients. After identification of possible CHF patients from the records, the GPs were asked to verify the diagnosis. Because of the larger study, CHF patients with a co-morbidity of diabetes type 2 were excluded. GPs present at the audit meeting of their peer review group were

48

Chapter 4

asked to complete a semi-structured questionnaire on their perceived problems with the recommended treatment for CHF. Perceived barriers

A questionnaire was developed with statements of possible internal and external barriers towards prescribing ACE inhibitors in patients with heart failure as identified from the literature 2-5 . These literature-based barriers included three general beliefs supporting the recommended treatment. Disagreement with these was considered an internal barrier. Six specific beliefs and attitudes opposing the general recommendations were presented, each also representing a possible internal barrier. Furthermore, two external barriers were included which were related to the sharing of responsibilities between primary and secondary care (Table 1). An open-ended question was added to identify any other barriers the GPs perceived with implementing evidence-based recommendations for CHF treatment. These self-reported barriers were categorised in nine issues by the first two authors. Actual treatment

Actual treatment data were extracted from computerised medical records by trained abstractors who visited the GPs' practices. A random sample of up to 10 CHF patients per GP was identified. In most of the practices that were not singlehanded, lists of the GP’s personal patients were used. In 3 practices, one GP shared the responsibility for the same patients with a partner. In such cases, prescribing decisions for these patients were assigned to both GPs reflecting their joint prescribing policy. Data collected for the patients included age, gender, date of CHF onset, specialist referrals, and current medication. For each GP, the percentage of patients currently or previously treated with an ACE inhibitors was calculated as outcome variable, as well as the average dosing of the ACE inhibitor currently prescribed. The ACE inhibitor dosages were first converted to standardised dosages according to target daily doses for heart failure as recommended in the Dutch desk reference book 9 . This method of standardisation, which has been used before, uses 20 mg of enalapril as reference dose 10 . Based on the conversion, enalapril 20 mg equivalents are captopril 150 mg, ramipril 10 mg, quinapril 20 mg, lisinopril 20 mg, fosinopril 40 mg, and perindopril 4 mg. This conversion is an alternative for the more commonly used defined daily dosage (DDD) method, which can not be applied in this case since the DDDs for ACE inhibitors are based on their use for hypertension. Data analysis

To assess the relationship between the GPs’ perceived barriers and their prescribing behaviour analyses were conducted on GP level. Firstly, the number of 49

Perceived barriers

different barriers perceived was related to the percentage of patients prescribed an ACE inhibitor and the average standardised ACE inhibitors dose prescribed with Spearman rank correlations (?). This non-parametric statistic was used since the number of barriers perceived did not have a normal distribution. Two sub-analyses were conducted to assess whether relations differed for internal versus external barriers, and for literature-based versus self-reported barriers. Secondly, we looked at the relationship between individual barriers and ACE inhibitors prescribing. Univariate analyses were conducted to identify possible relevant factors, especially in specific patient groups. The data were further explored by means of scatter plots to identify possible outliers or subgroups that could mask possible relationships. A multivariate regression model was used to assess the relevance of the various barriers for explaining differences in ACE inhibitors prescribing. Finally, the complete data analysis was repeated for the subgroup of patients who had not been referred to a cardiologist in the year prior to data collection. This was decided when it became clear that a substantial number of patients had been referred in the last year, and one might expect that treatment initiated by the specialist confounds the analysis 11 .

Results Fifty-eight GPs completed the questionnaire, and prescribing behaviour was measured for 43 of them, resulting in an overall response rate of 45% (Figure 1). The GPs participating in this study were mainly male (88%), and on average 47 years old (SD 6.9), which was not significantly different from the non-responding GPs. Prescribing behaviour was assessed for 339 of their patients (Figure 1). At that moment, the GPs prescribed an ACE inhibitor to an average of 44.9% (SD 15.9) of their CHF patients in an average standardised dose of 13.5 mg (SD 6.6). Another 3.5% of the patients had been using an ACE inhibitor prior to the study period, including 7 patients that had stopped using ACE inhibitor because of various side effects and 5 who had stopped without a documented reason. Including these patients, the GPs prescribed or had previously prescribed an ACE inhibitor to 48.6% of their patients (SD 17.9). This was not significantly different from GPs who did not complete the questionnaire. Angiotensin-II-antagonists were prescribed to 6% of the patients. All but two GPs considered ACE inhibitors as standard therapy for all CHF patients, and most GPs agreed that ACE inhibitors should be dosed as high as possible (Table 1). On average, the GPs perceived four barriers in prescribing ACE inhibitors or optimising ACE inhibitors dosage. All 43 GPs perceived at least one barrier; 41 GPs perceived at least one internal barrier, and 37 GPs perceived at least one external barrier.

50

Chapter 4

Figure 1. General practitioners (GPs) and patients in study 95 GPs participating in peer groups 58 GPs completed the questionnaire

- 34 GPs did not attend meeting where questionnaire was distributed - 3 GPs did not complete questionnaire - Prescribing data could not be collected for 15 GPs

43 GPs participated Maximum of patients from the 43 participating GPs (n=430) Available patients from the 43 participating GPs (n=359) Patients included (n=339)

- 13 GPs with less than 10 verified CHF patients - 3 Joint practices with shared patients - Patients excluded for having diabetes (n=20)

Relationship between number of barriers and ACE inhibitors prescribing

No relationship appeared to exist between the number of barriers and the ACE inhibitor prescribing (Table 2). No significant correlations were found between the total number of barriers perceived by the GPs and the percentage of patients receiving an ACE inhibitor (? = .02) or the average ACE inhibitor dose prescribed (? = -.08). Also, no significant relationships were found with the number of internal or external barriers, nor with the number of literature-based or selfreported barriers. Literature-based barriers

With regard to initiating an ACE inhibitor, a substantial number of GPs (42%) reported that they were afraid of endangering a stable situation and reluctant to start an ACE inhibitor when a patient already received a diuretic (Table 1). The most important barrier regarding the ACE inhibitor dosing was the difficulty perceived with titrating this dose. A majority of the GPs (77%) found it hard to change treatment initiated by a cardiologist. The univariate analysis showed no significant relationships between the individual barriers and ACE inhibitor prescribing, and the scatter plots also revealed no patterns. Even GPs who believed it is not useful to prescribe ACE inhibitors to very old CHF patients did not have less patients of 85 years or older on these drugs. In the multivariate regression model, none of the specific barriers was related to the percentage of patients currently of previously receiving an ACE inhibitor. The model did not significantly explain the prescribing differences. 51

Perceived barriers

52

Table 1: Perceived internal and external barriers for prescribing ACE inhibitors for CHF, divided in literature-based and self -reported barriers (N=number of GPs reporting barrier) Internal

Literature-based barriers

N

Do not agree with: I believe that the standard therapy for new CHF patients

1

Self-reported barriers

N

should be an ACE, irrespective of the severity of the disease I believe that the standard therapy for known CHF patients should be an ACE, irrespective of the severity of the disease I believe that ACE should be prescribed in as high a dose

2

2

as possible for CHF patients Agree with:

Chapter 4

I believe one should be reserved in prescribing ACE to CHF patients, because of the risk of renal insufficiency

11

Starting, checking, and titrating ACE dose is difficult

3

I believe one should be reserved in prescribing ACE to CHF patients, because of the risk of hypotension

12

Fears about adverse effects of ACE

8

I find initiating ACE difficult in CHF patients already using a diuretic

18

I find it difficult to frequently titrate the ACE dose in CHF patients

25

I believe tha t CHF patients who are stable on their current medication, should not be put on an ACE

18

Not wanting to change treatment when patients are stable

4

I believe it is not useful to prescribe ACE to very old CHF patients

10

Doubts about usefulness of ACE, especially in elderly patients

3

Difficulties with treating complex cases (comorbidity/polyfarmacy)

3

53

Table 1 (continued): Perceived internal and external barriers for prescribing ACE inhibitors for CHF, divided in literature-based and self-reported barriers (N=number of GPs reporting barrier) Literature-based barriers

N

External I believe that a cardiologist should initiate ACE therapy in

3

CHF patients I find it hard to change treatment initiated by a

33

Self-reported barriers

N

Problems with patient compliance or motivation

5

Problems in interacting with specialist care

9

Time constraints

1

Difficulties with screening for undertreated heart failure patients

4

cardiologist

Perceived barriers

Surprisingly, the two GPs who did not agree that the ACE inhibitor dose should be as high as possible, prescribed higher doses than GPs who did agree with this recommendation. This barrier was significantly associated in the multivariate model explaining differences in ACE inhibitor dosages (beta 0.42, p=.03), even after exclusion of the two outliers. The GPs who agreed that it is not useful to prescribe ACE inhibitors to very old CHF patients were prescribing lower ACE inhibitors doses (beta 0.34, p=.04). Self-reported barriers

The most common self-reported barrier concerned the sharing of responsibilities with specialists (Table 1). According to several GPs co-management with a cardiologist made it difficult to change the therapy, and some GPs felt the cardiologist interfered too much. Furthermore, eight GPs mentioned possible adverse effects of ACE inhibitors as a barrier towards prescribing. A few GPs mentioned problems with patient motivation as a barrier. Addition of the selfreported barriers to the multivariate model did not significantly alter any of the findings. Analysis of patients not referred to a cardiologist

Cardiologist treatment could have confounded our analysis. Patients not referred to a cardiologist in the year prior to data collection were prescribed an ACE inhibitor less often than the 36% of patients that had been referred (44% versus 61% on ACE inhibitors, t-test = -2.2, p=.03). No significant difference was found regarding ACE inhibitor dosage. Analysis including only the non-referred patients, however, hardly changed our findings. Again no relationship was found between the number of barriers and ACE inhibitors prescribing. In the multivariate model there were no barriers significantly explaining differences in the percentage of patients currently or previously receiving an ACE inhibitor. One additional factor was found to be associated in the model explaining differences in ACE inhibitor dosages. GPs who believed that CHF patients stable on their current medication should not be put on an ACE inhibitor prescribed higher dosages of ACE inhibitors (beta -0.48, p=.02).

54

Chapter 4

Table 2: Number of perceived barriers and average ACE inhibitors prescribing in CHF patients Number of barriers

N

% patients on ACE inhibitor

standardised ACE inhibitor dose (mg)*

1

1

80.0

13.7

2

9

49.7

13.5

3

7

42.2

10.9

4

11

48.1

15.0

5

7

41.4

15.4

6

4

67.1

13.4

7

2

31.7

11.2

8

1

62.5

6.2

10

1

55.6

9.2

average = 4.1 (SD 1.86)

43

48.6

13.5

average internal barriers = 2.8 (SD 1.64) average external barriers = 1.2 (SD 0.88)

41

48.5

13.5

37

47.1

12.9

* = based on a conversion using a standardised target dose of 20 mg N= number of GPs

Discussion In this study we found remarkably few relationships between perceived barriers and actual prescribing for CHF. The problems that certain GPs acknowledged, such as their reluctance to initiate ACE inhibitors in already treated CHF patients or the difficulties with gradually increasing the ACE inhibitor dose, were not reflected in their prescribing of these drugs. No matter what barrier is reported, it does not seem to affect the GPs’ management of CHF patients in general practice. The scatter plots between perceived barriers and ACE inhibitors prescribing also showed no meaningful patterns, indicating that our lack of finding any significant relationships can not be explained by having too low numbers or a few outliers in the study. For some patients, GPs tried to initiate an ACE inhibitor but treatment had been stopped for various reasons. We included these cases in our analysis, thereby focussing on all attempts of a GP to start ACE inhibitors treatment in CHF patients. Many of the patients in our study were seen by a cardiologist in the year prior to data collection, which was found to be related to receiving more ACE inhibitors. However, subgroup analysis including only prescriptions for patients not recently referred to a cardiologist did not show any concealed relationships. In our study we took the overall prescribing of ACE inhibitors for CHF patients as primary outcome measure, expecting to find relationships between perceived barriers and the general prescription pattern. On a more specific level the 55

Perceived barriers

association might be stronger, for instance, GPs who believe that it is not useful to prescribe ACE inhibitors to very old patients could be expected to prescribe less ACE inhibitors especially in this subgroup of patients. However, even on this more specific level no significant relationship could be found. Our findings are in line with those from a recent explanatory study on effective management of type 2 diabetes, where no relationship was found between the number of recommendations followed by physicians and the presence of barriers perceived at patient level 12 . Also in the IMPROVEMENT of heart failure study, physicians’ knowledge and attitudes did not seem to be predictive of appropriate ACE inhibitor treatment 13 . The low response rate might be considered as a limitation of our study. However, there is no indication that the relationship between the doctors’ perceptions and performance would be different for participating and non-participating GPs, and there was no difference regarding their prescribing of ACE inhibitors for CHF. Another possible limitation is our use of medical records to measure the GPs’ prescribing behaviour for CHF patients. As is the case with more than 90% of Dutch GPs, the GPs in this study prescribe electronically, and these prescriptions are automatically stored in the medical records. Patients were selected as having CHF according to their GP, without independently confirming the diagnosis. This was done since our study sought to relate perceived barriers with current management for those patients who the GP considered as having CHF. Interventions to improve quality of care often focus on education and addressing perceived barriers for optimal performance. The findings from our study imply that targeting only those doctors that perceive a specific barrier with a tailor-made programme will not be an efficient approach. Variation in the quality of care between GPs can not be explained by differences in the barriers they perceive. It might even be true that being aware of a barrier stimulates some doctors to be more active in dealing with that barrier. In future research on an extended population we will try to assess whether specific factors at patient or practice level may better explain differences in the quality of care, in order to find more efficient ways to optimise the treatment of patients with CHF.

References 1

2

56

Pont LG, Sturkenboom MC, Van Gilst WH, Denig P, Haaijer-Ruskamp FM. Trends in prescribing for heart failure in Dutch primary care from 1996 to 2000. Pharmacoepidemiol Drug Saf 2003; 12: 327-334. Fuat A, Hungin AP, Murphy JJ. Barriers to accurate diagnosis and effective management of heart failure in primary care: qualitative study. BMJ 2003; 326: 196.

Chapter 4

3

4 5

6 7

8 9 10

11

12

13

57

Horne R, Coombes I, Davies G, Hankins M, Vincent R. Barriers to optimum management of heart failure by general practitioners. Br J Gen Pract 1999; 49: 353357. Hickling JA, Nazareth I, Rogers S. The barriers to effective management of heart failure in general practice. Br J Gen Pract 2001; 51: 615-618. Khunti K, Hearnshaw H, Baker R, Grimshaw G. Heart failure in primary care: qualitative study of current management and perceived obstacles to evidence-based diagnosis and management by general practitioners. Eur J Heart Failure 2002; 4: 771777. Grol R. Implementing guidelines in general practice. Qual Health Care 1992; 1: 184191. Hobbs FD, Jones MI, Allan TF, Wilson S, Tobias R. European survey of primary care physician perceptions on heart failure diagnosis and management (Euro-HF). Eur Heart J 2000; 21: 1877-1887. Harries C, Evans JSBT, Dennis I. Measuring doctors’ self-insight into their treatment decisions. Appl Cognit Psychol 2000; 14: 455-477. CVZ (National Health Insurance Board). Desk reference book 2003. Utrecht: CVZ, 2003. Luzier AB, Forrest A, Adelman M, Hawari FI, Schentag JJ, Izzo JL, Jr. Impact of angiotensin-converting enzyme inhibitor underdosing on rehospitalization rates in congestive heart failure. Am J Cardiol 1998; 82: 465-469. Rutten FH, Grobbee DE, Hoes AW. Differences between general practitioners and cardiologists in diagnosis and management of heart failure: a survey in every-day practice. Eur J Heart Failure 2003; 5: 337-344. Grant RW, Hamrick HE, Sullivan CM, et al. Impact of population management with direct physician feedback on care of patients with type 2 diabetes. Diabetes Care 2003; 26: 2275-2280 Cleland JGF, Cohen-Solal A, Aguilar JC, Dietz R, Eastaugh J, Follath F et al. Management of heart failure in primary care (the IMPROVEMENT of Heart Failure Programme): an international survey. Lancet 2002; 360(9346): 1631-1639

Perceived barriers

58

Chapter 4

Chapter 5 Current treatment of chronic heart failure: Do physician, organisational and patient characteristics have an impact in general practice? W.N. Kasje, P. Denig, R.E. Stewart, P.A. de Graeff, and F.M. HaaijerRuskamp Aims: To assess the influence of physician, organisational and patient characteristics on the treatment of chronic heart failure in primary care with ACE inhibitors. Methods and Results: Data from 735 randomly selected heart failure patients were extracted from the medical records of 97 general practitioners. Physician and organisational data were collected by means of a questionnaire. Multilevel analysis was used to assess the effect of physician, organisational and patient factors simultaneously on the treatment of an angiotensin converting enzyme (ACE) inhibitor both in terms of prescription rate and dosage. Dispensing GPs were more likely to prescribe an ACE inhibitor to their CHF patients. Patients who visited a cardiologist or an outpatient heart failure clinic were more likely to get an ACE inhibitor. In addition, relatively young, male patients and patients already using a diuretic were more likely to receive an ACE inhibitor. Furthermore, male patients and patients with concomitant hypertension were more likely to receive a higher ACE inhibitor dosage. Conclusion: In general practice, differences in ACE inhibitor prescribing seem to be linked more to patient characteristics than physician characteristics. Interventions to improve the quality of care should therefore be aimed at specific patient groups. Specialised care, particularly through outpatient clinics, could lead to improvement in use of ACE inhibitors.

British Journal of General Practice. 2004 (submitted)

Introduction Chronic heart failure (CHF) leads to high morbidity and mortality rates. It is estimated that half of the patients die within 5 years after diagnosis 1 . Several clinical trials have shown that with appropriate treatment CHF patients can survive longer with reduced morbidity. Most guidelines recommend angiotensin converting enzyme (ACE) inhibitors as standard therapy for all chronic heart failure patients 2 . Although the rates of prescription differ between countries 3 , ACE inhibitors are generally underused in general practice, both in terms of percentage of patients receiving this treatment and of dosage prescribed 4,5 . A Dutch study examining trends in prescribing for heart failure patients showed over the period 1996-2000 that the percentage of patients receiving ACE inhibitors remained low and no significant increase in the use of ACE inhibitors was seen 6 . Many interview and questionnaire studies have been conducted to assess barriers to effective management of heart failure. These studies revealed a number of problems that general practitioners perceive, such as difficulties with establishing an accurate diagnosis, lack of time and available resources, poor communication between primary and secondary care, and fears about using ACE inhibitors in elderly and frail patients 7-10 . Other studies focussed particularly on specialist type, indicating that cardiologists use echocardiography more frequently than general practitioners (GPs), and they prescribe ACE inhibitors both more frequently and in a higher dosage 11,12. Relevant patient characteristics associated with quality of heart failure care were gender and age. Female and elderly patients were less likely to be referred to a specialist or to a hospital outpatient clinic, had less access to echocardiography, and received less ACE inhibitor treatment 3,13-15 . The influence of organisational factors has also been studied 16 . After hospital discharge, patients attending heart failure clinics were found to receive more adequate doses of ACE inhibitor than those in primary care 17 . Lack of resources, especially poor access of echocardiography, was related to difficulties in diagnosis and a barrier for management of heart failure 7 . None of these studies, however, examined physician, organisational and patient factors in relation to each other, although it has been shown that there may be relevant differences in patient population at physician or organisational level 12,18 . At patient level, characteristics such as age and gender are clearly related in the way they affect the management of heart failure 15 . Therefore, it is important to examine all variables simultaneously. The aim of this study is to assess the influence of physician, organisational and patient characteristics on the quality of chronic heart failure treatment in primary care. The focus is on both treatment with an ACE inhibitor and the dosage of the ACE inhibitor.

60

Chapter 5

Method Study design and population

This study was part of the baseline of a larger study conducted from September 2001 to May 2002 in the north of the Netherlands, evaluating two audit programs for peer review groups focussing on the treatment of CHF and treatment of hypertension in diabetic patients 19 . A total of 95 GPs participated in this study. Physician and organisational characteristics were measured by a structured questionnaire. All patients with ICPC code K77 20 or with the following text ‘heart failure’, ‘cardiac asthma’, ‘cardiac decompensation’ or ‘left ventricular dysfunction’ in their medical records have been selected from the medical records. The GPs were asked to verify the CHF diagnosis. From this list of patients, data were extracted by trained data extractors from GPs computerised medical records for a random sample of ten CHF patients per GP or practice. In addition, all cases were screened to exclude misclassification, and to exclude patients with diabetes mellitus as comorbidity. These patients were excluded because they fell into both the control and intervention groups for the larger study. Data were collected on patient prescriptions of cardiovascular medication, on possible contra-indications for cardiovascular drugs, and on previous medication problems as mentioned in the medical record. All prescriptions with a start date no more than six months prior to data collection were included. This time window was chosen to adjust for prescriptions collected at irregular times. In the Netherlands, chronic medication is commonly prescribed for a three-month period. Outcome variables

Outcome variables were based on recommendations given in the regional as well as national treatment guidelines; an ACE inhibitor is the drug of first choice and its dosage should be maximised 21 . The first outcome measure focussed on whether an ACE inhibitor was prescribed or not. The second outcome measure was the average standardised dosage of the ACE inhibitors prescribed. ACE in hibitor dosages were converted to enalapril-equivalent dosages according to the target daily doses recommended for heart failure in the Dutch reference desk book 22 . This method has been used before 23 , and uses enalapril 20 mg as reference dose with equivalent doses of captopril 150 mg, ramipril 10 mg, quinapril 20 mg, lisinopril 20 mg, fosinopril 40 mg, perindopril 4 mg. Determinants

Determinants included at the physician level were the GP’s gender, work experience (<10 years, 10 to 20 years, > 20 years), and dispensing status (GPs who dispense medicines themselves or not). Size and type of the practice (singlehanded versus partnership), and location of the practice were measured as

61

Current treatment of chronic heart failure

organisational characteristics at the physician level. The practice location was classified as urban, urbanisation or rural. Patient demographics included were age and gender. Age was divided in patients aged 85 years and over, and under 85 years since the choice for an ACE inhibitor is decreasing sharply over the age of 85 24 . Other patient characteristics included were comorbidities documented in the medical record, such as cerebrovascular disease (stroke, transient ischemic attack), hypertension, angina, peripheral vascular disease, atrial fibrillation, and the presence of COPD or asthma. In addition, serum creatinine above normal level (defined as > 80 µmol/l for females and > 110 µmol/l for males) was included as a factor which may influence the choice of treatment. The use of a diuretic was included as GPs indicated to be reluctant to prescribe or increase the dosage of an ACE inhibitor when patients are already treated with a diuretic 9,25. Finally, the objectivity of the diagnosis of heart failure was included in the model. The latter was constructed from a registered ejection fraction below 40% and/or an echocardiography indicating heart failure or left ventricular dysfunction. Organisational factors included in the analysis at patient level were visits to a CHF outpatient clinic, hospitalisations and referrals to a cardiologist during the previous year. Since a patient may remain under the care of a cardiologist for longer periods without a new referral, we also included the influence of referrals to a cardiologist during the last three years. Statistical analysis

Multilevel analysis was used to assess the influence of physician, organisational, and patient characteristics simultaneously on each of the outcome variables. Two random intercept models with two levels were estimated taking into account the clustering of patients within the practice of a GP. A logistic regression model was used for treatment with an ACE inhibitor as a dichotomous outcome variable. To estimate the effect of the determinants on average ACE inhibitor dosage a regression model was built with the standardised dosage as continuous outcome variable 26 . Organisational characteristics were included in the model at both GP and patient level. The intra-class correlation coefficient (ICC) was calculated to assess whether the variance at the physician level differed from zero, i.e. whether differences between GPs were relevant when controlling for the effects of the other characteristics included in the model. When the ICC is too low, a non-hierarchical regression model will be calculated. The deviance test was used to evaluate whether the determinants in the model are a good fit for predicting the outcome variable, comparing the final with the empty two-level model. A possible interaction effect between age and gender of the patient was built-in the first model, because it is known that especially older women may receive more diuretics and less ACE inhibitors 13 . The influence of referrals to a cardiologist 62

Chapter 5

Table 1. Patient factors registered in the medical records

Mean ± SD

N

Age (yrs)

76.3 ± 11.4

735

Creatinine (µmol/l)

123.6 ± 67.7

248

Potassium (mmol/l)

4.3 ± 0.6

207

3.3 ± 3.2

446

Objective diagnosis 1

%

11

Duration of CHF (yrs) Male

52 35.1 ± 14.1

Ejection fraction

43

Cerebrovascular disease

7

Myocardial infarction

26

Angina pectoris

28

Atrial fibrillation

33

Hypertension

32

Peripheral vascular disease

4

COPD or asthma

32

Organisational characteristics Hospitalisation in previous year

20

Specialist care in previous year

33

Care by outpatient heart failure clinic in previous year

3

Treatment (%) No medication

10

ACE inhibitor

47

AII-antagonist

8

Diuretic

67

1 patients

with a documented ejection fraction below 40% and/or an echocardiography confirming heart failure or left ventricular dysfunction

during the last year or during the last three years was analysed in two separate models. Results Characteristics of the population (Tables 1 and 2)

Most of the 95 GPs were male (85%) and their mean age was 47 years. The majority worked in a single-handed practice (58%), and in a rural area (61%). Of the 735 CHF patients, 52% was male and their mean age was 76 years. The average recorded duration of their heart failure was 3.3 years. An ejection fraction was documented in less than 6% of the patients’ medical records. Thirty-three percent had been referred to a cardiologist in the previous year, whereas 49% had a referral in the last three years (not in Table 1). Only 3% visited an outpatient heart failure clinic. The theoretical number of 970 patients was not achieved as not 63


all practices could provide ten CHF patients due to a relatively young patient population. Furthermore, patients with a comorbidity of diabetes and misclassified patients were excluded. Most CHF patients (67%) were treated with diuretics, as monotherapy or in combination with other medication. Forty-seven percent were treated with ACE inhibitors, and another 8% received an angiotensin-II antagonist. A noteworthy proportion of patients (10%) did not receive any medical CHF treatment. The medical history of four patients, who did not receive an ACE inhibitor, reported cough as the reason to stop ACE inhibitor use. Other side effects were mentioned for another four patients as a reason to stop using an ACE inhibitor. For six patients ACE inhibitors were stopped without any reason mentioned in the medical record. Table 2. General practitioner and practice characteristics (n=95) Mean ± SD Age (yrs) Male

%

46.9 ± 6.4 85

Work experience <10 yrs

30

10-20 yrs

32

> 20 yrs

38

Dispensing doctor

25

Organisational characteristics Single-handed practice

58

Practice Location Urban

30

Urbanisation

8

Rural

62

Characteristics associated with ACE inhibitor therapy (Table 3)

In the multilevel model, the intraclass correlation coefficient (ICC=.061) showed that there were differences between GPs in prescribing behaviour of ACE inhibitors. Only one physician characteristic included in the model did explain these differences. Dispensing GPs were more likely to prescribe an ACE inhibitor. An organisational characteristic found to have a significant impact after adjusting for patient characteristics was the CHF outpatient clinic. Patients who were visiting a heart failure outpatient clinic had a higher chance of being prescribed an ACE inhibitor. In the model including all referrals to a cardiologist in the previous three years, patients who had been referred were more likely to receive an ACE inhibitor (odds 1.85; 95% CI 1.28-2.68, model not shown).

64

Chapter 5

Table 3. Multilevel l ogistic model predicting treatment with an ACE inhibitor and linear regression model predicting the dosage of the ACE inhibitors prescribed Treatment with ACE inhibitor (N=735) odds (CI 95%)

Dosage ACE inhibitor (N=320) regression coefficients (CI 95%)

Physician level Physician characteristics Gender (male)

1.15 (0.65-2.04)

Work experience <10 yr Work experience 10-20yr Work experience >20yr

1.00 0.81 (0.50-1.31) 1.08 (0.68-1.70)

Dispensing

1.65* (1.04-2.61)

Organisational characteristics Practice type (single-handed)

1.27 (0.82-1.97)

Practice location urban Practice location urbanisation Practice location rural

1.00 1.28 (0.63-2.58) 1.24 (0.74-2.07)

Practice size

1.00 (0.99-1.00)

Patient level Patient characteristics Age Gender

0.52* (0.34-0.80)

1.98

(-1.54 - 5.50)

1.59* (1.12-2.25)

-2.69* (-5.19 - -0.20)

Objective diagnosis

1.76 (0.99-3.15)

-1.70

(-5.52 - 2.12)

Myocardial infarction

0.90 (0.60-1.35)

-1.70

(-4.50 - 1.10)

Hypertension

1.31 (0.92-1.86)

4.87*

(2.35 - 7.40)

Peripheral vascular disease

0.81 (0.35-1.89)

2.10

(-4.34 - 8.55)

Atrial fibrillation

1.23 (0.87-1.75)

-0.81

(-3.34 - 1.71)

Angina pectoris

0.98 (0.68-1.42)

-1.98

(-4.67 - 0.70)

COPD or asthma

0.87 (0.61-1.25)

-0.99

(-3.63 - 1.65)

Cerebrovascular diseases

0.77 (0.41-1.45)

-3.22

(-8.03 - 1.60)

Creatinine > normal

1.21 (0.81-1.82)

-1.22

(-3.97 - 1.52)

Diuretic

1.86* (1.30-2.66)

-2.27

(-5.03 - 0.50)

Interaction term gender*age

0.49 (0.21-1.18)

1

Organisational characteristics Hospitalisation

1.47 (0.95-2.30)

-1.27

(-4.26 - 1.72)

Outpatient heart failure clinic

3.84* (1.23-12.07)

2.78

(-3.25 - 8.81)

Specialist care (< 1 year)

1.42 (0.97-2.08)

-1.37

(-3.83-1.09)

* significant at p<.05 level with 95% confidence interval 1 the reference category was male in the ACE inhibitor model but female in the dosage model

65


After adjusting for all other characteristics, male patients and patients who were using a diuretic had a higher probability of receiving an ACE inhibitor, whereas patients over the age of 85 had less chance of receiving an ACE inhibitor. The deviance test for the treatment model was significant (Chi-squared = 41.53, df = 23, p< .05) indicating that the fit of the model was sufficient for predicting treatment with an ACE inhibitor. Characteristics associated with ACE inhibitor dosage (Table 3)

Of the 320 patients who received an ACE inhibitor for which the dosage was registered, the average enalapril equivalent dose was 13.5 mg. In the multilevel model predicting the ACE inhibitor dosage, the intraclass correlation coefficient was 0.018, and the deviance test showed that the multilevel model did not provide a significant fit (Chi-squared=16.47, df=23, p>.05). Therefore, the results of the normal linear regression model are presented. After adjustment for all other patient characteristics, females were less likely to receive a high dosage than males. CHF patients with an additional comorbidity of hypertension were more likely to receive higher dosages of the ACE inhibitor. Discussion Quality of care in patients with heart failure may be influenced by factors that are related to the patients themselves, the GPs or the way that this care is organised. In this study these characteristics are studied in one model to explain differences in terms of patients receiving an ACE inhibitor and the dosages used, thereby taking into account possible confounding factors at different levels. After controlling for the influence of patient characteristics, only one of the GP or practice characteristics had an impact on the prescribing of an ACE inhibitor but there was no impact on the dose of these drugs. GPs that are allowed to dispense drugs were prescribing more ACE inhibitors than their colleagues. These dis pensing GPs are different with regard to the area they work in, which is usually a rural environment. Although the average consumption of drugs is lower in such areas, dispensing GPs have been shown to prescribe more drugs to their patients than their non-dispensing colleagues in the same area 27 . A beneficial effect on the use of ACE inhibitors could be demonstrated when patients had attended an outpatient heart failure clinic, although this involved only a small percentage of patients. It has been suggested that given the complicated treatment of heart failure and comorbid diseases, the multifaceted approach of heart failure clinics may be better equipped for treating chronic heart failure patients than general practitioners alone 16 . Patients with a referral to a cardiologist in the last three years were also more likely to receive an ACE inhibitor. These findings show that earlier described differences observed in treatment patterns

66

Chapter 5

between general practitioners and cardiologists remain significant after adjustment for differences in patient population. The diagnosis of heart failure in general practice is often based on symptoms and signs 28 . This may in part explain why 10 percent of the CHF patients in our study were not using medication. Especially for patients in NYHA classes 1 and 2 the percentage of CHF patients receiving no drug treatment was found to be high 29 . In our study, the recording of an objectively made diagnosis based on an echocardiography or ejection fraction was associated with a somewhat higher use of ACE inhibitors but this was not significant. It should be noted, however, that we adjusted for specialist care, and there were only 9 patients who had an objective diagnosis without such specialist care. The finding that elderly patients were prescribed less ACE inhibitors than younger patients has been shown several times before. GPs seem reluctant to prescribe these drugs in heart failure patients aged 85 years and over, despite recent findings showing their benefits in very old and frail patients 1 . After adjusting for age, female patients were also less likely to receive ACE inhibitors. This is in contrast to a previous study where the influence of gender decreased after controlling for age 15 , but in line with a large international study 3 . Our findings did not support the concept that women are less likely to receive ACE inhibitor treatment because of a lower referral rate 30 . It therefore seems more likely that low ACE inhibitor use in these patients is explained by a general attitude of using less aggressive treatment in female patients 24 . This notion is strengthened in our study by the finding that, even after adjusting for age, female patients were also more likely to receive a low ACE inhibitor dose. Patients on diuretics had a greater chance to receive an ACE inhibitor that could not be attributed to relevant comorbidities. Most treatment guidelines recommend to prescribe an ACE inhibitor in addition to a diuretic, but general practitioners have expressed the fear for hypotension and reluctance to start an ACE inhibitor in patients already using diuretics 9 . Apparently, these concerns do not prevent them from prescribing ACE inhibitors. Patients having a comorbidity of hypertension were more likely to receive a higher ACE inhibitor dose. This relationship between concomitant hypertension and target dose has been observed before 31,32, and may indicate that hypertension is treated more aggressively than CHF in general practice. In the medical records of 14 patients we could determine that an ACE inhibitor had been used in the past but stopped with or without a documented reason. This can not sufficiently explain the lack of ACE inhibitor use. The use of angiotensinII-antagonists, which may be considered as alternative in patients who cannot tolerate ACE inhibitors, was small. Our study does have some limitations. The population of GPs in our study including a relative large proportion of single -handed, male, dispensing GPs is 67


typical for our region. This regional selection may influence drawing conclusions about the quality of treatment in general, but it does not limit the analysis of factors influencing this quality. Excluding the subgroup of CHF patients with concomitant diabetes from our study forms a limitation since ACE inhibitors are prescribed more frequently in this group of patients 5 . The use of medical records implies that only clinical information known and considered relevant by the general practitioners has been included; therefore under-recording of especially normal findings is likely 12 . In our analyses, we assume that no registered measurement implies no abnormal finding, but some of these patients may have an undocumented abnormal finding. Prescriptions are made electronically by the GPs in our study, and are automatically recorded in the medical records. Only initial prescriptions of specialists may be missed, but chronic medication started by a specialist will usually be continued by the general practitioner and then recorded in the medical record. In conclusion, underuse and underdosing of ACE inhibitors in general practice are not linked to general GP characteristics, such as work experience or gender. Specialised care, for instance through outpatient heart failure clinics, could lead to improvement in use of ACE inhibitors. Aside from physician and organisational factors, patient characteristics, such as gender and age, concomitant hypertension and use of a diuretic, determine whether heart failure patients are treated with an ACE inhibitor in appropriate dosages. Interventions should therefore be aimed at assisting GPs to improve quality of care for specific patient groups. References 1

2

3

4

5

68

Gambassi G, Lapane KL, Sgadari A, Carbonin P, Gatsonis C, Lipsitz LA et al. Effects of angiotensin-converting enzyme inhibitors and digoxin on health outcomes of very old patients with heart failure. SAGE Study Group. Systematic Assessment of Geriatric drug use via Epidemiology. Arch Intern Med 2000; 160(1): 53-60. Kulig M, Erika S, Norbert WS. Comparing methodological quality and consistency of international guidelines for the management of patients with chronic heart failure. Eur J Heart Fail 2003; 5(3): 327-335. Cleland JG, Cohen-Solal A, Aguilar JC, Dietz R, Eastaugh J, Follath F et al. Management of heart failure in primary care (the IMPROVEMENT of Heart Failure Programme): an international survey. Lancet 2002; 360(9346): 1631-1639. Nilsson G, Strender LE. Management of heart failure in primary health care. A retrospective study on electronic patient records in a registered population. Scand J Prim Health Care 2002; 20(3): 161-165. Komajda M, Follath F, Swedberg K, Cleland J, Aguilar JC, Cohen-Solal A et al. The EuroHeart Failure Survey programme--a survey on the quality of care among patients with heart failure in Europe. Part 2: treatment. Eur Heart J 2003; 24(5): 464-474.

Chapter 5

6

7

8 9

10

11

12

13

14

15

16

17

18

69

Pont LG, Sturkenboom MC, Van Gilst WH, Denig P, Haaijer-Ruskamp FM. Trends in prescribing for heart failure in Dutch primary care from 1996 to 2000. Pharmacoepidemiol Drug Saf 2003; 12(4): 327-334. Khunti K, Hearnshaw H, Baker R, Grimshaw G. Heart failure in primary care: qualitative study of current management and perceived obstacles to evidence-based diagnosis and management by general practitioners. Eur J Heart Fail 2002; 4(6): 771777. Hickling JA, Nazareth I, Rogers S. The barriers to effective management of heart failure in general practice. Br J Gen Pract 2001; 51(469): 615-618. Fuat A, Hungin AP, Murphy JJ. Barriers to accurate diagnosis and effective management of heart failure in primary care: qualitative study. BMJ 2003; 326(7382): 196. Horne R, Coombes I, Davies G, Hankins M, Vincent R. Barriers to optimum management of heart failure by general practitioners. Br J Gen Pract 1999; 49(442): 353-357. Edep ME, Shah NB, Tateo IM, Massie BM. Differences between primary care physicians and cardiologists on management of congestive heart failure: Relation to practice guidelines. J Am College Cardiol 1997; 30: 518-526. Rutten FH, Grobbee DE, Hoes AW. Differences between general practitioners and cardiologists in diagnosis and management of heart failure: a survey in every-day practice. Eur J Heart Fail 2003; 5(3): 337-344. Mejhert M, Holmgren J, Wandell P, Persson H, Edner M. Diagnostic tests, treatment and follow-up in heart failure patients--is there a gender bias in the coherence to guidelines? Eur J Heart Fail 1999; 1(4): 407-410. Johansson S, Wallander MA, Ruigomez A, Garcia R. Treatment patterns among newly diagnosed heart failure patients in general practice. Eur J Clin Pharmacol 2002; 57(11): 813-817. Hood S, Taylor S, Roeves A, Crook AM, Tlusty P, Cohen J et al. Are there age and sex differences in the investigation and treatment of heart failure? A population-based study. Br J Gen Pract 2000; 50(456): 559-563. Grady KL, Dracup K, Kennedy G, Moser DK, Piano M, Stevenson LW et al. Team management of patients with heart failure - A statement for healthcare professionals from the Cardiovascular Nursing Council of the American Heart Association. Circulation 2000; 102(19): 2443-2456. Akosah KO, Schaper AM, Havlik P, Barnhart S, Devine S. Improving care for patients with chronic heart failure in the community: the importance of a disease management program. Chest 2002; 122(3): 906-912. Ahmed A, Allman RM, Kiefe CI, Person SD, Shaneyfelt TM, Sims RV et al. Association of consultation between generalists and cardiologists with quality and outcomes of heart failure care. Am Heart J 2003; 145(6): 1086-1093.


19 Schaars CF, Denig P, Kasje WN, Stewart RE, Wolffenbuttel BHR, Haaijer-Ruskamp FM. Physician, organizational, and patient factors associated with suboptimal blood pressure management in type 2 diabetic patients in primary care. Diabetes Care 2004; 27(1): 123-128. 20 WONCA. ICPC International Classification of Primary Care. 1 ed. Oxford: Oxford University Press, 1987. 21 Proeftuin Farmaceutische Zorg. The Groningen transmural guidelines. 1 ed. Groningen: 2000. 22 CVZ (National Health Insurance Board). Desk reference book. Utrecht: CVZ, 2003. 23 Luzier AB, Forrest A, Adelman M, Hawari FI, Schentag JJ, Izzo JL, Jr. Impact of angiotensin-converting enzyme inhibitor underdosing on rehospitalization rates in congestive heart failure. Am J Cardiol 1998; 82(4): 465-469. 24 Gambassi G, Forman DE, Lapane KL, Mor V, Sgadari A, Lipsitz LA et al. Management of heart failure among very old persons living in long-term care: has the voice of trials spread? The SAGE Study Group. Am Heart J 2000; 139(1 Pt 1): 85-93. 25 Houghton AR, Cowley AJ. Why are angiotensin converting enzyme inhibitors underutilised in the treatment of heart failure by general practitioners? Int J Cardiol 1997; 59(1): 7-10. 26 Snijders T, Bosker R. Multilevel analysis. An introduction to basic and advanced multilevel modeling. 2 ed. London: SAGE, 2002. 27 SFK (Stichting Farmaceutische Kengetallen). Pharmacy in numbers. Pharmaceutisch Weekblad 2001; 136(31): 1121. 28 Khunti K, Baker R, Grimshaw G. Diagnosis of patients with chronic heart failure in primary care: usefulness of history, examination, and investigations. Br J Gen Pract 2000; 50(450): 50-54. 29 Pont LG, Van Gilst WH, Lok DJ, Kragten HJ, Haaijer-Ruskamp FM; Dutch Working Group on Heart Failure. The relevance of heart failure severity for treatment with evidence-based pharmacotherapy in general practice. Eur J Heart Fail 2003 Mar; 5(2): 187-93. 30 Shah MR, Granger CB, Bart BA, McMurray JJV, Petrie MC, Michelson EL et al. Sexrelated differences in the use and adverse effects of angiotensin-converting enzyme inhibitors in heart failure: The Study of Patients Intolerant of Converting Enzyme Inhibitors Registry. Am J Med 2000; 109(6): 489-492. 31 Chen YT, Wang Y, Radford MJ, Krumholz HM. ACE inhibitor dosages in elderly patients with heart failure. Am Heart J 2001; 141(3): 410-417. 32 Manyemba J, Mangoni A, Pettingale K, Jackson S. Determinants of failure to prescribe target doses of angiotensin-converting enzyme inhibitors for heart failure. Eur J Heart Fail 2003; 5(5): 693-696.

70

Chapter 5

Chapter 6 Physician, organizational, and patient factors associated with suboptimal blood pressure management in type 2 diabetic patients in primary care C. F. Schaars, P. Denig, W.N. Kasje, R.E. Stewart, B.H.R. Wolffenbuttel, and F.M. Haaijer-Ruskamp Objective: To assess the quality of hypertension care in patients with type 2 diabetes in general practice and identify physician, organizational, and patient factors associated with suboptimal care. Research design and methods: Data from 895 randomly selected diabetic patients were extracted from electronic medical records of 95 general practitioners. Physician and organizational characteristics were collected with a questionnaire. We conducted a multilevel analysis to identify associations with blood pressure registration, hypertension treatment, and achievement of target blood pressure levels. Results: For 652 patients (73%), a blood pressure measurement was recorded in the last year. Of these patients, 132 (20%) reached a target level of 135/85mmHg. In total, 595 patients were classified as having hypertension, of whom 192 received no treatment (32%), 193 received an ACE inhibitor (32%), and 219 received other antihypertensives. Patients visiting a diabetes facility, referred to a specialist, with a female general practitioner, or with a general practitioner with less than 10 years work experience had better recordings of their blood pressure. Suboptimal treatment was higher in older patients and smoking patients. Treatment was better in patients with coronary comorbidity, hyperlipidemia, or those referred to a specialist. Not achieving the blood pressure target was related to older age of the patients. Conclusions: Hypertension management of type 2 diabetic patients in primary care is suboptimal. Characteristics of general practitioners as well as additional care provided by a diabetes facility or a specialist are associated with better processes of care, but blood pressure outcomes are not as clearly related to these factors.

Diabetes Care, 2004. Vol. 27,1:123-128

Introduction Treatment guidelines uphold stringent target levels for blood pressure control in patients with diabetes because this significantly reduces the risk of developing cardiovascular and microvascular diseases. This has not resulted in adequate blood pressure control 1 . Suboptimal management in both diagnosis and treatment of hypertension in type 2 diabetic patients has repeatedly been shown 1–6 . The quality of diabetes management can be influenced by physician, organizational, and patient factors 7 . Variation in quality of care has been found between physicians as well as patients 5,6,8–11 . Factors of influence are the age and work experience of the physician, size of the practice, presence of a recall system, and proportion of patients attending hospital clinics 5,9,11 . Patient characteristics influencing the quality of diabetes and blood pressure management include age, sex, ethnicity, and presence of comorbidities, such as coronary artery disease 6,10,12–14 . To determine which aspects interventions should target for change, the influence of physician-related factors on the quality of care must be assessed in relation to the impact of patient-related factors 15 . In a multilevel approach, one can account for possible confounding effects of patient characteristics or case-mix differences on the physician or practice level. Recently, a study using this approach 16 showed that poor blood pressure outcomes in type 2 diabetic patients depended partly on the organizational setting and the physician’s sex. No attention was paid to the management activities performed by the physicians, leaving unanswered questions about the association between these factors and the blood pressure monitoring and treatment. The aim of this study is to identify the relative influence of physician, organizational, and patient factors on the quality of blood pressure management in type 2 diabetic patients in primary care. Quality of management is assessed in terms of registration of blood pressure, treatment of hypertension, and achievement of blood pressure target levels. Methods This study is part of a larger study evaluating the effect of two audit programs for general practitioner peer review groups on the management of hypertension in type 2 diabetes and on the management of heart failure. The study was conducted in 21 peer groups consisting of 150 general practitioners in the northern region of the Netherlands. In total, 95 general practitioners were included in this study (Fig. 1). Physician characteristics and organizational factors were determined by a structured questionnaire. All practices were computerized. Patient data were extracted from electronic medical records by trained abstractors who visited the general practitioners in the baseline period from September 2001 to May 2002. A maximum of 10 type 2 diabetic patients were randomly selected per general 72

Chapter 6

practitioner. The general practitioners were asked to verify the diagnosis of the obtained cases. All extracted cases were subsequently screened to exclude remaining cases of type 1, gestational, and steroid-induced diabetes and patients with heart failure as comorbidity (Fig. 1). Patients with this comorbidity were excluded because they fell into both the control and intervention groups for the larger study. Measurements

Patient data included demo graphics, clinical background, and the three most recently registered blood pressure measurements. Data were collected on prescriptions of blood glucose-lowering and antihypertensive medication, possible contraindications for antihypertensive drugs, and previous medication problems mentioned in the medical records. All prescriptions with a calculated end date not more than 3 months before the data collection were included. This time window was chosen to adjust for prescriptions collected at irregular times. In the Netherlands, chronic medication is commonly prescribed for 3-month periods. The outcome variables were based on recommendations given in the regional treatment guideline, i.e., hypertension should be treated in type 2 diabetic patients with a blood pressure >135/85 mmHg, and an ACE inhibitor is the recommended first-choice drug. Because there are other national and international guidelines available those have slightly different recommendations 17 , we included additional outcome variables focusing on the annual registration of blood pressure, the treatment with other antihypertensive drugs, and the continuous range of blood pressure levels. Registration of blood pressure was defined as having at least one blood pressure measurement recorded during the previous year. Treatment of patients with hypertension was subdivided into "no treatment," "treatment with first-choice antihypertensive" (ACE inhibitor), and "treatment with other antihypertensives" (diuretics, ß-blocking agents, calcium-channel blockers, angiotensin II antagonists, -blocking agents, and centrally acting antihypertensives). Patients were defined as having hypertension when this diagnosis was recorded in their medical record or when their average blood pressure during the previous year was >135/85 mmHg. Achievement of target level was defined as having an average systolic blood pressure 135 mmHg and diastolic blood pressure 85 mmHg. General physician and organizational characteristics previously identified as being related to quality of diabetes care were included as explanatory variables 5,7,9,11. Physician factors were the general practitioner’s sex, work experience (10, 10–20, >20 years), and license to dispense medicines.

73

Suboptimal management in hypertension in diabetic patients

Figure 1 — General practitioners (GPs) and patients in the study .

150 GPs invited to participate 50 GPs declined 100 GPs interested in participating

5 GPs not included due to failure to visit the practice

95 participating GPs

Maximum of patients from the 95 GPs(n=950) Available patients from the participating GPs (n=921) Patients included (n=895)

Patients with heart failure, type 1 diabetes, steroid diabetes, gestational diabetes (n=26)

Organizational factors at practice level were the size and type of the practice (single handed versus partnership) and location of the practice (urban, semirural, and rural). Organizational factors included at the individual patient level were visits to a cardiologist or internist for cardiovascular or diabetes-related problems and visits to a diabetes facility during the previous year. Patients can be referred to this diabetes facility for evaluation and education, but the general practitioner retains responsibility for the treatment. Patient characteristics in the analysis included documented cardiovascular risk factors such as smoking, being overweight, hyperlipidemia, and comorbidities, including cerebrovascular disease (stroke and transient ischemic attack), coronary artery disease (angina pectoris and myocardial infarction), and asthma or chronic obstructive pulmonary disease. Statistical analysis

Possible associations were first tested in univariate analyses using 2 tests, t tests, or ANOVA. To assess the influence of physician, organizational, and patient characteristics simultaneously on each of the outcome variables, we used multilevel analysis. Hierarchical models were estimated taking the clustering of 74

Chapter 6

patients (level 1) within the practice of a general practitioner (level 2) into account 18 . Random intercept models were used incorporating random effects at both levels in addition to the levels 1 and 2 explanatory variables. For dichotomous outcome variables, i.e., the registration and achievement of blood pressure levels, hierarchical logistic regression models were estimated using the statistical program MLwiN 19 . Continuous explanatory variables were centered around the mean. For the treatment of hypertension, a mu ltinomial logistic regression model was fitted using the MIXNO program, which allows for the analysis of categorical outcomes 18,20 . The likelihood of receiving treatment with an ACE inhibitor was compared with receiving no antihypertensive treatment and with receiving a treatment with another antihypertensive drug. The deviance test was used to assess whether the proportion of variance at the physician level significantly differed from zero. Finally, a multilevel multivariate regression model was used to estimate the effect of the explanatory variables on diastolic and systolic blood pressures as continuous outcome variables. The multivariate term refers to the two dependent variables (diastolic and systolic blood pressures) that are analyzed jointly 18 . The asthma/chronic obstructive pulmonary disease comorbidity was only included in the treatment model because it may affect the choice of treatment. Furthermore, a possible interaction effect between age and sex of the patient was included in the treatment model because it appears that older women especially receive more diuretics and fewer ACE inhibitors for hypertension 13 . Results Most of the 95 general practitioners were men (85.3%), and their mean age was 47 ± 6.4 years (mean ± SD). Work experience was <10 years for 28.4% and >20 years for 38.9%. The majority worked in a single -handed practice (57.9%) and in a rural area (61.1%). The mean practice size was 2,299 ± 531 patients, and 25.3% were dispensing practices. Of the 895 type 2 diabetic patients, 56% were women, and their mean age was 67 years (Table 1). The average recorded duration of diabetes was 5.5 years, ranging from 0.5 to 31 years (median 4.1). Of the 481 (54%) patients having a recent HbA1c measurement, 36% had a value <7%, whereas 14% had an HbA1c >8.5%. Blood pressure management

Registration of blood pressure in the past year was found in 652 (73%) of the case subjects. In the 243 subjects without recent registration, 115 had blood pressure measurements recorded >1 year before, 80% of which were >135/85 mmHg. Of the 595 type 2 diabetic patients with hypertension, 32% were not receiving antihypertensive treatment, 32% were receiving an ACE inhibitor as monotherapy or in combination with other antihypertensives, and 35% were receiving antihypertensive treatment not including an ACE inhibitor, such as monotherapy 75


with a ß-blocking agent (7.4%), diuretic (5.0%), or treatment including an angiotensin II antagonist (6.3%). As for the number of antihypertensives prescribed, 46% of the 403 treated hypertension patients received monotherapy, whereas 18% received three or more different antihypertensives. Of the patients not receiving ACE inhibitor treatment, five had side effects mentioned in their medical record as reason to quit ACE inhibitor use. In another three patients there was mention of previous ACE inhibitor use, but no reasons for quitting were documented. For another nine patients, problems with medication compliance were stated in their medical records. Table 1— Patient factors registered in medical records (n = 895) Mean ± SD % (SE) Age (years) 67.3 ± 12.7 Duration of diabetes (years) * 5.5 ± 5.2 Diastolic blood pressure (mmHg) † 83.3 ± 9.2 Systolic blood pressure (mmHg) † 149.9 ± 18.2 HbA1c (%) ‡ 7.5 ± 1.2 Female 55.8 (1.7) Hyperlipidemia § 16.0 (1.2) 25.1 (1.5) Overweight ¦ 9.7 (1.0) Smoking 5.9 (0.8) Cerebrovascular disease 17.9 (1.3) Coronary artery disease 14.6 (1.2) COPD/asthma 20.4 (1.4) Specialist care 38.1 (1.6) Care by diabetes facility Antidiabetic treatment No medication 18.2 (1.3) Oral blood glucose lowering drugs 67.5 (1.6) Insulin alone or with oral agents 14.4 (1.2) * available for 599 patients † average blood pressure in the last year in the 652 patients (73%) with available measurements ‡ latest recording in the 481 patients (54%) with HbA1c measurements in the last year § total cholesterol measured in the last year (22%) >5.0 mmol/l and/or hyperlipidemia in the medical record ¦ BMI measured in the last three years (23%) >27 and/or being overweight in the medical record

In the 652 patients with available blood pressure measurements, the mean systolic blood pressure was 150 mmHg and the mean diastolic blood pressure was 83 mmHg (Table 1). Twenty percent of the population with available blood pressure measurements had a blood pressure 135/85, 24% were <140/90, and 66% were <160/95 mmHg. Most of the problems in achieving target levels were seen in the systolic blood pressure because only 21% of the patients achieved a systolic blood pressure 135 mmHg, whereas 63% had a diastolic blood pressure 85 mmHg. There 76

Chapter 6

were four patients with a diastolic blood pressure 60 mmHg, and they all had a systolic blood pressure 120 mmHg. Factors associated with blood pressure management and control

Patient factors associated with a good registration of blood pressure were being overweight and having coronary artery disease (Table 2, model 1). In the univariate analysis, mean duration of diabetes was significantly shorter and HbA1c lower for patients with a blood pressure registration in comparison with those without blood pressure registration (duration 5.2 vs. 6.4 years, P = 0.02; HbA1c 7.4 vs. 7.7%, P = 0.03). Both of these variables could not be incorporated in the multilevel analyses because information was lacking in >30% of patients. Taking all of the other patient factors into account in the multilevel model, patients receiving care from a specialist or the diabetes facility were more likely to have a good blood pressure registration. Adjusting for patient- and practice-related characteristics, patients treated by female general practitioners had a significantly better registration of blood pressure compared with male general practitioners, as did patients treated by general practitioners with <10 years of work experience compared with general practitioners with 10–20 years of work experience. Patients receiving care from a specialist and patients with hyperlipidemia were more likely to be treated with an ACE inhibitor than with no treatment, whereas smokers had a significantly higher chance of not being treated (Table 2, model 2A). Older patients were somewhat more likely to receive other antihypertensive treatments than ACE inhibitors, such as diuretics (Table 2, model 2B). Duration of diabetes and HbA1c were not significantly associated with hypertension treatment. Older patients were less likely to achieve the target level of 135/85 mmHg (Table 2, model 3). No other factors were significantly related to achievement of the target level. In the multivariate model analyzing the continuous values of diastolic and systolic blood pressures, older age of the patients was significantly associated with a lower diastolic blood pressure and a higher systolic blood pressure (data not shown). The deviance tests of random intercept were highly significant in all of the models (2 = 100.5 for blood pressure registration, P < 0.001; 2 = 173.3 for treatment of hypertension, P < 0.001; 2 = 19.9 for blood pressure target level, P < 0.001), indicating that there remained significant differences between general practitioners after controlling for the effect of the included physician, practice, and patient characteristics.

77


78

Table 2— Multilevel analyses for the three aspects of hypertension management Registration of blood pressure (n=895) Model 1

Chapter 6

Patient factors Age Sex (male) Overweight Smoking Hyperlipidemia Coronary artery disease Cerebrovascular disease COPD/asthma Interaction factor age x sex Organizational factors Specialist care Care by diabetes facility Type of practice (partnership) Size of practice Location of practice Urban Semi-rural Rural Physician factors Sex GP (male) Work experience ≤ 10 years 10 to 20 years > 20 years Dispensing doctor

Treatment of hypertension (n=595) No treatment vs. ACE-inhibitor Model 2a

Other treatment vs. ACE-inhibitor Model 2b

Blood pressure target level ≤ 135/85 mmHg (n=652) Model 3

1.01 (1.00-1.03) 0.75 (0.52-1.07) 1.87 (1.16-3.03) 1.05 (0.57-1.93) 1.37 (0.80-2.33) 1.96 (1.16-3.29) 0.88 (0.40-1.92) Not included Not included

1.01 (0.99-1.04) 1.51 (0.76-3.00) 0.92 (0.48-1.79) 3.78 (1.09-13.11) 0.42 (0.19-0.92) 0.52 (0.21-1.29) 1.00 (0.21-4.74) 1.93 (0.78-4.76) 0.98 (0.94-1.02)

1.05 (1.01-1.09) 1.07 (0.61-1.89) 0.85 (0.41-1.77) 3.15 (0.79-12.63) 0.65 (0.26-1.61) 1.62 (0.74-3.57) 2.17 (0.63-7.47) 1.66 (0.64-4.30) 0.97 (0.91-1.02)

0.97 (0.95-0.98) 1.20 (0.78-1.84) 0.67 (0.40-1.11) 1.41 (0.74-2.69) 1.17 (0.66-2.08) 1.38 (0.79-2.40) 0.85 (0.33-2.21) Not included Not included

3.40 (2.00-5.80) 2.37 (1.56-3.61) 1.14 (0.61-2.13) 1.00 (1.00-1.00)

0.40 (0.20-0.80) 1.41 (0.71-2.81) 1.58 (0.75-3.34) 1.00 (1.00-1.00)

0.62 (0.34-1.13) 1.13 (0.57-2.24) 2.17 (0.94-5.00) 1.00 (1.00-1.00)

0.57 (0.32-1.01) 1.15 (0.72-1.84) 1.01 (0.58-1.78) 1.00 (1.00-1.00)

1.00 0.88 (0.30-2.61) 0.88 (0.42-1.85)

1.00 2.43 (0.40-14.97) 0.75 (0.31-1.80)

1.00 1.37 (0.20-9.34) 0.68 (0.30-1.54)

1.00 1.09 (0.45-2.65) 0.58 (0.29-1.15)

0.30 (0.12-0.71)

0.90 (0.35-2.30)

0.53 (0.17-1.62)

0.81 (0.40-1.66)

1.00 0.46 (0.23-0.91) 0.61 (0.31-1.21) 1.72 (0.83-3.55)

1.00 1.03 (0.47-2.24) 1.34 (0.59-3.02) 0.72 (0.30-1.73)

1.00 0.60 (0.26-1.38) 1.02 (0.42-2.51) 1.18 (0.50-2.79)

1.00 0.99 (0.52-1.88) 0.78 (0.42-1.44) 1.14 (0.57-2.25)

Discussion Our study shows that registration of blood pressure in primary care was adequate in 73% of the patients with type 2 diabetes. The proportion of these patients with a blood pressure 135/85 mmHg was 20%, and 24% were <140/90 mmHg. The need for improvement is seen when our results are compared with the goals set by the Diabetes Physician Recognition Program Comparison, which state that in 97% of adult patients a blood pressure should be taken once a year and that the proportion of adult patients with a blood pressure <140/90 mmHg should be 65% 21 . In several clinical trial settings, however, stringent target levels were reached in only 50– 60% of the patients, and it has been suggested that in routine diabetes practice it is more realistic to aim for 75% of patients to be <160/95 mmHg 22 . In our study population, this level was reached in 66% of the subjects. The lack of achievement of blood pressure target levels was largely due to a lack of systolic blood pressure control in this elderly population. There were, however, no patients in this population combining high systolic blood pressure levels with a low diastolic blood pressure. Many hypertensive patients could have had their treatment intensified. The percentage of patients not receiving antihypertensives was 32%, which is comparable with the range of 27– 43% found in other studies 2,4 . In addition, almost half of the patients received only monotherapy for their hypertension. It seems that physicians are willing to accept a higher systolic blood pressure than put forward by the treatment guidelines 23 . A survey among primary care physicians in the U.S. also showed that they were more likely to start or intensify treatment for a mildly elevated diastolic blood pressure than for a mildly elevated systolic blood pressure 24 . Of the hypertension patients treated with medication, less than half received treatment with an ACE inhibitor. Contraindications or documented lack of patient compliance could account for only a very small percentage of this. The use of angiotensin II antagonists, which may be considered an alternative in case of side effects from ACE inhibitors, was relatively small. Assessing the relative influence of specific physician and practice characteristics in relation to patient factors is important for the development of targeted interventions to improve the quality of care 15 . Our study showed that several patient-related factors are associated with the quality of hypertension management. Type 2 diabetic patients with risk factors, such as being overweight and having a cardiovascular comorbidity, had a better blood pressure registration than that of patients without these additional risk factors. From the point of view that stringent blood pressure control is especially needed in a high-risk population, this could reflect an efficient way of dealing with time pressures experienced in general practice 25 . The choice of treatment was also influenced by patient factors. Older hypertensive diabetic patients were more likely to receive other antihypertensives, 79


such as diuretics, instead of ACE inhibitors. This preference for diuretics in older patients has also been described for hypertension treatment in general 26 . Finally, hypertensive patients who smoked were more likely to receive no treatment. It is not clear whether this is partly a patient compliance problem. Patients who cannot be persuaded to stop smoking might also be less motivated to take preventive medication. Controlling for patient- and practice-related factors, there was a significant influence of the physician on the management activities, i.e., blood pressure registration and hypertension treatment. Female physicians showed better blood pressure registrations, as did physicians with <10 years of work experience. Previous studies 11,15 have also shown a positive relation between female physicians and quality-of-care aspects. Regarding the choice of treatment, we could not identify specific general practitioner characteristics that were related to better treatment, but the deviance test showed that there remained significant differences between general practitioners after controlling for the effect of the included physician, practice, and patient characteristics. There may be other characteristics, e.g., personal beliefs about optimal treatment, which may further explain differences between general practitioners. Although Pelligrini et al. 16 showed that physician beliefs about blood pressure management in diabetic patients were not related to blood pressure control, there may be relevant differences in beliefs about the choice of treatment. These could be related to differences in the general practitioners’ preference for following a specific guideline. Most guidelines recommend ACE inhibitors as first-choice drugs, but the Dutch guidelines for general practitioners recommend diuretics in patients without microalbuminuria. Also, target levels recommended in the various guidelines range from 130/80 to 150/85 mmHg 17 . Patients visiting the diabetes facility had a better registration of their blood pressure, but this did not appear to lead to better treatment of hypertension or better achievement of target levels. This is probably due to the fact that the diabetes facility in our study region advises the general practitioners mainly about blood glucose-lowering treatment and only reports the blood pressure measurements to the general practitioner. More active recommendations are probably needed to trigger changes in hypertension treatment. General practitioners may be helped by having an alerting system for patients with consistent suboptimal blood pressure recordings 27 . Specialist care was positively associated with better registration of blood pressure and treatment of hypertension with ACE inhibitors but had no detectable influence on the achievement of target levels. Despite our adjustment for age, sex, and comorbidity of the patients, there may be other patient-related factors explaining why blood pressure levels of patients referred to a specialist are more difficult to control. 80

Chapter 6

The population of general practitioners included in our study was typical for our region, including a relatively large proportion of single-handed, male, dispensing general practitioners. This is a potential limitation for drawing conclusions about the quality of hypertension management in general, but it does not hamper the analysis of factors influencing this quality. A similar restriction should be noted for the patient population because patients with heart failure were excluded. This subpopulation is more likely to have a rigorous monitoring of blood pressure and treatment with ACE inhibitors and ß-blocking agents. The prevalence of heart failure in type 2 diabetes has been estimated at 12% 28 . Another limitation of the study is its reliance on review of medical records. This source reflects the clinical information considered relevant by the general practitioner, but may result in an underestimation of the quality of care 29 . Physicians usually record issues like smoking habits and being overweight more often when present than when absent, but they were found to be quite accurate in recording physical examinations and blood pressures 29,30. Underestimates are expected in the recording of other conditions, such as hyperlipidemia. Assessment of blood pressure levels was limited to patients who had a blood pressure recorded in the last year. Among the 115 patients who did have earlier blood pressure measurements, 80% did not reach the target level, suggesting that our estimates regarding achievement of blood pressure target levels were not much affected by lack of blood pressure registration. As for the registration of drug treatment, 95% of the general practitioners in the Netherlands prescribe electronically and their prescriptions are automatically recorded in the electronic medical records. Only initial drug prescriptions from specialists are usually not recorded in the medical files of the general practitioner. Commonly, specialists’ prescriptions intended for chronic use are repeated by the general practitioners and will subsequently appear in their medical records. We used blood pressure measurements as recorded in the medical records. These are measured by a variety of methods and individuals. Some may be more affected by white coat hypertension than others. This could lead to an overestimation of the number of patients classified as having hypertension. We conclude that hypertension management in type 2 diabetic patients in primary care is suboptimal. Characteristics of the general practitioners as well as additional care provided by a diabetes facility or a specialist are associated with either better registration or better treatment of blood pressure, but blood pressure outcomes are not as clearly related to these factors. Interventions aimed at achieving better process-of-care goals could be targeted at certain general practitioners. To achieve better outcomes of care, however, support should be given in general to intensify the treatment of hypertension, focusing especially on systolic blood pressure. In addition, extra attention is needed for hypertensive patients who smoke.

81


References 1

2

3 4 5

6

7 8

9

10 11 12

13

14

82

Berlowitz DR, Ash AS, Hickey EC, Glickman M, Friedman R, Kader B. Hypertension management in patients with diabetes. the need for more aggressive therapy. Diabetes Care 2003; 26: 355–359. Donnelly R, Molyneaux L, McGill M, Yue DK. Detection and treatment of hypertension in patients with non-insulin-dependent diabetes mellitus. does the "rule of halves" apply to a diabetic population? Diabetes Res Clin Pract 1997; 37: 35–40. Coon P, Zulkowski K. Adherence to American Diabetes Association standards of care by rural health care providers. Diabetes Care 2002; 25: 2224–2229. Geiss LS, Rolka DB, Engelgau MM. Elevated blood pressure among U. S. adults with diabetes, 1988–1994. Am J Prev Med 2002; 22: 42–48. Khunti K, Ganguli S, Baker R, Lowy A. Features of primary care associated with variations in process and outcome of care of people with diabetes. Br J Gen Pract 2001; 51: 356–360. Saaddine JB, Engelgau MM, Beckles GL, Gregg EW, Thompson TJ, Venkat Narayan KM. A diabetes report card for the United States: quality of care in the 1990s. Ann Intern Med 2002; 136: 565–574. Khunti K. Use of multiple methods to determine factors affecting quality of care of patients with diabetes. Fam Pract 1999; 16: 489–494. Arday DR, Fleming BB, Keller DK, Pendergrass PW, Vaughn RJ, Turpin JM, Nicewander DA. Variation in diabetes care among states. do patient characteristics matter? Diabetes Care 2002; 25: 2230–2237. Kenny SJ, Smith PJ, Goldschmid MG, Newman JM, Herman WH. Survey of physician practice behaviors related to diabetes mellitus in the U. S. physician adherence to consensus recommendations. Diabetes Care 1993; 16: 1507–1510. Srinivasan M, Przybylski M, Swigonski N. The Oregon Health Plan. predictors of office-based diabetic quality of care. Diabetes Care 2001; 24: 262–267. Streja DA, Rabkin SW. Factors associated with implementation of preventive care measures in patients with diabetes mellitus. Arch Intern Med 1999; 159: 294–302. Mehta SS, Wilcox CS, Schulman KA. Treatment of hypertension in patients with comorbidities. results from the study of hypertensive prescribing practices. Am J Hypertens 1999; 12: 333–340. Pears E, Hannaford PC, Taylor MW. Gender, age and deprivation differences in the primary care management of hypertension in Scotland. a cross-sectional database study. Fam Pract 2003; 20: 22–31. Frijling BD, Spies TH, Lobo CM, Hulscher ME, Van Drenth BB, Braspenning JC, Prins A, van der Wouden JC, Grol RP. Blood pressure control in treated hypertensive patients. clinical performance of general practitioners. Br J Gen Pract 2001; 51: 9–14.

Chapter 6

15 Davis P, Gribben B, Lay-Yee R, Scott A. How much variation in clinical activity is there between general practitioners? A multi-level analysis of decision-making in primary care. J Health Serv Res Policy 2002; 7: 202–208. 16 Pellegrini F, Belfiglio M, De Berardis G, Franciosi M, Di Nardo B, Greenfield S, Kaplan SH, Sacco M, Tognoni G, Valentini M, Corrado D, D’Ettore A, Nicolucci A. Role of organizational factors in poor blood pressure control in patients with type 2 diabetes. the QuED Study Group. quality of care and outcomes in type 2 diabetes. Arch Intern Med 2003;163: 473–480. 17 Burgers JS, Bailey JV, Klazinga NS, Van der Bij AK, Grol R, Feder G. Inside guidelines: comparative analysis of recommendations and evidence in diabetes guidelines from 13 countries. Diabetes Care 2002; 25: 1933–1939. 18 Snijders T, Bosker R. Multilevel Analysis. An Introduction to basic and advanced multilevel modeling. London, Sage Publications, 1999 19 Goldstein H, Browne WJ, Rasbash J. Multilevel modelling of medical data. Stat Med 2002; 21: 3291–3315. 20 Hedeker D, Gibbons RD. MIXOR: a computer program for mixed-effects ordinal regression analysis. Comput Methods Programs Biomed 1996; 49: 157–176. 21 Diabetes Physician Recognition Program [article online], 2002. Available from http://www.ncqa.org/dprp. Accessed 5 June 2003 22 Winocour PH. Effective diabetes care: a need for realistic targets. BMJ 2002; 324: 1577–1580. 23 Oliveria SA, Lapuerta P, McCarthy BD, L’Italien GJ, Berlowitz DR, Asch SM. Physician-related barriers to the effective management of uncontrolled hypertension. Arch Intern Med 2002; 162: 413–420. 24 Hyman DJ, Pavlik VN. Self-reported hypertension treatment practices among primary care physicians. Arch Intern Med 2000; 160: 2281–2286. 25 Valk GD, Kriegsman DMW, Nijpels G. Treatment of type 2 diabetes mellitus in general practice in the Netherlands. Ned Tijdschr Geneeskd 2001; 145: 1536–1540. 26 Klungel OH, de Boer A, Paes AHP, Seidell JC, Bakker A. Sex differences in antihypertensive drug use: determinants of the choice of medication for hypertension. J Hypertens 1998; 16: 1545–1553. 27 Renders CM, Valk GD, Griffin S, Wagner EH, Van Eijk JT, Assendelft WJJ. Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings (Cochrane Review). Cochrane Database Syst Rev 2001; 1: CD001481. 28 Nichols GA, Hillier TA, Erbey JR, Brown JB. Congestive heart failure in type 2 diabetes: Prevalence, incidence, and risk factors. Diabetes Care 2001; 24: 1614–1619. 29 Luck J, Peabody JW, Dresselhaus TR, Lee M, Glassman P. How well does chart abstraction measure quality? A prospective comparison of standardized patients with the medical record. Am J Med 2000; 108: 642–649.

83


30 Goudswaard AN, Lam K, Stolk RP, Rutten GEHM. Quality recording of data from patients with type 2 diabetes is not a valid indicator of quality of care: a cross-sectional study. Fam Pract 2003; 20: 173–177.

84

Chapter 6

Chapter 7 Evaluating an educational program to improve adherence to joint guidelines in general practice W.N. Kasje, P.Denig, R.E. Stewart, P.A. de Graeff, and F.M. HaaijerRuskamp

Background: Peer review groups are considered helpful for quality improvement in primary care. An educational program for peer review groups was developed, focussing on the implementation of newly developed treatment guidelines. Objective : To evaluate the effect of the program on adherence to regional treatment guidelines in general practice. Methods: A cluster randomised trial using a balanced incomplete block design was used; one arm received a program on treatment of chronic heart failure (CHF), the other on hypertension treatment in diabetes mellitus type 2 (T2DM). A random sample of 10 CHF and 10 T2DM patients per GP was drawn, for whom data were extracted from electronic patient records before and 6 months after the intervention. The outcomes were prescribing of ACE inhibitors, and antihypertensive treatment in T2DM. The effect was analysed separately for both programs using multilevel regression models. Results: All 27 peer review groups in one region in the Netherlands were randomised, of which 16 participated. No significant effects were observed in the CHF group or in the T2DM group. The opportunity for change was limited, since only 53% of the CHF patients and 60% of the T2DM patients had a contact with their GP between the intervention and follow-up measurement. Conclusion: The peer review program was not successful for changing the treatment of chronic patients. Although the programme focussed at dealing with barriers perceived by the participants, not all problems perceived can be solved in a peer group discussion.

Family Practice, 2004 (submitted)

Introduction In the year 2000, regional programs were set up in the Netherlands to improve the quality of treatment across the primary -secondary care interface. The approach chosen in several regions was to develop joint treatment guidelines to be used by both general practitioners and specialists 1 . To implement these treatment guidelines in general practice, an educational program was developed within the context of the existing infrastructure for continuing professional education. In the Netherlands, a nation-wide system of peer review groups exists in general practice focussing on pharmacotherapy. A self-supporting educational program was made for these peer review groups of general practitioners (GPs) and pharmacists. Peer review groups have gained popularity for quality improvement in primary care 2 . They are seen as helpful for improving the quality of patient care, since they encourage professional autonomy and support critical insight in the care provided in daily practice 3 . Some positive results have been found in studies evaluating the effect of peer review groups 4-8 . A combination of peer review and feedback aimed at clear actions appears the most promising approach. The educational program that was developed to implement the joint treatment guidelines included a combination of strategies focussing on education, feedback and social influence. It concentrated on discussing and evaluating current treatment of a chronic disease for a random sample of patients from the GPs’ practices. It aimed to give patient specific feedback in discussion format within the peer review groups, in contrast to common interventions which focus more on general management of a disease 9 . Problems and possible solutions with changing chronic treatment were also discussed in the groups. Packages were made for the treatment of chronic heart failure (CHF), and the treatment of hypertension in type 2 diabetes mellitus (T2DM). Patients with these chronic diseases are regularly seen by general practitioners as well as specialists, indicating that the joint treatment recommendations are especially relevant for the treatment of these patients 10 . In addition, the prevalence of these diseases is rather high, and improvement in treatment is still possible 11-14 . A randomised study was conducted to evaluate the effect of this educational program for peer review groups on adherence to the joint treatment guidelines for two chronic diseases in general practice. A process evaluation was conducted to explain why the program was effective or not 15 . Method Study design

The effect was evaluated in a cluster-randomised trial using a balanced incomplete block design; one arm received the educational program on the treatment of chronic heart failure, and the other arm on hypertension treatment in diabetes mellitus type 2 patients. The CHF-groups provided intervention patients for the

86

Chapter 7

CHF treatment and control patients for the treatment of hypertension in T2DM. The T2DM-groups provided intervention patients for the hypertension treatment in T2DM and control patients for the CHF treatment. A survey was conducted among the GPs who attended the educational program to evaluate the perceived usefulness of the program itself, and their barriers and intentions towards implementing changes. Setting and study population

A regular meeting of the peer review groups in the Groningen region was chosen as the setting for the educational program. The peer review groups usually consist of a small group of general practitioners and community pharmacists working together in a local area. Most groups perform noncommittal consultations on a regular basis, some groups make agreements on pharmacotherapy 16 . It is common for these groups to discuss drug prescribing and management of patients. The contact persons of all 29 known peer review groups in the Groningen region were invited to participate. Two declined at first contact because their group was not active at that moment. The remaining 27 groups (245 GPs) were randomised, and individual GPs were approached for data collection. The participating peer review groups received a small financial reward and additional feedback information regarding changes in prescriptions on group level and individual GP level after the completion of the study. Educational program (described in Box 1)

The self-supporting educational program was made by the Dutch Institute for Rational Drug Use (DGV) that is responsible for the development of material and educational packages for peer review groups in the Netherlands. Each peer review group held one meeting on management of one of the two chronic diseases moderated by a general practitioner or community pharmacist from their group. To prepare for the meeting, the moderator received a package including the intended structure of the meeting (Box 1), supportive overhead sheets, and some background material. The meetings lasted approximately one hour, and were mostly held in the late afternoon or the evening. During these meetings, a summary of the key recommendations in the joint treatment guideline was presented and discussed in relation to the GPs’ personal views on optimal treatment. The GPs were asked to bring data from five of their own patients with one of the diseases to the meeting. These would preferably be a random selection of five of the patients whose treatment was monitored by the researchers to evaluate the effect of the program. The GPs discussed the current management of these patients and received feedback from their colleagues during the meeting. In addition, obstacles perceived for providing care in accordance with the guideline

87

Evaluation of educational program

were discussed and possible solutions sought. Finally, each GP formulated his personal intentions for the future. Box 1: Educational program 1.

2.

3. 4.

Start with an open discussion on the views of optimal treatment. Discuss the recommendations of the joint treatment guidelines: Heart failure − First choice treatment is an ACE-inhibitor − Dosage of ACE-inhibitor should be maximized Hypertension in patients with T2DM − First choice treatment is an ACE-inhibitor − Treatment should be intensified aiming at target blood pressure level of 135/85 mmHg Next, each GP evaluates current management for a random selection of five of his patients, and identified problems in light of the guideline recommendations are discussed in the group. List barriers for changing treatment on a white board, and ask participants to give possible solutions for these barriers. Finally, ask participating GPs to formulate their personal intentions with regard to their patients on paper.

Data collection

Baseline data were collected shortly before the intervention in 2001-2002; followup data were collected around 6 months after the intervention in 2002-2003. Trained abstractors collected patient data from a maximum of 10 randomly chosen CHF patients and 10 randomly chosen T2DM patients per GP. Patients were identified with a computer code or text indicating heart failure (CHF) or diabetes mellitus type 2 (T2DM). Patients with both CHF and T2DM were excluded. Diabetic patients were defined as having hypertension when this diagnosis was recorded in their medical record or when their average blood pressure during the previous year was higher than 135/85 mmHg. The inclusion criteria and data collection has been described in detail elsewhere 10 . The follow-up comprised the same patients as at baseline. For the process evaluation, a questionnaire was administered asking participating GPs to judge the four elements of the educational program as useful, not useful, or not conducted, and to evaluate the structure of the meeting. They were also asked to write down perceived barriers and intentions for implementing changes. Outcome measures

To assess the effect of the educational program on the treatment of chronic heart failure, two outcome measures were selected based on the recommendations in the

88

Chapter 7

joint treatment guideline for CHF. The first outcome measure concerned whether an ACE inhibitor was prescribed or not at follow-up. The second outcome measure was the average standardised dosage of the ACE inhibitors prescribed. ACE inhibitor dosages were converted to enalapril-equivalent dosages according to the target daily doses recommended for heart failure in the Dutch reference desk book 17 . This method has been used before 18 , and uses enalapril 20 mg as reference dose with equivalent doses of captopril 150 mg, ramipril 10 mg, quinapril 20 mg, lisinopril 20 mg, fosinopril 40 mg, perindopril 4 mg. Similarly, the two outcome measures to assess the effect of the educational program on hypertension treatment in T2DM were selected. The first outcome measure was again whether an ACE inhibitor was prescribed or not at follow-up. The second outcome measure was the number of antihypertensives prescribed, since in non-responsive patients more than one antihypertensive is often needed to lower the blood pressure 19 . Other determinants of treatment

Several physician and patient characteristics were included in the statistical analysis which have been found to affect the management of these chronic diseases at baseline 10,20. At the GP level, the GPs’ gender and work experience (< 10 years, 10-20 years and above 20 years) were included; patient characteristics taken into account were the patient’s age and gender, and whether they had a contact with their GP or with a specialist in the six months follow-up period. Furthermore, visits to an outpatient specialised clinic, such as diabetic service and heart failure outpatient clinic, were included in the model. Analysis

To assess the effect of the intervention multilevel analysis was performed to adjust for the clustering of patients within GPs. In this analysis, the impact of physician and patient characteristics was assessed simultaneously with that of the intervention. The baseline value of the outcome variable was included as covariate in all models. In addition, an interaction term between the intervention and the baseline value was included to assess whether the effect of the intervention was dependent on the baseline level of the outcome variable. A multilevel logistic regression model was applied to analyse the effect on ACE inhibitor use, while multilevel regression models were used to assess the effect of the heart failure program on dosage of the ACE inhibitor and the number of antihypertensives for the hypertension in T2DM program. Results Nine groups decided not to participate although some individual GPs were willing to do so. Another two groups had to be excluded from the analysis, because they did not use the provided educational program during the study period. In the 89


remaining ten CHF-groups, 57 of the 97 GPs (59%) could be visited both at baseline and follow-up for patient chart reviews; this was the case for 28 of the 46 GPs (61%) in the six T2DM-groups (Figure 1). Figure 1. Process of participants through trial

27 peer review groups (PRGs)

13 Chronic heart failure PRGs

14 Hypertension in T2DM PRGs

10 PRGs (97 GPs) held educational meeting

6 PRGs (46 GPs) held educational meeting

57 GPs baseline & follow-up 57 GPs process evaluation

28 GPs baseline & follow-up 13 GPs process evaluation

The attendance rate of the GPs at the educational meetings, which was measured in all but two groups, was 76% for the CHF-groups and 67% for the T2DMgroups. The process evaluation questionnaire was completed by 57 of the attending GPs in the CHF-groups (response rate 86%), and 13 GPs in the T2DMgroups (response rate 45%). GPs in the CHF-groups were practising more often in an urban area than GPs in the T2DM-groups (Table 1). There were no major differences in the patient characteristics between patients in both study arms at baseline. Some differences, however, were observed in prescribing patterns. More heart failure patients in the CHF intervention group received diuretics at baseline in comparison to the control group (Table 2). Patients in the T2DM intervention group were prescribed more betablocking agents than patients in the control group. Effect on the treatment of CHF

Half of CHF patients (54%) had a contact with their GP during the six months follow-up; this was comparable in the intervention (53%) and control group (55%). In general, only small changes were achieved in the quality of treatment of this chronic disease irrespective of the educational program. In the intervention group, the percentage of patients receiving an ACE inhibitor increased with 5% to 53% at follow-up. In the control group, there was a 3% increase to 58% at fo llowup. 90

Chapter 7

Table 1: GP characteristics in the both study arms at baseline Heart failure intervention (n=57) 86%

Hypertension in T2DM intervention (n=28) 89%

48 (s.d.6.6)

46 (s.d.6.5)

Work experience <10 yrs 10-20 yrs >20 yrs Dispensing

23% 34% 43% 30%

33% 30% 37% 22%

Practice type (single-handed)

58%

68%

37%

18%*

Sex (male) Age

Practice location (urban) * p<.05

The average dosage of the ACE inhibitor remained the same in the intervention group (13.0 mg (s.d. 10.0) at baseline versus 13.2 mg (s.d. 10.5) at follow-up), but decreased in the control group (13.8 mg (s.d. 7.8) versus 11.6 mg (s.d. 8.8) at follow-up). The multilevel analysis did not show any significant overall effect of the educational program on the treatment nor the dosing of ACE inhibitors in chronic heart failure (Table 3). However, as the interaction term indicates, patients in the intervention group who already received a higher dosage at baseline, had a higher chance of receiving a high dosage at follow-up. Patients who had a contact with their GP did not have a greater chance of getting an ACE inhibitor at follow-up. This chance did appear to be higher in patients who had visited a specialist. One physician characteristic was found to have a significant impact on the quality of CHF treatment at follow-up. Female GPs prescribed ACE inhibitors to more of their heart failure patients than male GPs after the intervention. Effect on the treatment of hypertension in T2DM

More than half of the patients (60%) had a contact with their GP during the six months follow-up. This did not differ significantly between intervention (58%) and control group (61%). Small changes were observed in the quality of treatment of hypertension in diabetic patients after six months, but there was no significant effect that could be attributed to the educational program (Table 4). The percentage of patients receiving an ACE inhibitor increased with 4% to 44% at follow-up in the intervention group, and also with 4% to 36% in the control group. There was an increase in the number of antihypertensives being prescribed to patients in the intervention group (1.45 (s.d. 1.1) at baseline versus 1.62 (s.d. 1.2) at follow-up) and in the control group (1.19 (s.d. 1.2) versus 1.38 (s.d. 1.4) at follow-up).

91


Table 2: Patient characteristics in the both study arms at baseline Factors

Sex (male)

Heart failure Intervention Control (n=333) (n=175) 54% 56%

Hypertension in T2DM Intervention Control (n=186) (n=285) 43% 43%

Age

76 (SD=11.3)

75 (SD=10.5)

69 (SD=10.7)

68 (SD=12.8)

Contact specialist Outpatient clinic

35% 2%

32% 5%*

23% 41%

18% 39%

Hospitalisation

17%

18%

7%

3%

Cerobrovascular diseases Astma/COPD

8% 34%

7% 28%

8% 13%

4% 14%

ACE inhibitors

48%

55%

40%

32%

AII-antagonist Beta-blockers

8% 45%

13% 45%

9% 35%

9% 25%*

Digoxin

28%

25%

-

-

Calcium antagonists Diuretics

18% 76%

13% 63%*

20% 39%

20% 32%

Nitrates

21%

21%

1%

4%

Spironolactone Insulin

18% -

13% -

1% 19%

1% 18%

-

-

74%

78%

Oral antidiabetics *p<.05

Irrespective of the educational program, contact with a GP during the six months follow-up contributed to a higher chance of receiving an ACE inhibitor and more antihypertensive drugs at follow-up. Furthermore, older patients were more likely to get more antihypertensive drugs at follow-up. Evaluation of the educational program

The program was not fully conducted as intended. In all groups, the GPs’ views on optimal treatment in relation to the joint guideline recommendations was discussed, and this was viewed as a useful part of the program by all GPs (Table 5). One third of the GPs in the CHF-groups and three quarter of those in the T2DM -groups did not receive feedback regarding their own patients. For about half of the GPs, the researchers had collected material for a random sample of patients from the GPs’ medical records before the educational meeting. This material could then be used by the GP to bring to the meeting. When this was not the case, the GPs were asked to extract data for five randomly chosen patients themselves before the meeting, but this was often perceived as too difficult or time-consuming. Most of the GPs that did get such feedback rated it as useful.

92

Chapter 7

Table 3: Multilevel logistic model predicting treatment with an ACE inhibitor and multilevel regression model for equivalent dosages of ACE inhibitors in CHF patients Treatment with ACE inhibitor (n=498) adjusted odds ratio (95% CI)

Dosage ACE inhibitor (n=216) regression coefficients (s.e.)

Intervention

1.19 (0.52-2.69)

2.15 (1.08)

Interaction term between intervention and baseline

0.82 (0.22-3.11)

0.23 (0.10)*

Contact with GP (6 months follow-up)

1.05 (0.57-1.94)

0.07 (0.78)

Contact with specialist (6 months follow-up)

2.02 (0.99-4.11)

0.20 (0.88)

Outpatient heart failure clinic

0.38 (0.07-1.97)

0.84 (2.18)

Gender (female)

4.76 (1.64-13.84)*

3.29 (1.68)


1.00 1.17 (0.51-2.70) 1.83 (0.81-4.09)

1.00 -0.22 (1.38) 2.28 (1.28)

Gender

0.90 (0.49-1.66)

-0.09 (0.77)

Age

0.98 (0.96-1.01)

0.02 (0.04)

Physician characteristics

Patient characteristics

* significant with Wald test

The formulation of personal intentions was conducted by two third of the GPs as part of the educational program, but not seen as useful by all. The meetings were perceived as well structured by most GPs. The barrier most often mentioned for changing the CHF treatment was related to perceived difficulties with changing treatment initiated by a specialist (Table 6). Furthermore, some GPs were hesitant to change the treatment of stable CHF patients who already may use many different drugs. One third of the GPs did not mention any barrier for changing their CHF prescribing in accordance with joint guideline recommendations. 75% of the GPs expressed their intention after the meeting that they were going to be more alert on using ACE inhibitors for their CHF patients, and increase the dosage more often.

93


Table 4: Multilevel logistic model predicting treat ment with an ACE inhibitor and multilevel regression model for number of antihypertensives in hypertensive T2DM patients Treatment with ACE inhibitor (n=459) adjusted odds ratio (95% CI)

Number of antihypertensives (n=459) regression coefficients (s.e.)

Intervention

1.49 (0.63-3.53)

0.008 (0.07)

Interaction term between intervention and baseline

0.54 (0.12-2.34)

0.03 (0.06)

Contact with GP (6 months follow-up)

2.18 (1.05-4.52)*

0.15 (0.07)*

Contact with specialist (6 months follow-up)

0.76 (0.32-1.80)

0.13 (0.08)

Diabetes service

1.27 (0.62-2.59)

-0.10 (0.07)

Gender (female)

1.44 (0.47-4.43)

0.03 (0.11)


1.00 1.05 (0.40-2.74) 1.38 (0.58-3.26)

1.00 -0.09 (0.09) -0.01 (0.08)

Physician characteristics

Patient characteristics Gender

1.94 (0.96-3.93)

0.05 (0.06)

Age

1.00 (0.97-1.02)

0.007 (0.003)*

* significant with Wald test

Table 5: Evaluation of the educational program (% of GPs indicating part as useful or good) Parts of the program

Heart failure n= 57 NC

Useful

Not useful

NC

-

100%

-

-

6%

35%

23%

-

77%

7%

9%

92%

-

8%

11%

24%

69%

-

31%

Useful

Not useful

Discussing optimal treatment

100%

-

Evaluating own patients

60%

Discussing barriers

84%

Formulating personal intentions

66%

Good structure of meeting

Hypertension in T2DM n= 13

85%

92%

NC = not conducted

94

Chapter 7

Table 6: Perceived barriers to implement recommendations from joint guidelines Heart failure (n=57) Problems with ACE inhibitors Side-effects (n=9) 16% Difficult to titrate dose (n=5) 9%

Hypertension in T2DM (n=13) Problems with ACE inhibitors Side-effects (n=1) 8%

Other drug problems Changing stable patients Motivating & compliance patients Polypharmacy & complexity Digoxine (place & dosing) Diuretics (stopping)

Other drug problems Polypharmacy & compliance

Organisational problems Changing cardiologist's therapy Tracing problem patients Renal function check None

(n=8) 14% (n=8) 14%

(n=6) 46%

(n=6) 11% (n=2) 4% (n=1) 2% (n=11) 19% (n=6) 11% (n=2) 4% (n=19) 33%

Problems with target level Difficult to reduce tension Dangerous for elderly

(n=4) 31% (n=2) 15%

None

(n=1) 8%

A barrier mentioned by almost half of the GPs that completed the questionnaire on the hypertension in T2DM program, concerned expected problems with compliance from patients already on many drugs (Table 6). Furthermore, several GPs perceived problems with one of the key messages in the program. They felt that the target blood pressure level of 135/85 mmHg was too stringent and difficult to reach. Despite this fact, three quarter of the GPs intended that they were going to aim for the target blood pressure level in their diabetic patients with hypertension.

Discussion A self-supporting educational program for peer review groups was developed to implement joint treatment guidelines. This program had no significant effect on quality of prescribing in two chronic diseases. There were also no clear associations between physician or patient characteristics and improvements in treatment outcomes. Treatment quality did improve somewhat for both diseases regardless of the intervention. Several factors can be pointed out that might explain the lack of effect of the educational program. For a change in prescribing to occur, a contact between the GP and the patient is required. The patient-doctor contact was an important factor explaining improvements in hypertensive treatment in T2DM patients. Only half of the patients did have a contact with their GP during the six months of follow-up. The 95


effect of the intervention is therefore limited to these patients. The educational program might have been more effective when all patients had been contacted by their GP. In CHF patients, a contact with the specialist seemed to influence the treatment more than a contact with the GP, indicating that the GP may often not have the first responsibility for the treatment of these patients . This limits the effect of an intervention that is only aimed at the GPs. Secondly, not all parts of the program were conducted as intended. Incomplete use of an intervention program to implement guidelines has been identified before as possible explanation for its lack of effect to change practice 15 . In most groups, there had been a discussion of the optimal treatment, as well as of barriers to change treatment in line with the key recommendations of the guidelines. The idea was that by sharing experiences and learning from peers possible solutions to perceived barriers might be offered. Although this discussion was considered useful, it was not sufficient to overcome all barriers. The educational program did not address the barriers systematically nor provided the GPs with supportive material or resources to deal with specific barriers. Especially, dealing with treatments initiated by a specialist for heart failure or motivating diabetic patients for additional hypertensive medication was still considered a problem at the end of the meetings. Some GPs in the hypertension in T2DM program did not fully agree with the key recommendation regarding the target blood pressure level of 135/85 mmHg. This recommended target level was considered too stringent or difficult to achieve. GPs appear to consider higher blood pressure levels as acceptable 21 . A recent intervention showed that only a targeted, intensified intervention aimed at multiple risk factors could reduce the blood pressure below 130/80 mmHg in 50% of patients with type 2 diabetes 22 . Most GPs do not have the organisational resources to incorporate such changes into daily practice 23 . Evaluation of the GPs’ own patients at the peer review meetings was seen as useful, but there were problems to conduct this part without external support. As a consequence, a substantial number of GPs did not get any feedback on their own patients. GPs consider lack of adequate support as an important explanation of a lack of effect for an intervention 15 . In addition, the program was set up to evaluate a random selection of patients, so that the GPs would learn how to identify patients in need for change. This implied that some of the patients discussed at the meeting did not have any problems, which might have been considered as less useful. For the GPs it is probably more efficient when a selection of patients, who are not optimally treated, is made for them. Such an approach has shown to lead to an increased adherence to guideline recommendations for patients with type 2 diabetes 24 . Many participating GPs formulated intentions such as prescribing ACE inhibitors in higher dosages or trying to aim for the target blood pressure, but their actual behaviour after six months did not indicate that they followed those intentions. 96

Chapter 7

The GPs themselves did not perceive writing down such intentions as the most useful part of the program. These intentions were made in private and this may not be sufficient to initiate change. Public commitment has more chance to have an impact on changing behaviour than private commitment 25 . Furthermore, one meeting may not be enough to actually change treatment. Behavioural theories stress the importance of repetition, especially for changing routine behaviour. Another factor that may have contributed to the lack of effect was that the educational program focussed on changing the treatment in chronic patients, and its effect was therefore evaluated by the follow-up of patients registered at baseline. It is possible that the program did have some effects for the treatment of newly diagnosed patients, as it is easier to start a new treatment policy in such patients than to change long-term medication in already treated patients 7,8 . Limitations

The high rate of non-participants in the hypertension in T2DM program is a matter of concern. Although this did not lead to clear differences in the patient population studied, it may have lead to differences in the GP population. GPs participating in the hypertension in T2DM program worked more in rural areas, and appeared to prescribe already more in adherence to the joint treatment guidelines, both regarding treatment of hypertension and treatment of heart failure. These baseline differences in prescribing were taken into account in our statistical models. The evaluation of the program was conducted in a selection of the GPs and their patients. Part of this selection was due to logistic problems with collecting the data from the practices in time. However, a third of the GPs was not visited because the GP did not have the time or willingness to do so. We consider it unlikely that the educational program would have had more effect in this less motivated group of GPs. Not all GPs participating in the study actually attended the educational meeting. We conducted the evaluation on an intention-to-treat basis. It is possible that also non-attenders have learned about the key messages addressed at the peer review meeting from their peers or from minutes send to them after the meeting. In a previous study in the Netherlands, no clear relationship was found between actual attendance and the effect of a program conducted in peer review groups 26 . One of the key messages in the both study arms concerned the treatment with ACE inhibitors albeit for a different patient population. This might have led to some transfer effects which may mask the true effect of the intervention. Since there was no difference in effect regarding the other key messages, we believe this does not form a serious limitation.

97


Conclusion

There are no intervention strategies that are successful for changing professional practice in all circumstances. Multifaceted interventions combining educational, behavioural and organisational approaches are promoted as being the most successful, but there is also a call for low-cost intervention programs that are feasible to provide to large numbers of doctors. A self-supporting educational program was developed for peer review groups in general practice. Although it included a combination of strategies focussing on education, feedback and social influence, this program was not successful for changing the treatment of chronic patients. This type of continuing medical education may be considered as a starting point for change, but more active support is probably needed for improving the treatment of patients for whom the current treatment may appear to be sufficient. For such patients, there are little triggers or incentives to change their treatment. A systematic procedure to assist the review and recall of individual patients in daily practice could help GPs to move from intentions to making actual changes.

References 1

2 3

Kasje WN, Denig P, Haaijer-Ruskamp FM. Specialists' expectations regarding joint treatment guidelines for primary and secondary care. Int J Qual Health Care. 2002 Dec;14(6): 509-518. Van Eijk ME. Effects of outreach strategies in quality of pharmacotherapy. University of Utrecht, 2001. Beyer M, Gerlach FM, Flies U, Grol R, Krol Z, Munck A et al. The development of quality circles/peer review groups as a method of quality improvement in Europe: results of a survey in 26 European countries. Family Practice 2003; 20(4): 443-451.

4

Johnston G, Crombie IK, Davies HT, Alder EM, Millard A. Reviewing audit: barriers and facilitating factors for effective clinical audit. Qual Health Care 2000; 9(1): 23-36.

5

Van Eijk ME, Avorn J, Porsius AJ, De Boer A. Reducing prescribing of highly anticholinergic antidepressants for elderly people: randomised trial of group versus individual academic detailing. BJM 2001; 322(7287): 654-657. Wensing M, Van der Weijden T, Grol R. Implementing guidelines and innovations in general practice: which interventions are effective? Br J Gen Pract 1998; 48(427): 991997. Veninga CCM, Denig P, Zwaagstra R, Haaijer-Ruskamp FM. Improving drug treatment in general practice. J Clin Epidemiol 2000; 53(7): 762-772.

6

7

98

Chapter 7

8 9

10

11

12

13

14

15

16

17 18

19

20

21

99

De Vries CS. Collaboration in health care: The tango to drug safety. University of Groningen, 1998. Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay CR, Vale L, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess. 2004 Feb; 8(6): iii-iv, 1-72. Kvamme OJ, Olesen F, Samuelson M. Improving the interface between primary and secondary care: a statement from the European working party on quality in family practice (EQuiP). Qual Health Care 2001; 10(1):33-39. Schaars CF, Denig P, Kasje WN, Stewart RE, Wolffenbuttel BHR, Haaijer-Ruskamp FM. Physician, organizational, and patient factors associated with suboptimal blood pressure management in type 2 diabetic patients in primary care. Diabetes Care 2004; 27(1): 123-128. Berlowitz DR, Ash AS, Hickey EC, Glickman M, Friedman R, Kader B. Hypertension management in patients with diabetes: the need for more aggressive therapy. Diabetes Care 2003; 26(2): 355-359. Pont LG, Sturkenboom MC, Van Gilst WH, Denig P, Haaijer-Ruskamp FM. Trends in prescribing for heart failure in Dutch primary care from 1996 to 2000. Pharmacoepidemiol Drug Saf 2003; 12(4): 327-334. Cleland JG, Cohen-Solal A, Aguilar JC, Dietz R, Eastaugh J, Follath F et al. Management of heart failure in primary care (the IMPROVEMENT of Heart Failure Programme): an international survey. Lancet 2002; 360(9346): 1631-1639. Flottorp S, Havelsrud K, Oxman A. Process evaluation of a cluster randomized trial of tailored interventions to implement guidelines in primary care--why is it so hard to change practice? Family Practice 2003; 20(3): 333-339. De Groot J, Cambach W. Peer review groups; more than noncommittal (De vrijblijvendheid voorbij. Farmacotherapiegroepen kunnen beter functioneren). Medisch Contact 2003; 38(3): 102-104. CVZ (National Health Insurance Board). Desk reference book. ed. Utrecht: CVZ, 2003. Luzier AB, Forrest A, Adelman M, Hawari FI, Schentag JJ, Izzo JL, Jr. Impact of angiotensin-converting enzyme inhibitor underdosing on rehospitalization rates in congestive heart failure. Am J Cardiol 1998; 82(4): 465-469. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group. BMJ. 1998; 317(7160): 703-713. Kasje WN, Denig P, Stewart RE, De Graeff PA, Haaijer-Ruskamp FM. Current treatment in chronic heart failure: Do physicians, organisational, and patient characteristics have an impact in general practice? (included as Chapter 5 in this thesis) Pellegrini F, Belfiglio M, De Berardis G, Franciosi M, Di Nardo B, Greenfield S, et al. Role of organizational factors in poor blood pressure control in patients with type 2


diabetes: the QuED Study Group --quality of care and outcomes in type 2 diabetes. Arch Intern Med. 2003; 163(4): 473-480.

22 Gaede P, Vedel P, Larsen N, Jensen GVH, Parving HH, Pedersen O. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med 2003; 348(5): 383-393. 23 Khunti K, Baker R, Grimshaw G. Diagnosis of patients with chronic heart failure in primary care: usefulness of history, examination, and investigations. Br J Gen Pract 2000; 50(450): 50-54. 24 Grant RW, Hamrick HE, Sullivan CM, Dubey AK, Chueh HC, Cagliero E, et al. Impact of population management with direct physician feedback on care of patients with type 2 diabetes. Diabetes Care 2003; 26(8): 2275-2280. 25 Meertens RW, van Grumbkow J. Sociale psycholgie. second ed. Groningen: WoltersNoordhoff, 1992. 26 Veninga CCM, Lagerlov P, Wahlstrom R, Muskova M, Denig P, Berkhof J et al. Evaluating an educational intervention to imprve the treatment of asthma in four European countries. Am J Resp Crit Care Med 1999; 160(4): 1254-1262.

100

Chapter 7

Chapter 8 General discussion Introduction This thesis has focussed on the implementation of joint treatment guidelines for specialists and general practitioners. The studies were done in the context of a large regional project in the Groningen region that seeks to bridge the gap between primary and secondary outpatient care. The impact of joint treatment guidelines was studied in two major chronic diseases, chronic heart failure (CHF) and hypertension in diabetes mellitus (T2DM). These chronic disorders were chosen because they are common both in primary and secondary care, necessitating close collaboration regarding their management, which is still not optimal at this moment. Three issues were addressed: 1. Attitudes physicians experience towards guidelines, in particular joint treatment guidelines. 2. The various determinants that influence prescribing quality, in particular the relationship between perceived barriers and actual prescribing behaviour and the impact of determinants at different levels (organis ational, physician or patient level). 3. The effect of an educational program for peer review groups in general practice on adherence to these guidelines. In this final chapter the main findings and limitations of these studies are presented. Their implications for approaches to improve joint treatment care are discussed, and recommendations for further initiatives are given.

Attitudes towards (joint) treatment guidelines The first issue centred on the attitudes and views towards guidelines in general, and joint treatment guidelines in particular. Firstly, a qualitative approach was used to elicit the views of specialists, since little is known about their views on these issues. This approach enables to study the views in greater depth then using a quantitative approach 1 . By describing in detail what people mean when they describe their attitudes, qualitative methods provide an accurate representation of the phenomena studied. In general, the internists, cardiologists and gastroenterologists, who were interviewed expressed fairly negative views about using guidelines themselves in their own field of expertise in outpatient care. Some specialists were more willing to use guidelines for diseases outside their own field of expertise. In contrast to these views, the specialists did expect benefits from a uniform regional treatment 101

General discussion

policy, and expressed support for making joint regional guidelines. With regard to the development of joint guidelines, they had concerns about the content (e.g. restrictive, exclusion of newer drugs), the development process (e.g. adequate representation of own group, too much emphasis on cost reduction), and the negative consequences of their implementation (e.g. increase of bureaucratic nonsense, loss of research and conference opportunities sponsored by the industry). Joint guidelines were mainly seen as useful tools for residents (specialists in training) and GPs. A limitation of a qualitative approach is that the group studied may be unique in respect to the particular context or time period 2 . The participants in the focus group study may have been more interested in the issue than the general population of specialists, since they were willing to spend one hour discussing their attitudes towards guidelines. However, in the following quantitative survey most of the views expressed in the focus groups were confirmed. In this quantitative evaluation, views of both specialists and GPs about guidelines in general and the joint guidelines developed in the Groningen regional project in particular were studied. Both groups of doctors reported to use some guidelines in their daily practice, but they relied on different guidelines. Specialists were more inclined to use international guidelines and agreements within their own hospital departments, whereas GPs preferred national and regional guidelines. Both groups of doctors believed that the newly developed joint treatment guidelines were evidence based and developed by experts who appropriately represented them. Both groups had some concerns about the dominance of financial interest. Concerning the content of the guidelines, both hospital specialists and GPs agreed that the recommendations were compatible with existing practice. Nevertheless, the specialists indicated to have reservations against some restrictions within drug classes as mentioned in the guidelines. They also believed that the guidelines oversimplified medical practice, and that they did not need the guidelines for their own practice. GPs, on the other hand, saw the guidelines as a good source of advise but feared problems with patients not willing to change to the recommended treatment. Both groups of doctors agreed that communication and co-operation between them could be improved, and that joint treatment guidelines could facilitate this process. A common problem in quantitative surveys is the tendency of people to give socially desirable answers. We have tried to limit this by using positive as well as negative statements, and by emphasizing that the data would be processed anonymously 3 . Looking at both positive and negative statements, a consistent pattern emerges showing that GPs were more positive towards this initiative to develop and implement joint guidelines than specialists. These findings indicate that specialists have a different readiness for implementing the joint treatment

102

Chapter 8

guidelines than the GPs. While specialists still need to be motivated to use such guidelines, GPs seemed to be more ready for actual adoption and implementation.

Determinants for guidelines adherence The second issue focussed on determinants of prescribing in adherence with the guideline recommendations in general practice. The baseline study showed that less than half of the chronic heart failure (CHF) patients were being treated with an angiotensin converting enzyme (ACE) inhibitor, which is recommended as standard treatment, indicating that there was room for improvement. No direct link, however, was found between reported barriers and guideline adherence for the CHF treatment. Although many different barriers to adhere to this guideline were reported by the participating GPs, this had no observable impact on their prescribing of ACE inhibitors. Even when very specific barriers were linked to the treatment of specific patient groups, for instance when perceptions about the usefulness of ACE inhibitor treatment in very old CHF patients was linked to prescribing of ACE inhibitors in these elderly patients, no relationship was detected. Patient characteristics appeared to be the most important determinant of the management of CHF. As has been observed elsewhere 4 , female patients and patients above the age of 85 had a lower chance to receive an ACE inhibitor than male or younger patients. Patients who were taking a diuretic had a higher chance to receive an ACE inhibitor. Male patients and patients with concomitant hypertension were more likely to receive a higher dosage of the ACE inhibitor. After adjusting for age, gender and comorbidity, patients who had been referred to a specialist and patients visiting an outpatient heart failure clinic were more likely to receive ACE inhibitor treatment. The analysis also showed that GPs differed in their adherence to the guidelines, but the study did not identify many relevant GP characteristics. Only dispensing GPs were more likely to prescribe an ACE inhibitor to their CHF patients. Hypertension management in T2DM patients in primary care was also suboptimal. Only a third of the patients with hypertension received treatment with an ACE inhibitor, the recommended drug in this situation. Being older and being a smoker were patient characteristics associated with less optimal treatment, whereas treatment was better in patients with coronary comorbidity or hyperlipidemia. Patients with cardiovascular comorbidity and overweight had a higher chance of having their blood pressure registered. Visiting a diabetes facility increased the likelihood of having a recently registered blood pressure measurement, visits to a specialist also increased the likelihood of receiving an ACE inhibitor. As was the case with the treatment of CHF, adherence to the guideline differed between GPs, but relevant GP characteristics were identified for only some aspects of

103

General discussion

management. Registration of blood pressure measurements was better for female and younger GPs. These studies showed that guideline adherence depends partly on patient characteristics, such as age, gender and comorbidity, but that after adjusting for differences in patient population there remained differences in adherence between GPs. No conclusive results were found regarding specific GP characteristics associated with guideline adherence. Most remarkable was the lack of association between reported barriers and prescribing behaviour. This implies that the assessment of perceived barriers is not helpful for targeting an intervention to specific doctors. On the other hand, problems identified by some GPs may be relevant for the quality of treatment in general, and may then be used to tailor an intervention program aimed at all GPs.

Effect of the educational program The last part of the thesis focussed on implementing the joint guidelines. A selfsupporting educational program was developed for peer review groups in general practice focussing on the treatment of hypertension in T2DM and of chronic heart failure. The program included a combination of strategies, concentrating on discussing and evaluating possible problems and solutions regarding the current treatment for a random sample of the GPs’ own patients with these chronic diseases. Evaluation of this program did not show a significant effect on the treatment with an ACE inhibitor or its dosing in CHF patients, nor on the treatment with an ACEinhibitor or number of antihypertensives pres cribed for the treatment of patients with hypertension and type 2 diabetes. Several factors were identified that might explain this lack of effect. Only part of the patients did have contact with their GP during the six months of follow-up, and primarily the specialist, who was not involved in this intervention, may determine treatment. The program did not solve all problems with following the guidelines, such as the view that the recommended target levels for blood pressure in T2DM were considered difficult to achieve or the reservations GPs have for changing a treatment initiated by a specialist. A substantial number of GPs did not get any specific feedback on their own patients, as they had problems with extracting the necessary patient data themselves. In addition, patients were chosen randomly, and were therefore not always in need for change as their treatment was already appropriate. Finally, our study only evaluated changes in the treatment of patients who were already diagnosed, whereas the program may have had some effect on the treatment of newly diagnosed patients. The high rate of non-participants in the hypertension in T2DM program was a matter of concern. Although this did not lead to clear differences in the patient

104

Chapter 8

population studied, it may have lead to differences in the GP population. GPs participating in the hypertension program worked more in rural areas, and appeared to prescribe already more in adherence to the joint treatment guidelines, both regarding treatment of hypertension and treatment of heart failure. We adjusted for these differences in the analysis. There were no indications that the program was more successful for specific GPs. For all GPs there appeared to be enough room for improvement.

Implications Many interventions have been developed to implement research findings and innovations in daily practice or to change performance but there is no superior implementation strategy at this moment to disseminate and adopt guidelines in practice 5 . An educational program with active involvement, feedback and discussion in small peer review groups does not necessarily lead to changes in daily practice. One meeting to discuss complex treatment problems such as addressed in this study may be insufficient to actually change treatment. In general, chronic diseases have been shown before to be more difficult to change in peer review group meetings than other diseases 6,7 . Behavioural theories stress the importance of repetition to learn the desired behaviour especially when it concerns routine behaviour. To increase the efficacy of an intervention program, potential barriers for changing treatment need to be addressed 8 . Only discussing possible problems and exchanging experiences during peer review meetings might be too noncommittal. Many GPs expressed their intention to make changes in their treatment policy but they did not act upon these intentions. In the theory of planned behaviour 9 , the link between attitudes, intentions and behaviour is mediated by other factors such as social norm and self-efficacy. As suggested before, adequate support is needed to implement guidelines in general practice 10 as well as in hospital outpatient clinics 11 . An important barrier experienced in general practice for changing prescribing, especially for the CHF patients, were problems connected with shared care. This should have been addressed better in the intervention program. Lack of consistency and cooperation between primary and secondary care can lead to inefficient care 12 . A joint treatment guideline was seen as a useful tool to establish a communication channel to discuss patients and their management between hospital specialists and GPs. Without adequate attention for specialist involvement, an educational program for GPs to improve the treatment of chronic diseases is probably too limited. Three alternative approaches can be suggested, two of these focus on co-operation and joint meetings, and one on separate programs which are held simultaneously. Joint meetings, like the peer review group meetings in general practice, with both

105

General discussion

specialists and GPs might facilitate discussions about mutual patients and the best treatment that should be provided. Furthermore, they could provide insight into the problems at the interface that the GPs are experiencing, and lead to more understanding about each other roles in treating patients. Taking into account the relative negative attitude towards joint treatment guidelines by specialists, however, a joint implementation program in both primary and secondary care may be difficult to accomplish. Although specialists do not reject joint treatment guidelines, their motivation to use such guidelines themselves is rather low. Motivation should be present for any behavioural change to occur 13 . In addition, the specialists in these studies mentioned drawbacks regarding the content of the guidelines as well as in the development process. These barriers affect the acceptance of the guidelines by specialists. Moreover, it is considered difficult to set up such peer review meetings with hospital specialists and GPs, as one hospital specialist is involved with many GPs and vice versa. An alternative could be to organise workshops for hospital specialists and GPs aimed at one specific disease or arranged around the service area of a hospital. During such workshops certain agreements could be made regarding the evaluation and adjustment of the treatment of shared patients. The third approach centres on two separate programs for hospital specialists and GPs, but held at the same time. This approach takes into account that different barriers are playing a role for hospital specialists and for GPs. An implementation program aimed at hospital specialists could focus on the complementary roles of both physician groups, and the benefits for patient and health care providers when the same guidelines are being used. The program aimed at GPs could address how to cope with individual patients who require a change in treatment, and what to do with the treatment of patients who also have visited a specialist. In this thesis, it has also been shown that guideline adherence may depend on patient and organisational factors. Implementation programs should therefore not be fixed on the physicians alone, and attention should be paid to the patient population and the setting. Disease management programs have emerged as a means for improving the quality of care for patients with chronic diseases. This is a population approach aimed at identifying patients at risk and implementing intervention programs to improve care across the complete health care system 14 . Most disease management programs are associated with improvement in care, but it remains uncertain which parts of such programs are most effective 15,16. Key components in heart failure management programs, for example, were education and counselling by a specialised nurse, accessibility of the health care provider, attention for optimal medication, increased support after discharge, and self-care behaviour such as daily weighing or restricting fluid intake 16,17. As was shown in this thesis, specialised outpatient clinics or services, which are often responsible for these programs, may improve patient care. Nurse practitioners often play an 106

Chapter 8

important role in the organisation of these clinics. At present nurse practitioners are also increasingly involved in primary care. This provides another option for the implementation of guidelines by supporting GPs to review and adapt medication of their patients. In summary, future implementation of joint treatment guidelines should focus on both specialists and GPs. Specialists should become aware of the need to use such joint treatment guidelines, not just for themselves but also to defragmentise the health care that is given to the patient. Agreements between GPs and hospital specialists must be made on a regional level as how to communicate about patients and their treatment. Implementation programs for GPs should focus on specific patient groups. An average patient may be sufficiently managed with standard treatment, but specific subgroups of patients such as the elderly or patient with additional risk factors need more attention on an individual basis. Specialised care, such as provided by outpatient CHF clinics or diabetes facilities, can aid the GPs in this respect. Finally, improvement in the use of electronic patient charts is important for better monitoring of the quality of care. This will improve identification of patients in need for change, and enhance possibilities to implement treatment guidelines.

References 1 2 3 4

5

6 7 8

107

Runciman WB. Qualitative versus quantitative research-balancing cost, yield and feasability. Qual Safe Health Care 2002; 11: 146-147. Pope C, Royen Pv, Baker R. Qualitative methods in research on healthcare quality. Qual Saf Health Care 2002; 11: 148-152. Neale JM, Liebert RM. Science and behavior. An introduction to methods of research. third ed. Eaglewood Cliffs, New Jersey: Prentice-Hall, 1986. Cleland JG, Cohen-Solal A, Aguilar JC, Dietz R, Eastaugh J, Follath F et al. Management of heart failure in primary care (the IMPROVEMENT of Heart Failure Programme): an international survey. Lancet 2002; 360(9346): 1631-1639. Grimshaw JM, Thomas RE, MacLennan G, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess. 2004 Feb; 8(6): iii-iv, 1-72. De Vries CS. Collaboration in health care: The tango to drug safety. University of Groningen, 1998. Veninga CCM. Improving prescribing in general practice. University of Groningen, 2000. Grol R, Wensing M. What drives change? Barriers to and incentives for achieving evidence-based practice. Med J Aust 2004; 180: S57-60.

General discussion

9 10

11

12

13 14

15

16

17

108

Ajzen I, Fishbein M. Attitude-behavior relations: a theoretical analysis and review of empirical research. Psychological Bulletin 1977; 84: 888-918. Flottorp S, Havelsrud K, Oxman AD. Process evaluation of a cluster randomized trial of tailored interventions to implement guidelines in primary care--why is it so hard to change practice? Fam Pract 2003; 20(3): 333-9. Dijkstra R, Braspenning J, Uiters E, Van Ballegooie E, Grol R. Perceived barriers to the implementation of diabetes guidelines in hospitals in the Netherlands. Neth J Med 2000; 56(3): 80-85. Kvamme OJ, Olesen F, Samuelsson M. Improving the interface between primary and secondary care: a statement from the European working party on quality in family practice (EQuiP). Qual Health care 2001; 10: 33-39. Meertens RW, van Grumbkov J. Sociale Psychologie. Second Ed. Groningen, WoltersNoordhoff, 1992. Weingarten SR, Henning JM, Badamgarav E, Knight K. Hasselblad V, Gano A, Ofman JJ. Interventions used in disease management programmes for patients with chronic illness-which ones work? Meta-analysis of published reports. BMJ 2002; 325(7370): 925. Akosah KO, Schaper AM, Havlik P, Barnhart S, Devine S. Improving care for patients with chronic heart failure in the community: the importance of a disease management program. Chest 2002; 122(3): 906-912. Jaarsma T, Van der Wal MH, Hogenhuis J, Lesman I, Luttik ML, Veeger NJ, van Veldhuisen DJ. Design and methodology of the COACH study: a multicenter randomised Coordinating study evaluating Outcomes of Advising and Counselling in Heart failure. Eur J Heart Fail 2004; 6(2): 227-33. Stromberg A, Martensson J, Fridlund B, Levin LA, Karlsson JE, Dahlstrom U. Nurseled heart failure clinics improve survival and self-care behaviour in patients with heart failure: results from a prospective, randomised trial. Eur Heart J 2003; 24(11): 101423.

Chapter 8

Summary Improving the quality of health care has been the focus of attention over the last decades. One of the means to improve treatment quality involves the development and dissemination of clinical guidelines. For the treatment of chronic diseases, agreement and harmonization between primary and secondary care about diagnosis and optimal treatment is very important. This thesis focuses on the improvement of two chronic diseases, chronic heart failure (CHF) and hypertension in diabetes mellitus type 2, by implementing new joint guidelines developed by committees of specialists, general practitioners (GPs) and pharmacists in the region of Groningen. An implementation program aimed at improving the quality of prescribing is the main focus of this thesis. Three themes for implementing treatment guidelines will be presented in this thesis. Firstly, physicians’ attitudes and barriers towards guidelines, and in particular towards the new joint guidelines are explored. Insight into those factors is essential for developing the best fitting implementation strategy. The second theme concerns the various determinants influencing the quality of prescribing. The third theme focuses on the evaluation of the implementation program, and measures the effect of this program on prescribing for these two chronic diseases. In Chapter 1 we discuss three ingredients for an effective implementation of guidelines. Firstly, several guidelines’ characteristics and its development process are important for acceptance of guidelines. Acceptance of guidelines, however, does not automatically mean that guidelines will be followed. Several barriers may hinder the behavioral change needed to actually perform according to guideline recommendations in daily practice. Therefore, the second ingredient for successful implementation consists of insight into barriers which hinder change. These barriers can be found on different levels of the health care system: on the level of the organization, on the level of the individual physician, and on the level of the patient. Therefore, a combination of different implementation strategies is often needed for an effective implementation of guidelines. These different implementation strategies, such as regulatory strategies, financial strategies, patient related strategies, organizational strategies and professional oriented strategies are the third ingredient. Most research has been conducted with professional oriented strategies with mixed results. Interactive strategies, in which physicians are actively involved in the teaching process, seem promising. In addition, feedback and in particular individual feedback on prescribing, has been effective in implementing guidelines.

109

Summary

In the last part of the first chapter the implementation program developed for implementing new joint treatment guidelines is described. The effect of this program is evaluated in this thesis. This program is intended for self-supporting use by peer review groups. Peer review groups are small groups consisting of GPs and community pharmacists in a city or region, who regularly meet to discuss pharmacotherapy. The main part of the program focuses on the discussion with colleagues of the treatment of GPs own patients compared to guideline recommendations. The emphasis lies on receiving feedback on prescribing in comparison to the guideline recommendations, and discussing with colleagues possible barriers and solutions for improving treatment. Furthermore, GPs own prescribing behavior can be compared with that of colleagues, which can be an extra motivation for change. Two programs for implementing joint guidelines have been made with the same structure but with different topics. One program was developed to improve treatment of chronic heart failure, and the other program was developed to imp rove treatment of hypertension in diabetes mellitus type 2 patients. Chapter 1 ends with the aims and research questions of this thesis. The first aim is to investigate the specialists’ and GPs’ attitudes and views on joint treatment guidelines. Next, the influence of these attitudes on actual prescribing will be investigated in general practice and organizational, physician related, and patient related factors influencing the quality of prescribing are identified. The most important research question is whether the implementation program has an effect on prescribing and which factors contribute to the success or failure of the program. Chapter 2 describes the results of a focus group study on specialists’ views regarding the newly developed joint treatment guidelines. Most studies have investigated barriers for using treatment guidelines expressed by GPs. The aim of this study is to explore the factors that hinder or facilitate the use of joint guidelines as reported by specialists. Seven focus group studies have been held with 27 specialists in three different hospitals. The guidelines being discussed included the treatment of hypertension, the treatment of heart failure, and the treatment of gastric diseases. Only specialists concerned with these specialties were invited to the meetings. The specialists expressed a rather negative attitude towards the content of guidelines, in particular they expressed their fear that guidelines are often too restrictive. An important precondition mentioned was the involvement of specialists in developing guidelines. The specialist did not need guidelines for themselves. The feeling of having expertise on a specific subject appeared to be an important barrier for accepting recommendations of guidelines. However, they were willing to use guidelines outside their own expertise. Some specialists indicated that 110

Summary

certain patients can or will not be treated with standard therapy. The initiative to develop joint treatment guidelines was seen as a positive development, although specialists saw guidelines mainly as a useful tool for GPs. An organizational barrier mentioned was fear of losing industry-sponsored research and conferences. Based on these results, several recommendations are given regarding implementation of joint guidelines at the end of this chapter. Inclusion of more than one drug per drug group and regular updates of the guideline can remove some of the concerns expressed by the specialists. Feedback on current treatment of patients switching between primary and secondary care can show specialists that current practice may not be optimal. Furthermore, specialists can be involved in the implementation of guidelines in primary care. Chapter 3 continues with the views of both GPs and specialists, on specific joint treatment guidelines for chronic heart failure and hypertension in diabetes mellitus type 2 patients. A structured questionnaire was used to identify the willingness of both physicians to use joint treatment guidelines. A comparison was made between GPs and specialists to determine whether different implementation strategies are needed. Almost all specialists and GPs reported to use some kind of guideline. Specialists preferred international guidelines and local agreements, whereas GPs preferred to use national and regional guidelines. Both groups of physicians agreed that it is important to make joint treatment agreements. Regarding the content of the guideline, in particular specialists indicated that recommendations should have been given on drug group level and they considered the guideline as too conservative. More than half of the specialists perceived no need to use guidelines themselves and agreed that medical practice was presented as too simplistic. Most physicians were positive about the development process of the guidelines and considered the developers as experts. Some physicians perceived a barrier regarding the apparent dominance of financial interest. Most GPs and specialists regarded the joint guidelines as a good source of advice. They believed that joint treatment guidelines could facilitate communication and improve harmonization between primary and secondary care. A clear barrier was fear that government and insurance companies could misuse the guideline. One third of the specialists expected to lose pharmaceutical industry support for conferences and research. GPs more than specialists saw a problem with patients not wanting to be treated according to the guideline. These results indicate that specialists hold a different willingness for implementing these guidelines than GPs. Specialists have no desire to change their behavior and do not perceive the guidelines as useful for themselves. However, the GPs seem more aware of a problem between primary and secondary care, and have a more positive attitude towards using joint treatment guidelines. Therefore, two different implementation strategies seem necessary for both groups of physicians. 111

Summary

Chapter 4 concerns the treatment of chronic heart failure in general practice. The aim of this study is to determine to what extent barriers perceived by GPs for prescribing angiotensin converting enzyme (ACE) inhibitors in chronic heart failure patients are related to actual prescribing of these drugs. Implementations programs are often aimed at perceived barriers. However, it is not clear to what extent these barriers are relevant for not achieving optimal management. Prescribing data were extracted from electronic medical records in general practice for a random sample of ten chronic heart failure patients. Barriers were collected by means of a semi-structured questionnaire. This questionnaire consisted of internal and external barriers towards prescribing an ACE inhibitor as identified from the literature and open-ended questions to identify self-reported barriers. For 43 GPs, the prescribing data as well as barriers could be identified. They prescribed an ACE inhibitor in an average dose of 13,5mg to 45% of their patients. No relationship could be found between the number of barriers perceived and GPs prescribing of ACE inhibitors. Also, no relationship appeared to exist between the barriers reported in the literature nor between the self-reported barriers and prescribing of an ACE inhibitor. Even the GPs who reported they did not think it is useful to prescribe an ACE inhibitor to very old patients, did not prescribe less ACE inhibitors to their patients over 85 years of age. These results point out that tailor-made implementation strategies focused on specific barriers reported by physicians will not be the most effective approach. Variation in prescribing does not seem to be fully explained by differences in perceived barriers. Other factors, on physician, practice, and patient level might play a role in explaining variation in prescribing. In Chapter 5 we continue with the results of Chapter 4 and describe the influence of physician related, organizational, and patient related factors on the treatment of chronic heart failure. Although much is known about factors that have an influence on the management of chronic heart failure from the literature, few studies have been conducted to investigate these factors in relation to each other. Data from 735 randomly selected chronic heart failure patients were collected from electronic medical records of 95 GPs. Physician related and organizational factors were identified with a structured questionnaire. Multilevel analysis has been used to measure the influence of these factors simultaneously on the prescribing and dosing of ACE inhibitors. Dispensing GPs prescribed an ACE inhibitor more often. Patients who had visited a heart failure outpatient clinic had a higher chance of receiving an ACE inhibitor, after adjusting for age, sex and comorbidity. Patients who had been referred to a specialist were also more likely to receive an ACE inhibitor. After adjusting for all other factors, male patients and patients receiving a diuretic had a higher chance of 112

Summary

receiving an ACE inhibitor. Patients over 85 years were less likely to receive an ACE inhibitor. Regarding the dosage of ACE inhibitors, patients with concurrent hypertension were more likely to receive a higher dosage, and female patients were less likely to receive a high dosage of an ACE inhibitor. This study shows that in particular patient related factors have a great influence on the prescribing of ACE inhibitors in general practice. Therefore an implementation program aimed at management of chronic heart failure should focus on the treatment of specific patient populations. Furthermore, more specialized care as provided in heart failure outpatient clinics seems to improve treatment. Chapter 6 describes the influence of physician related, organizational, and patient related factors on the treatment of hypertension in diabetes mellitus type 2 patients in a similar way as in Chapter 5. Data from 835 patients with diabetes mellitus type 2 were extracted in practices of 95 GPs. Multilevel analysis was performed to determine the influence of these factors on blood pressure registration, on the treatment of hypertension and on achieving the target level of 135/85mmHg. Overweight patients and patient with coexisting coronary artery disease were more likely to have a blood pressure registration. Adjusting for patient factors, patients who visited a diabetes facility or who were referred to a specialist had a higher chance of recent blood pressure measurements. Female GPs and GPs with less than 10 years of work experience were more likely to register blood pressures of their patients. Concerning the management of hypertension, only 20% of patients achieved the target level of 135/85mmHg, and many patients received just one or even no antihypertensive drug. Patients referred to a specialist and patients with concurrent hyperlipidemia were more likely to receive an ACE inhibitor, whilst patients who smoked were less likely to receive an ACE inhibitor. Elderly patients had a higher chance to receive another antihypertensive than an ACE inhibitor and were less likely to achieve the level of 135/85mmHg. This study shows that both patient related as well as physician related factors are associated with quality of treatment of hypertension in diabetes patients. Also, more specialized care of the diabetes facility enhances the registration of blood pressure measurements and specialist care improves both registration and treatment of blood pressure. However, their influence on blood pressure outcomes seems small. An implementation program should be targeted at more intensive treatments to achieve better blood pressure outcomes. In Chapter 7 the evaluation of the implementation program for adherence to the joint treatment guidelines is discussed. The effect of two programs is assessed in a cluster-randomized study. One study arm received the program on chronic heart 113

Summary

failure and the other arm received the program on hypertension in diabetes mellitus type 2. The chronic heart failure group provided intervention patients for the CHF treatment and control patients for the treatment of hypertension in diabetes mellitus type 2. The hypertension group provided intervention patients for the treatment of hypertension in diabetes mellitus type 2 and control patients for the treatment of CHF. Multilevel analysis was conducted to assess simultaneously the influence of physician related and patient related factors, and the program itself. The outcome measures were based on the recommendations in the joint treatment guidelines and focussed on ACE inhibitor treatment for both programs. Furthermore, the second outcome measure for the treatment of CHF was the dosage of the ACE inhibitor, and for hypertension in diabetes patients the number of antihypertensives prescribed was investigated. The GPs present at the educational program also evaluated the program itself by reporting which parts of the program were perceived as useful or were not conducted. No effect could be found of the implementation program on the treatment of CHF. Small changes were detected in the quality of treatment irrespective of the program. In both the intervention and control group the percentages of patients receiving an ACE inhibitor increased at follow-up. Patients who received a high dosage at baseline were more likely to receive a higher dosage at follow-up. Female GPs prescribed more ACE inhibitors than their male colleagues at followup. No significant effect of the implementation program on the treatment of hypertension in diabetes mellitus type 2 could be found, although small changes in the quality of treatment could be observed. The percentages of patients receiving an ACE inhibitor increased, as well as the number of antihypertensives being prescribed after six months. Patients who had contact with their GP in the six months period had a higher chance of receiving an ACE inhibitor. Older patients were more likely to receive a higher number of antihypertensives. GPs considered both programs as useful. However, in many cases the evaluation of their own patients had not been conducted. This was largely due to the fact that many GPs did not bring data from their own patients to the meeting and therefore did not receive any feedback. Moreover, sharing of experiences and discussing barriers with peers was not sufficient to overcome these barriers. Practical solutions were not presented nor did the program provide them with supportive material. At the end of the meeting, many GPs still perceived several barriers. GPs in the CHF groups perceived barriers regarding changing specialist initiated therapy and GPs in the hypertension group perceived barriers with patient compliance. A combined strategy including education, feedback and mutual discussion of barriers did not have an effect on the treatment of two chronic diseases. The program might be effective on the treatment of new patients, as it is easier to start 114

Summary

new treatment than to change existing treatment. More active support is probably needed for improving the treatment of patients who are already treated. Finally, in Chapter 8, the most important findings and conclusions are listed. Implications for implementing joint treatment guidelines for primary and secondary care are discussed. The first studies showed that attitudes of specialists and GPs towards treatment guidelines were different. Specialists’ negative attitude towards using treatment guidelines for themselves and in particular, the expected negative consequences of the joint treatment guidelines, made it necessary to conduct separate implementation programs for GPs and specialists. Therefore, this thesis concentrated on the implementation of joint treatment guidelines in general practice. The implementation program for primary care was based on several ingredients that have been effective in previous studies: active involvement of participants, feedback on actual prescribing, and discussion in small groups with peers. Nevertheless, this program did not have an effect on the treatment of CHF nor on the treatment of hypertension in diabetes mellitus type 2. Apparently, one meeting on complex treatment problems was not sufficient to actually change treatment. Behaviora l theories stress the importance of repetition to change behavior especially when it concerns routine behavior. Only discussing possible problems and exchanging experiences is probably too noncommittal to tackle the barriers perceived. Many GPs expressed their concern with problems in shared care between primary and secondary care, even after the implementation program. An implementation program to improve the treatment of chronic diseases seems too limited without adequate attention for specialist involvement. Specific agreements should be made between GPs and specialists regarding the evaluation and adjustment of treatment of shared patients, and a joint treatment guideline can be a helpful tool for this. These agreements could be made in joint meetings or workshops. An alternative approach could be to start separate implementation programs for GPs and specialists simultaneously. These programs can take into account the differences in barriers experienced by the physicians. It has also been shown that patient related factors had an important role in adhering to guidelines, besides physician and organizational factors. Some patients can be sufficiently managed with standard treatment, but other patients need more attention on individual level. Specialized care, such as provided in heart failure outpatient clinics can aid by identifying patients at risk and providing additional support. Finally, more structured use of electronic medical records can facilitate a better monitoring and improvement of quality of care.

115

Summary

116

Summary

Nederlandse samenvatting Het verbeteren van de kwaliteit van behandelingen in de gezondheidszorg staat al geruime tijd in de belangstelling. Een belangrijke rol is daarbij weggelegd voor richtlijnen. Het ontwikkelen en verspreiden van richtlijnen is één van de manieren om de kwaliteit van behandeling te optimaliseren. Voor chronische ziekten is daarnaast van belang dat zowel eerste als tweede lijn actief betrokken zijn bij de behandeling. Overeenstemming tussen de verschillende beroepsgroepen over de optimale diagnostiek en behandeling is bij deze ziekten van eminent belang. Dit proefschrift richt zich op het verbeteren van de behandelingen van twee chronische ziekten, chronisch hartfalen en hypertensie bij diabetes mellitus type 2, door middel van imple mentatie van nieuwe transmurale richtlijnen, die door de Proeftuin farmaceutische Zorg Groningen zijn ontwikkeld. Belangrijk instrument voor deze implementatie vormt een nascholingsprogramma voor huisartsen gericht op de kwaliteit van medicamenteuze behandeling. Drie belangrijke thema’s voor het implementeren van richtlijnen komen in dit proefschrift aan de orde. Ten eerste de attitudes en de knelpunten die artsen ervaren met richtlijnen en in het bijzonder met transmurale richtlijnen. Inzicht in deze attitudes en knelpunten is nodig om een passend interventieprogramma te ontwikkelen dat rekening houdt met de wensen van de doelgroep. Het tweede thema richt zich op de verscheidene determinanten die van invloed zijn op de kwaliteit van voorschrijven. Het laatste thema behandelt de evaluatie van het eerder genoemde nascholingsprogramma en richt zich op het effect van dit programma op de medicamenteuze behandeling van de twee chronische ziekten. In hoofdstuk 1 bespreken we de drie ingrediënten voor een succesvolle implementatie van richtlijnen. Allereerst de richtlijn zelf, waarbij de manier waarop de richtlijn is ontwikkeld belangrijk is voor acceptatie van de richtlijn. Maar ook de kenmerken van de richtlijn zelf, zoals de complexiteit en de overeenstemming met bestaande opvattingen, zijn van invloed op de acceptatie van de richtlijn. Als de richtlijn is geaccepteerd wil dat nog niet zeggen dat de richtlijn ook gevolgd wordt. Een aantal knelpunten staan een gedragsverandering tot het daadwerkelijk toepassen van richtlijnen in de dagelijkse praktijk in de weg. Dit vormt het tweede ingrediënt voor een succesvolle implementatie; inzicht in de knelpunten die een verandering belemmeren, zodat een passende implementatiestrategie kan worden gekozen. Deze knelpunten kunnen zich voordoen op verschillende niveaus van het gezondheidszorgsysteem, namelijk op het niveau van de organisatie, op het niveau van de individuele arts en op het niveau van de patiënt. Doordat de knelpunten op verschillende niveaus kunnen 117

Samenvatting

liggen, is voor een effectieve implementatie van richtlijnen vaak een combinatie van verschillende implementatiestrategieën nodig. Het laatste ingrediënt bestaat derhalve uit de verschillende implementatiestrategieën die in de literatuur zijn beschreven, zoals wettelijke maatregelen, financiële interventies, patiëntgerichte interventies, organisatorische interventies en artsgerichte interventies. Veel onderzoek is uitgevoerd rond artsgerichte interventies. Deze studies laten wisselende uitkomsten zien. Interactieve strategieën waarbij artsen actief betrokken worden bij het leerproces, lijken succesvol. Daarnaast is terugkoppeling van informatie (feedback), met name specifieke terugkoppeling op het eigen handelen, effectief gebleken in het verbeteren van voorschrijven. In het laatste deel van het eerste hoofdstuk wordt het nascholingsprogramma beschreven dat voor het implementeren van nieuwe transmurale richtlijnen is ontwikkeld en in deze studie geëvalueerd zal worden. Dit programma is bedoeld om zelfstandig (zonder externe ondersteuning) te gebruiken in zogenaamde Farmaco Therapie Overleg (FTO) groepen. Dat zijn kleine groepen van huisartsen en openbare apothekers, in een stad of regio, die regelmatig bij elkaar komen om het farmacotherapeutisch beleid te bespreken. Het belangrijkste onderdeel van het nascholingsprogramma richt zich op het discussiëren met collegae over de behandeling van eigen patiënten in vergelijking met de aanbevelingen uit de transmurale richtlijn. De nadruk ligt hierbij op het terugkoppelen van informatie over de eigen behandeling in vergelijking met de richtlijn en het bediscussiëren met collegae van mogelijke barrières en oplossingen om de behandeling te verbeteren. Daarnaast kan het eigen handelen worden vergeleken met dat van collegae hetgeen een extra motivatie zou kunnen zijn voor gedragsverandering. Twee nascholingspakketten voor de implementatie van de transmurale richtlijnen zijn gemaakt met dezelfde structuur, echter voor verschillende onderwerpen. Het ene programma is ontwikkeld om de behandeling van chronisch hartfalen te verbeteren en het andere programma om de behandeling van hypertensie bij patiënten met diabetes mellitus type 2 te verbeteren. Hoofdstuk 1 eindigt met de doelstellingen en onderzoeksvragen die aan bod komen in dit proefschrift. Allereerst betreffen deze de meningen en attitudes van specialisten en huisartsen ten opzichte van transmurale richtlijnen. Vervolgens komt de invloed die deze attitudes hebben op het daadwerkelijk voorschrijven van de huisartsen aan de orde en wordt gekeken naar welke organisatorische, artsgebonden en patiëntgebonden factoren de kwaliteit van voorschrijven beïnvloeden. Uiteindelijk is de belangrijkste vraag of het nascholingsprogramma effect heeft gehad op het voorschrijven van geneesmiddelen bij de twee chronische ziekten en welke factoren hebben bijgedragen aan het succes of falen van het programma.

118

Samenvatting

Hoofdstuk 2 beschrijft de resultaten van een focusgroep studie naar de meningen van specialisten over de nieuw ontwikkelde transmurale richtlijnen. De meeste studies hebben vooral de knelpunten die huisartsen ervaren onderzocht. Het doel van deze studie is dan ook het opsporen van factoren die specialisten ervaren als belemmerend dan wel bevorderend voor het gebruik van transmurale richtlijnen. Zeven focusgroep discussies werden gehouden met 27 specialisten in drie verschillende ziekenhuizen. De richtlijnen waarover werd gediscussieerd betroffen de behandeling van hypertensie, de behandeling van hartfalen en de behandeling van dyspepsie. Alleen specialisten van de betrokken specialismen werden uitgenodigd voor deelname aan de focusgroepen. De specialisten hadden een vrij negatieve mening over de inhoud van richtlijnen, waarbij vooral de angst werd geuit dat richtlijnen te restrictief zijn. Een belangrijke voorwaarde voor acceptatie die werd genoemd, was de betrokkenheid van de specialisten bij het ontwikkelen van richtlijnen. De specialisten waren niet geïnteresseerd om zelf gebruik te maken van richtlijnen. De mening dat men zelf over genoeg expertise beschikt is een belemmering om aanbevelingen van richtlijnen te volgen. Wel waren ze bereid om richtlijnen over onderwerpen buiten hun eigen specialisme te gaan gebruiken. Daarnaast gaven een aantal specialisten aan dat sommige patiënten niet kunnen of willen worden behandeld met de standaardtherapie. Het idee om gezamenlijke transmurale richtlijnen te ontwikkelen werd positief ontvangen, hoewel men de richtlijn met name als een handig hulpmiddel voor de huisartsen zag. Een organisatorische belemmering was de angst om sponsoring van de farmaceutische industrie voor onderzoek en congressen te verliezen. Een aantal mogelijke oplossingen voor de genoemde barrières worden tenslotte in dit hoofdstuk besproken. Het includeren van meer dan één geneesmiddel per klasse en het regelmatig beschikbaar maken van nieuwe versies van de richtlijn zouden belemmeringen ten aanzien van de richtlijn zelf kunnen verminderen. Terugkoppeling van informatie over de huidige behandeling van patiënten die zowel de huisarts als de specialist bezoeken, kan de specialisten laten zien dat het ontbreken van goede afstemming tot onwenselijke situaties kan leiden. Verder zouden specialisten actief betrokken kunnen worden bij het gebruik van richtlijnen in de eerste lijn. Hoofdstuk 3 gaat vervolgens in op de meningen van beide beroepsgroepen, huisartsen en specialisten, over specifieke transmurale richtlijnen voor chronisch hartfalen en hypertensie bij diabetes mellitus. Met behulp van een gestructureerde vragenlijst is vastgesteld in hoeverre de artsen verschillen in hun bereidheid om richtlijnen te gebruiken. Een vergelijking wordt gemaakt tussen specialisten en huisartsen om te kunnen bepalen of gescheiden implementatieprogramma’s nodig zijn.

119

Samenvatting

Bijna alle specialisten en huisartsen gaven aan dat ze een of andere richtlijn gebruiken. Specialisten gaven de voorkeur aan internationale richtlijnen en lokale afspraken, terwijl huisartsen meer gebruik maakten van nationale en regionale richtlijnen. Beide groepen artsen vonden het belangrijk dat gezamenlijke afspraken worden gemaakt. Met betrekking tot de inhoud van de Groninger transmurale richtlijnen vonden met name de specialisten dat aanbevelingen alleen op geneesmiddelklasse hadden moeten worden gegeven en vonden zij de richtlijnen te conservatief. Daarnaast zag meer dan de helft van de specialisten geen noodzaak voor zichzelf om met een richtlijn te werken en vonden ze de medische praktijk daarin te simpel voorgesteld. De meeste artsen waren wel positief over het ontwikkelingsproces van de richtlijnen en beschouwden de mensen die de richtlijnen ontwikkeld hadden als experts. Enig wantrouwen werd genoemd rond de dominantie van financiële zaken. De meeste huisartsen en specialisten vonden de transmurale richtlijnen een goede bron van advies. Zij zagen daarin een mogelijkheid om tot harmonisatie tussen de eerste en tweede lijn te komen en de kwaliteit van zorg te verbeteren. De angst voor misbruik van de richtlijn door de regering en verzekeraars was een belangrijke barrière. Een derde van de specialisten verwachtte geen geldelijke steun meer te krijgen voor onderzoek of congressen van de farmaceutische industrie. Huisartsen ervoeren een probleem met patiënten die mogelijk niet behandeld willen worden volgens de richtlijn. Deze resultaten geven aan dat specialisten een andere bereidheid hebben voor het implementeren van de richtlijnen dan de huisartsen. Ze voelen zich niet geroepen om hun gedrag te veranderen en voor hen zijn de richtlijnen dan ook niet nodig. De huisartsen echter zijn zich meer bewust van een probleem tussen de eerste en tweede lijn en hebben een positieve attitude ten opzichte van het gebruik van transmurale richtlijnen. Verschillende strategieën om de richtlijnen te implementeren lijken derhalve nodig voor de twee beroepsgroepen. Hoofdstuk 4 richt zich op de behandeling van chronisch hartfalen in de huisartspraktijk. Onderzocht is in hoeverre knelpunten die huisartsen rapporteren voor het voorschrijven van ACE-remmers gerelateerd zijn aan hun daadwerkelijk voorschrijven van deze middelen aan hartfalenpatiënten. Implementatieprogramma’s voor het verbeteren van behandeling worden vaak gericht op gerapporteerde knelpunten. Het is echter niet duidelijk in hoeverre deze knelpunten relevant zijn voor het niet optimaal behandelen. De voorschrijfgegevens werden verzameld voor een willekeurige steekproef van tien hartfalenpatiënten uit de elektronische medische dossiers in de huisartspraktijk. De knelpunten werden verkregen uit een semi-gestructureerde vragenlijst. Deze vragenlijst bestond uit interne en externe knelpunten voor het voorschrijven van ACE-remmers geïdentificeerd uit de literatuur en daarnaast uit 120

Samenvatting

open vragen waarmee zelfgerapporteerde knelpunten werden geïdentificeerd. Van 43 huisartsen waren zowel de voorschrijfgegevens als ervaren knelpunten bekend. Zij schreven aan 45% van hun patiënten een ACE-remmer voor in een gemiddelde standaard dosering van 13,5 mg. Geen relatie tussen het aantal barrières en het voorschrijven van ACE-remmers kon worden gevonden. Er was ook geen relatie tussen de afzonderlijke knelpunten uit de literatuur noch tussen de zelfgerapporteerde knelpunten en het voorschrijven van een ACE-remmer. Zelfs de huisartsen die aangaven dat zij het niet nuttig achtten om een ACEremmer voor te schrijven aan zeer oude patiënten, schreven aan patiënten boven de 85 jaar niet minder ACE-remmers voor. Deze resultaten geven aan dat zogenaamde ‘tailor-made’ implementatieprogramma’s gericht op specifieke barrières die een arts rapporteert, niet de meest effectieve benadering zullen vormen. De variatie in het voorschrijven tussen artsen lijkt niet goed te kunnen worden verklaard met verschillen in ervaren barrières. Andere factoren op arts-, praktijk- of patiëntenniveau spelen mogelijk een belangrijke rol in het verklaren van verschillen in voorschrijven. Hoofdstuk 5 borduurt voort op de resultaten van het vorige hoofdstuk en concentreert zich op de invloed van artsgebonden, organisatorische en patiëntgebonden factoren op de behandeling van chronisch hartfalen. Alhoewel uit de literatuur veel bekend is over welke factoren invloed hebben op de behandeling van hartfalen, zijn er nog maar weinig studies uitgevoerd die hebben gekeken naar de invloed van deze factoren in relatie tot elkaar. Gegevens van 735 willekeurig geselecteerde chronisch hartfalenpatiënten werden verzameld uit elektronische dossiers van 95 huisartsen. Artsgebonden en organisatorische factoren werden gemeten met behulp van een gestructureerde vragenlijst. Multilevel analyse is gebruikt om gelijktijdig de invloed van de factoren te kunnen bepalen op de behandeling met een ACE-remmer en de dosering van een ACE-remmer. Apotheekhoudende huisartsen bleken vaker een ACE-remmer voor te schrijven. Patiënten die een hartfalenpolikliniek bezochten, hadden een hogere kans op het krijgen van een ACE-remmer, ook nadat voor verschillen in leeftijd, geslacht en co-morbiditeit gecontroleerd was. Daarnaast hadden patiënten die verwezen waren naar een specialist meer kans op een ACEremmer. Bij controle voor alle andere factoren hadden mannelijke patiënten en patiënten met een diureticum een hogere kans op een ACE-remmer. Patiënten ouder dan 85 jaar hadden daarentegen minder kans op het krijgen van een ACEremmer. Kijkend naar de dosering, hadden patiënten met de co-morbiditeit hypertensie meer kans om een hogere dosering te ontvangen en vrouwelijke patiënten hadden minder kans op een hoge dosering. De studie laat zien dat met name patiëntgebonden factoren een grote invloed hebben op het voorschrijven van een ACE-remmer voor hartfalen in de 121

Samenvatting

huisartspraktijk. Het is daarom aan te bevelen om in een implementatieprogramma gericht op de behandeling van hartfalen vooral aandacht te besteden aan de behandeling van specifieke patiëntenpopulaties. Daarnaast lijkt meer gespecialiseerde zorg zoals geboden in een hartfalenpolikliniek een verbetering in de behandeling te geven. In hoofdstuk 6 wordt op dezelfde manier als in hoofdstuk 5 gekeken naar de invloed van artsgebonden, organisatorische en patiëntgebonden factoren op de behandeling van hypertensie in patiënten met diabetes mellitus type 2. Gegevens van 835 patiënten met diabetes mellitus type 2 werden verzameld bij 95 huisartsen. Een multilevel analyse werd uitgevoerd om de invloed van deze factoren vast te stellen op de bloeddruk regis tratie, op de behandeling van hypertensie en op het bereiken van de streefwaarde van 135/85 mmHg. Patiënten met overgewicht en coronair vaatlijden bleken meer kans te hebben op een bloeddruk registratie. Los van deze patiëntfactoren, hadden patiënten die een specialist of een diabetesdienst bezochten ook meer kans op een recente bloeddrukmeting. Vrouwelijke huisartsen en huisartsen met minder dan 10 jaar werkervaring registreerden de bloeddruk van hun diabetespatiënten beter. Over het algemeen was de hypertensie behandeling bij de diabetes patiënten niet optimaal. Slechts 20% haalde de streefwaarden en veel patiënten werden niet of maar met één antihypertensivum behandeld. Kijkend naar de behandeling met een ACE-remmer, hadden patiënten die een specialist bezochten en patiënten met comorbiditeit hyperlipidemie meer kans op het krijgen van een ACE-remmer, terwijl rokers minder kans hadden op het krijgen van een ACE-remmer. Oudere patiënten hadden meer kans om andere antihypertensiva te krijgen dan een ACEremmer. Daarnaast hadden oudere patiënten minder kans op het bereiken van de streefwaarde van 135/85 mmHg. Uit deze studie komt naar voren dat zowel patiëntgebonden factoren als artsgebonden factoren een rol spelen bij de kwaliteit van behandeling van hypertensie bij diabetes mellitus type 2. Daarnaast leidt gespecialiseerde zorg van de diabetesdienst tot een betere registratie van de bloeddruk en de zorg van een specialist tot een betere registratie en behandeling van de bloeddruk. De invloed hiervan op de bloeddrukwaarde lijkt echter gering. Een implementatieprogramma zou vooral aandacht moeten schenken aan intensievere behandeling om de bloeddruk onder controle te krijgen. In hoofdstuk 7 wordt de evaluatie van het nascholingsprogramma op het volgen van de transmurale richtlijn in de huisartspraktijk beschreven. Het effect van de twee nascholingsprogramma’s is getoetst in een geclusterd gerandomiseerde studie waarbij één arm het programma over chronisch hartfalen ontving en de andere arm het programma over hypertensie bij diabetes mellitus type 2. De groep 122

Samenvatting

huisartsen die het programma over hartfalen kregen, leverden interventiepatiënten voor de behandeling van hartfalen en controlepatiënten voor de behandeling van hypertensie bij diabetes mellitus type 2. De hypertensie bij diabetes groep leverde interventiepatiënten voor de behandeling voor hypertensie bij diabetes mellitus type 2 en controlepatiënten bij hartfalen. Multilevel analyse is gebruikt om gelijktijdig de invloed van artsgebonden factoren, patiëntgebonden factoren en het programma zelf te analyseren. De uitkomstmaten waren gebaseerd op de aanbevelingen in de transmurale richtlijnen en betroffen het voorschrijven van een ACE-remmer voor beide programma’s. Voor hartfalen was verder de invloed onderzocht op de dosering van de ACE-remmer en voor hypertensie bij diabetes mellitus type 2 het effect van het programma op het aantal voorgeschreven antihypertensiva. Daarnaast hebben de aanwezige huisartsen het programma zelf beoordeeld door aan te geven welke onderdelen van het programma als nuttig of niet nuttig werden ervaren of welke delen niet uitgevoerd waren. De analyses lieten geen effect zien van het nascholingsprogramma voor hartfalen. Kleine veranderingen werden gevonden in de kwaliteit van behandeling los van het nascholingsprogramma. Zowel in de interventie- als in de controlegroep steeg het percentage patiënten op een ACE-remmer op de nameting. Patiënten die tijdens de voormeting een hoge dosering ACE-remmer ontvingen hadden ook meer kans op een hogere dosering op de nameting. Vrouwelijke huisartsen schreven bij de nameting meer ACE-remmers voor dan hun mannelijke collegae. Het programma voor hypertensie bij diabetes mellitus type 2 had eveneens geen effect op de behandeling van deze patiënten; wel zijn kleine veranderingen gevonden in de behandeling van hypertensie bij diabetes mellitus type 2. Het percentage patiënten op een ACE-remmer steeg zowel in de interventie- als in de controlegroep evenals het aantal antihypertensiva dat werd voorgeschreven in vergelijking met de voormeting. Daarnaast gaf contact met een huisarts in de periode tussen de voor- en de nameting een hogere kans op het krijgen van een ACE-remmer en hadden oudere patiënten een hogere kans om meer antihypertensiva te ontvangen. Beide programma’s werden over het algemeen nuttig bevonden door de deelnemers. De evaluatie van de eigen patiëntcasussen had echter in veel gevallen niet plaatsgevonden. Dit is toe te schrijven aan het feit dat veel huisartsen zelf geen patiëntcasussen hadden meegenomen om te bespreken. Daarnaast leidde de bespreking van ervaren knelpunten tijdens het overleg niet direct tot concrete oplossingen. Na afloop van het programma werden er nog veel knelpunten ervaren. Bij de hartfalengroep zag men vooral problemen met het veranderen van door de specialist gestarte therapie en bij de hypertensiegroep voorzag men problemen met therapietrouw van patiënten. Een gecombineerde strategie van educatie, terugkoppeling en gezamenlijk bespreken van knelpunten heeft geen effect gehad op de behandeling van twee 123

Samenvatting

chronische ziektebeelden. Wellicht zou het programma wel effect hebben gehad bij de behandeling van nieuwe patiënten, aangezien het eenvoudiger is om een nieuwe behandeling te starten dan een reeds bestaande behandeling te veranderen. Meer actieve ondersteuning is waarschijnlijk nodig om tot verbeteringen bij reeds behandelde patiënten te komen. In hoofdstuk 8 worden de belangrijkste bevindingen en conclusies van dit proefschrift op een rijtje gezet. Implicaties voor de implementatie van transmurale richtlijnen in de eerste en tweede lijn worden besproken. De eerste studies hebben laten zien dat er duidelijke verschillen in de attitude van huisartsen en specialisten zijn ten aanzien van transmurale richtlijnen. De negatieve attitude van specialisten ten opzichte van het nut van richtlijnen voor henzelf en met name de verwachte negatieve consequenties van de transmurale richtlijnen hebben ertoe geleid dat een gescheiden implementatieproject voor huisartsen en specialisten nodig werd geacht. Dit proefschrift heeft zich derhalve verder alleen gericht op de implementatie van transmurale richtlijnen in de huisartspraktijk. Het implementatieprogramma voor de eerste lijn was gebaseerd op een aantal ingrediënten, die in eerdere studies effectief waren gebleken waaronder actieve betrokkenheid van deelnemers, terugkoppeling op eigen handelen en discussie in kleine groepen met collegae. Toch heeft dit programma geen effect gehad op de behandeling van hartfalen noch op de behandeling van hypertensie bij diabetes mellitus type 2. Eén bijeenkomst gewijd aan complexe behandelingsproblemen is naar alle waarschijnlijkheid niet voldoende om daadwerkelijk de behandeling te veranderen. Gedragstheorieën geven ook aan dat herhaling belangrijk is om gedrag te veranderen, met name als het gaat om routinegedrag. Het bespreken van problemen en het uitwisselen van ervaringen is waarschijnlijk te vrijblijvend om ervaren knelpunten voldoende aan te pakken. Eén van de belangrijkste knelpunten, ook na het nascholingsprogramma, zijn problemen met gedeelde zorg voor patiënten tussen eerste en tweede lijn. Een nascholingsprogramma voor het verbeteren van chronische ziekten is te beperkt wanneer er geen aandacht wordt geschonken aan de inbreng van de specialis t. Er zullen concrete afspraken gemaakt moeten worden tussen huisartsen en specialisten over de evaluatie en eventuele aanpassing van de behandeling van gemeenschappelijke patiënten en een transmurale richtlijn kan hier zeker toe bijdragen. Afspraken zouden gemaakt kunnen worden in gezamenlijke bijeenkomsten of tijdens workshops. Een alternatieve aanpak is het gelijktijdig starten van afzonderlijke implementatieprogramma’s voor specialisten en huisartsen. Deze programma’s kunnen rekening houden met de verschillen in knelpunten die de artsen ervaren. Duidelijk is dat naast artsgebonden en organisatorische factoren, ook patiëntkenmerken een belangrijke factor kunnen zijn bij het al dan niet volgen van 124

Samenvatting

richtlijnen. Een deel van de patiënten is goed te behandelen volgens de standaard procedures, maar sommige patiënten hebben meer aandacht op individueel niveau nodig. Gespecialiseerde zorg, zoals geboden in een hartfalenpolikliniek, kan hierbij helpen door risicopatiënten te identificeren en extra ondersteuning te bieden. Tot slot zou een gestructureerder gebruik van elektronische patiëntendossiers kunnen bijdragen om de kwaliteit van zorg beter te kunnen volgen en verbeteren.

125

Samenvatting

126

Samenvatting

Appendix K77.2 Chronisch hartfalen Niet medicamenteuze maatregelen:

Beperking van zout, vocht inname en alcohol. Bij overgewicht dieetmaatregelen gericht op gewichtsvermindering. Lichaamsbeweging aangepast aan de individuele patiënt. Medicamenteuze behandeling:

Chronisch hartfalen wordt onderverdeeld in systolisch en diastolisch hartfalen. De behandeling is verschillend. De diagnose diastolisch falen is echter moeilijk te stellen, daarom proefondervindelijk behandelen, als systolische hartfalen. Indien de standaardtherapie (ACE-remmers en diuretica) faalt de patiënt verwijzen naar de tweede lijn voor verdere diagnostiek. Systolisch hartfalen De behandeling starten met een diureticum om klachten als gevolg van overvulling te verminderen. Zo spoedig mogelijk overgegaan op een ACEremmer vanwege reductie in mortaliteitsrisico, al dan niet in combinatie met een diureticum. Toevoegen van een ACE-remmer moet voorzichtig gebeuren ivm kans op acute hypotensie. Bij stoppen van het diureticum oppassen voor recidiveren vochtretentie. Als ACE-remmers niet verdragen worden vanwege hoest, dan kan worden overgestapt op een A-II-antagonist. Deze zijn hier nog niet opgenomen. Bij onvoldoende effect van diuretica en/of ACE -remmers, vooral bij sinustachycardie of atriumfibrilleren met snelle ventrikelrespons gaat de voorkeur uit naar digoxine. Bij klinisch stabiele patiënten met licht en matig ernstig hartfalen kunnen beta-blokkers in lage dosering worden toegepast. Het starten van een beta-blokker wordt voorlopig geïnitieerd in de tweede lijn. Spironolacton heeft een plaats na en in combinatie met beta-blokkers als adjuvans bij matig tot ernstig hartfalen, en wordt voorlopig alleen toegepast in de tweede lijn. Bij eventuele co-morbiditeit (angina pectoris, hypertensie) wordt naar het desbetreffende hoofdstuk verwezen.

DIURETICA Voor snelle symptoombestrijding is een lisdiureticum aangewezen; voor de onderhoudsbehandeling komt een thiazide diureticum meer in aanmerking.

127

Bij lisdiuretica gaat de voorkeur gaat uit naar furosemide. Indien hoge doseringen furosemide nodig zijn is bumetanide praktischer. Bij onvoldoende effect van furosemide in de hoogste dosering kan bumetanide worden geprobeerd. De werking van 5 mg bumetanide komt overeen met 100 mg furosemide. Combinatie van een lisdiureticum met een thiazide diureticum wordt soms toegepast vanwege een additief effect; dit dient beperkt te blijven tot de tweede lijn. Bij serumkalium lager dan 3,5 mmol/l een thiazide diureticum in combinatie met kaliumsparend diureticum geven. De voorkeur gaat uit naar triamtereen/hydrochloorthiazide.

Furosemide tablet 40 mg, 20 mg 1 dd 40 mg, zonodig verhogen tot 120 mg/dag. O: Zo nodig dosis verhogen tot 1 maal daags 3 tabletten. Bij nachtelijke benauwdheid innemen om ca. 17.00 uur om piekdiurese ’s nachts te vermijden. B: Electrolytverstoringen, daling van de glucose-tolerantie, hyperurikemie. C: Ernstige hypokaliëmie, overgevoeligheid voor sulfonamiden. V: Voorzichtigheid is geboden bij levercirrose en jicht. Gelijktijdig gebruik van aminoglycosiden kan leiden tot (soms irreversibele) gehoorschade. NSAID’s remmen het diuretisch effect. De lithiumspiegel kan worden verhoogd. Bij optreden van hypokaliëmie wordt de toxiciteit van hartglycosiden en ketanserine versterkt.

Bumetanide tablet 1 mg, 2 mg, 5 mg 1 dd 2-5 mg O: Bij nachtelijke benauwdheid innemen om ca. 17.00 uur om piekdiurese ’s nachts te vermijden. B: Electrolytverstoringen, daling van de glucose-tolerantie, hyperurikemie. C: Ernstige hypokaliëmie, overgevoeligheid voor sulfonamiden. V: Voorzichtigheid is geboden bij levercirrose en jicht. Gelijktijdig gebruik van aminoglycosiden kan leiden tot (soms irreversibele) gehoorschade. NSAID’s remmen het diuretisch effect. De lithiumspiegel kan worden verhoogd. Bij optreden van hypokaliëmie wordt de toxiciteit van hartglycosiden en ketanserine versterkt.

Hydrochloorthiazide tablet 25 mg, 50 mg 1 dd 25-50 mg. Zonodig verhogen tot max 100 mg per dag O: Onderhoudsdosering: 1 maal daags 12,5-50 mg. B: Electrolytverstoringen, daling van de glucose-tolerantie, hyperurikemie, duizeligheid, ongunstige verandering van plasmalipiden. C: Hypokaliëmie, overgevoeligheid voor sulfonamiden. V: Voorzichtigheid is geboden bij jicht. De lithiumspiegel kan worden verhoogd. NSAID’s remmen het diuretisch effect. Bij optreden van hypokaliëmie wordt de

128

toxiciteit van hartglycosiden en ketanserine versterkt. Bij nierfunctiestoornissen is de werkzaamheid verminderd.

Triamtereen/hydrochloorthiazide tablet 50 mg triamtereen en 25 mg hydrochloorthiazide 1 dd 1-2 tabletten O: Onderhoudsdosering: 1 maal daags 0,5-2 tabletten. B: Electrolytverstoringen, daling van de glucose-tolerantie, hyperurikemie, duizeligheid, ongunstige verandering van plasmalipiden, nierstenen. C: Hyperkalièmie, overgevoeligheid voor sulfonamiden, zwangerschap, lactatie. V: Voorzichtigheid is geboden bij nierstenen in de anamnese, leverfunctiestoornissen, jicht. Hyperkalièmie kan ontstaan in combinatie met ACE-remmers, spironolacton of kaliumzouten. De lithiumspiegel kan worden verhoogd. NSAID’s remmen het diuretisch effect. Bij nierfunctiestoornissen is de werkzaamheid verminderd.

ACE-REMMERS. De mortaliteitsreductie bij hartfalen is een groepseffect van de ACE-remmers; ze kunnen in dat opzicht als uitwisselbaar worden beschouwd. Ramipril is goed onderbouwd bij en geregistreerd voor licht tot matig hartfalen na een acuut myocardinfarct, het geeft preventie van hartfalen op lange termijn. Quinapril heeft als additief effect remming van weefsel ACE. Er is veel ervaring in de eerste lijn met enalapril en lisinopril Het is van groot belang ACE-remmers voldoende hoog te doseren.

Enalapril tablet 5 mg, 10 mg, 20 mg, 40 mg Aanvankelijk 1 dd 2,5 mg. Onderhoud 20 mg/dag in 1-2 doses O: Beginnen met een lage dosis in verband met mogelijk optredende symptomatische hypotensie. Geleidelijk, door verdubbeling van de dosis met een interval van een week, verhogen tot onderhoudsdosering: 20 mg per dag in 1-2 doses. Hoge doseringen diuretica eventueel (tijdelijk) verlagen. B: Hoofdpijn, duizeligheid, vermoeidheid, diarree, misselijkheid, kriebelhoest, angioneurotisch oedeem, (orthostatische) hypotensie, hyperkaliëmie, nierinsufficiëntie. C: Zwangerschap, lactatie. V: Voorzichtigheid is geboden bij nierarteriestenose, nierfunctiestoornissen. In dat geval klinische instelling overwegen. Eventueel nierfunctiecontrole 2 weken na starten van de therapie. Kans op hyperkaliëmie bij combinatie met kaliumsparende diuretica en kaliumzouten. NSAID’s remmen het antihypertensief effect. De lithiumspiegel kan worden verhoogd.

Lisinopril (Novatec®, Zestril®) tablet 5 mg, 10 mg, 20 mg, 40 mg Starten met 1 dd 2,5 mg. Onderhoud 1 dd 5-20 mg O: Bij combinatie met een diureticum of indien de hypertensie renovasculair is of bij bestaande decompensatio cordis of indien er een volume- of zoutdepletie 129

bestaat beginnen met een lage dosis (1 dd 2,5-5 mg) in verband met mogelijk optredende symptomatische hypotensie. Hoge doseringen diuretica eventueel (tijdelijk) verlagen. B: Hoofdpijn, duizeligheid, vermoeidheid, diarree, misselijkheid, kriebelhoest, angioneurotisch oedeem, (orthostatische) hypotensie, hyperkaliëmie, nierinsufficiëntie. C: Zwangerschap, lactatie. V: Voorzichtigheid is geboden bij nierarteriestenose, nierfunctiestoornissen. In dat geval klinische instelling overwegen. Eventueel nierfunctiecontrole 2 weken na starten van de therapie. Kans op hyperkaliëmie bij combinatie met kaliumsparende diuretica en kaliumzouten. NSAID’s remmen het antihypertensief effect. De lithiumspiegel kan worden verhoogd.

Quinapril (Acupril®) tablet 5 mg, 10 mg, 20 mg, 40 mg aanvankelijk 1 maal daags 5 mg. Onderhoud 10-20 mg in 1-2 dosis O: Bij combinatie met een diureticum of indien de hypertensie renovasculair is of bij bestaande decompensatio cordis of indien er een volume- of zoutdepletie bestaat beginnen met een lage dosis in verband met mogelijk optredende symptomatische hypotensie. Hoge doseringen diuretica eventueel (tijdelijk) verlagen. B: Hoofdpijn, duizeligheid, vermoeidheid, diarree, misselijkheid, kriebelhoest, angioneurotisch oedeem, (orthostatische) hypotensie, hyperkaliëmie, nierinsufficiëntie. C: Zwangerschap, lactatie. V: Voorzichtigheid is geboden bij nierarteriestenose, nierfunctiestoornissen. In dat geval klinische instelling overwegen. Eventueel nierfunctiecontrole 2 weken na starten van de therapie. Kans op hyperkaliëmie bij combinatie met kaliumsparende diuretica en kaliumzouten. NSAID’s remmen het antihypertensief effect. De lithiumspiegel kan worden verhoogd.

Ramipril (Tritace ®) capsule 10 mg, tablet 1,25 mg 2,5 mg, 5 mg Start 3-10 dagen na myocard infarct 2 dd 2,5 mg. Na 1-3 dagen verhogen tot 2 dd 5 mg, max 10 mg/dag O: Bij combinatie met een diureticum of indien de hypertensie renovasculair is of bij bestaande decompensatio cordis of indien er een volume- of zoutdepletie bestaat beginnen met een lage dosis in verband met mogelijk optredende symptomatische hypotensie. Hoge doseringen diuretica eventueel (tijdelijk) verlagen. B: Hoofdpijn, duizeligheid, vermoeidheid, diarree, misselijkheid, kriebelhoest, angioneurotisch oedeem, (orthostatische) hypotensie, hyperkaliëmie, nierinsufficiëntie. C: Zwangerschap, lactatie. V: Voorzichtigheid is geboden bij nierarteriestenose, nierfunctiestoornissen. In dat geval klinische instelling overwegen. Eventueel nierfunctiecontrole 2 weken na starten van de therapie. Kans op hyperkaliëmie bij combinatie met kaliumsparende diuretica en kaliumzouten. NSAID’s remmen het antihypertensief effect. De lithiumspiegel kan worden verhoogd.

130

HARTGLYCOSIDEN Digoxine tablet 0,0625 mg, 0,125 mg, 0,25 mg Onderhoud: 1 dd 0,0625-0,25 mg Digitalisatie: dag 1: 3x 0,25 mg. Dag 2: 2x 0,25 mg O: Digitalisatiedosering: de eerste dag 3 x 0,25 mg, de tweede dag 2 x 0,25 mg, vervolgens de onderhoudsdosering. Ouderen (>70 jaar) of mensen met een slechte nierfunctie laag doseren. Dit middel is veilig gebleken bij zwangerschap. B: De meeste bijwerkingen zijn tekenen van overdosering. Maag-darmstoornissen, moeheid, depressie, zwakheid, rusteloosheid, nachtmerries, persoonlijkheidsveranderingen, hoofdpijn, vertigo, verwardheid, fotofobie, ritmestoornissen, AV-block, visusstoornissen. C: Hypertrofische obstructieve cardiomyopathie, constrictieve pericarditis en AVblock. V: Voorzichtigheid is geboden bij hyper- of hypothyreoïdie, nierfunctiestoornissen. Amiodaron, diuretica, kinidine en verapamil verhogen de kans op toxiciteit van digoxine.

Middelen in de tweede lijn. Bij vochtretentie kunnen combinaties van lisdiuretica en thiazide diuretica worden gegeven onder controle van de K+-spiegels. Het initiëren van beta-blokkers en de toepassing van spironolacton vindt voorlopig in de tweede lijn plaats.

BETA-BLOKKERS Beta-blokkers worden toegevoegd aan de standaard therapie; ACE-remmers en diuretica.

Carvedilol (Eucardic®) tablet 6,25 mg, 25 mg 2 dd 3,125 mg. Eventueel per 14 dagen verhogen tot 12,5 mg of 25 mg O: Therapie insluipen. Bij staken behandeling de dosering in 2 weken geleidelijk afbouwen. Bij verergering van hartfalen stoppen. B: Hypotensie, bradycardie, moeheid, koude extremiteiten, verergering van de ziekte van Raynaud, bronchospasmen, duizeligheid, verergering decompensatio cordis. C: Ernstige bradycardie, “sick sinus” syndroom, AV-block, ernstige hypotensie, lactatie. V: Voorzichtigheid is geboden bij leverfunctiestoornissen, astma, COPD. Versterkt mogelijke doorbloedingsstoornissen veroorzaakt door ergotamine. Versterkt de dempende werking van verapamil en diltiazem op het geleidingssysteem van het hart. NSAID’s kunnen de antihypertensieve werking van beta-blokkers remmen. Plotseling staken kan leiden tot ernstige aritmieën, verergering van de angina of rebound hypertensie.

131

Bisoprolol (Bisobloc®, Emcor®) tablet 2,5 mg, 5 mg, 10 mg tablet 1 dd 1,25 mg, zo mogelijk verhogen naar 1 dd 2,5-5 mg, max. 10 mg/dag O: Therapie insluipen. Bij staken behandeling de dosering in 2 weken geleidelijk afbouwen. Bij verergering van hartfalen stoppen. B: Hypotensie, bradycardie, moeheid, koude extremiteiten, verergering van de ziekte van Raynaud, bronchospasmen, duizeligheid, verergering decompensatio cordis. C: Ernstige bradycardie, “sick sinus” syndroom, AV-block, lactatie. V: Voorzichtigheid is geboden bij leverfunctiestoornissen, astma, COPD. Versterkt mogelijke doorbloedingsstoornissen veroorzaakt door ergotamine. Versterkt de dempende werking van verapamil en diltiazem op het geleidingssysteem van het hart. NSAID’s kunnen de antihypertensieve werking van beta-blokkers remmen. Plotseling staken kan leiden tot ernstige aritmieën, verergering van de angina of rebound hypertensie. Bij een hypoglykemie kunnen symptomen gemaskeerd worden.

SPIRONOLACTON. Spironolacton heeft een plaats na en in combinatie met beta-blokkers als adjuvans bij matig tot ernstig hartfalen. Het geeft sterfte-reductie, minder progressie van hartfalen en minder hospitalisatie.

Spironolacton tablet 25 mg, 50 mg, 100 mg 1 dd 12,5-25 mg B: Hyperkaliëmie,duizeligheid, orthostatische hypotensie, droge mond, moeheid, maagdarmstoornissen, spierkrampen, libidoverlies impotentie, pijnlijke borsten, menstruatiestoornissen. C: Hyperkaliëmie, hyponatriëmie, zwangerschap, lactatie. V: Voorzichtigheid is geboden bij leverin- en/of nierinsufficiëntie, diabetes mellitus, orale coagulantia, vermindering van de werking door salicylaten

Diastolisch hartfalen De diagnose diastolisch hartfalen en het initiëren van de medicatie vindt plaats in de tweede lijn. Bij diastolisch hartfalen hebben beta-blokkers (doseren als bij systolisch hartfalen) en ACE-remmers de voorkeur. Daarnaast worden sommige Caantagonisten toegepast.

132

K86, K87

Hypertensie

Niet medicamenteuze interventie: voldoende lichaamsbeweging, gewichtsreductie, natriumbeperking, roken staken. De beslissing om te starten met medicamenteuze behandeling van hypertensie dient niet alleen afhankelijk te zijn van de hoogte van de bloeddruk, maar van het totale risico op cardiovasculaire morbiditeit en mortaliteit van de individuele patiënt (WHO-ISH, 1999). Streefwaarden voor de bloeddruk dienen ook beschouwd te worden in combinatie met andere risicofactoren; hoe hoger het totale risico, des te lager de streefwaarde. Bij diabetes mellitus wordt bijvoorbeeld een streefwaarde van maximaal 135/85 mmHg geadviseerd (UKPDS, HOT). De geïsoleerde systolische hypertensie (systolisch > 160 mmHg en diastolisch < 90 mmHg) geldt als een onafhankelijke risicofactor en dient derhalve behandeld te worden. Beta-blokkers, diuretica, ACE remmers en calcium-entry blockers doen in principe niet voor elkaar onder als eerste keus bij de behandeling van hypertensie. Voor angiotensine-II antagonisten zijn op dit moment onvoldoende gegevens beschikbaar met betrekking tot morbiditeit en mortaliteit om deze middelen als eerste keuze aan te merken. Bij onvoldoende effect van één middel is het niet zinvol om tot de maximale dosis te verhogen. Overweeg een ander middel of een combinatie met een ander antihypertensivum. Bij zwangerschap(swens) dient labetalol of α-methyldopa gebruikt te worden. Na een jaar behandeling met goed resultaat kan overwogen worden de medicatie gecontroleerd te verminderen of te stoppen.

BETA-BLOKKERS Atenolol (Tenormin®, Unibloc®) tabl 25, 50, 100 mg Start 1dd25 mg; maximaal 100 mg in 1-2 doses O: Wordt renaal geklaard. Bij staken geleidelijk afbouwen. beta-Blokkers kunnen de dempende werking van verapamil en diltiazem op de cardiale functie potentiëren. B: Toename decompensatio cordis, hypotens ie, bradycardie, vermoeidheid, koude extremiteiten, Raynaudklachten, bronchospasmen, duizeligheid. C: Sick-sinus syndroom, AV-block; lactatie. V: Voorzichtigheid is geboden bij nierfunctiestoornissen, astma/COPD. Versterkt mogelijk arteriële doorbloedingsstoornissen veroorzaakt door ergotamine. Versterkt de dempende werking van verapamil en diltiazem op het geleidingssysteem van het hart. NSAID’s kunnen de antihypertensieve werking van beta-blokkers remmen. Plotseling staken kan leiden tot ernstige aritmieën,

133

toename van angina pectoris of rebound hypertensie. Bij hypoglycemie kunnen de symptomen gemaskeerd worden.

Metoprolol (Lopresor®, Selokeen®) tabl 50 mg, 100 mg tabl mga (lopresor OROS®)100 mg, 200 mg tabl mga (Selokeen ZOC®)100 mg, 200 mg Start 1dd50 mg; max 200 mg per dag O: Wordt hepatisch geklaard. Bij staken geleidelijk afbouwen. beta-Blokkers kunnen de dempende werking van verapamil en diltiazem op de cardiale functie potentiëren. B: Toename decompensatio cordis, hypotensie, bradycardie, vermoeidheid, koude extremiteiten, Raynaudklachten, bronchospasmen, duizeligheid, levendige dromen. C: Sick-sinus syndroom, AV-block; lactatie. V: Voorzichtigheid is geboden bij leverfunctiestoornissen, astma/COPD. Versterkt mogelijk arteriële doorbloedingsstoornissen veroorzaakt door ergotamine. Versterkt de dempende werking van verapamil en diltiazem op het geleidingssysteem van het hart. NSAID’s kunnen de antihypertensieve werking van beta-blokkers remmen. Plotseling staken kan leiden tot ernstige aritmieën, toename van angina pectoris of rebound hypertensie. Bij hypoglycemie kunnen de symptomen gemaskeerd worden. Richtlijn voor keuze medicament Nevendiagnose/co-morbiditeit

1e keuze

alternatief

Geen

ß-blokker, of diureticum, of ACE remmer, of Ca-entry blocker

Geen voorkeur

Leeftijd > 60 jaar

Diureticum

COPD

Diureticum

Diabetes mellitus

ACE remmer

Chronisch hartfalen / linker ventrikeldysfunctie

ACE remmer

ß-blokker 2)

Coronairlijden

ß-blokker

Ca-entry blocker1)

Perifeer vaatlijden

Ca-entry blocker*

Nierziekte met micro-/macroalbuminurie

ACE remmer

Systolische hypertensie

Diureticum

Ca-entry blocker1)

Zwangerschap(swens)

Labetalol

α-methyldopa

Bij jicht geen diuretica Bij migraine bij voorkeur een ß-blokker.

1) Dihydropyridine

134

Ca-entry blocker 1)

of diltiazem (eucardic®) of Bisoprolol (bisobloc ®, emcor®). Langzaam insluipen. 2) Carvedilol

DIURETICA Diuretica bij serumkalium lager dan 3.5 mmol/L, in het bijzonder bij aritmie en/of digoxinegebruik, combineren met een kaliumsparend diureticum: triamtereen/hydrochloorthiazide.

Hydrochloorthiazide (Esidrex®) Tabl 25 mg, 50 mg 1dd12.5 mg (maximaal 1dd25 mg) B: Electrolytverstoringen, daling van de glucosetolerantie, hyperurikemie, duizeligheid, ongunstige verandering van plasmalipiden. C: Hypokaliëmie, overgevoeligheid voor sulfonamiden. V: Voorzichtigheid is geboden bij jicht. De lithiumspiegel kan worden verhoogd. NSAID’s remmen het diuretisch effect. Bij optreden van hypokaliëmie wordt de toxiciteit van hartglycosidenen ketanserine versterkt. Bij nierfunctiestoornissen is de werkzaamheid verminderd.

Triamtereen/hydrochloorthiazide (Dytenzide®) tabl (triamtereen 50, HCT 25) 1dd1 tabl; max. 1dd2 tabl B: Electrolytverstoringen, daling van de glucosetolerantie, hyperurikemie, duizeligheid, ongunstige verandering van plasmalipiden, nierstenen. C: Hypokaliëmie, overgevoeligheid voor sulfonamiden, zwangerschap, lactatie. V: Voorzichtigheid is geboden bij nierstenen in de anamnese, bij leverfunctiestoornissen en bij jicht. Hyperkaliëmie kan ontstaan in combinatie met ACE-remmers, spironolacton of kaliumzouten. De lithiumspiegel kan worden verhoogd. NSAID’s remmen het diuretisch effect. Bij nierfunctiestoornissen is de werkzaamheid verminderd.

ACE REMMERS Enalapril (Renitec®) tabl 5 mg, 10 mg, 20 mg, 40 mg Start 1-2 dd 10 mg; max 40 mg O: In combinatie met een diureticum, renovasculaire hypertensie, hartfalen of ondervulling starten met een lage dosis (1 dd 2.5-5 mg). Hoge dosering diuretica eventueel (tijdelijk) verlagen. B: Kriebelhoest, angioneurotisch oedeem, hyperkaliëmie. C: Zwangerschap, lactatie. V: Voorzichtigheid is geboden bij nierarteriestenose en nierfunctiestoornissen. Kans op hyperkaliëmie bij combinatie met kaliumsparende diuretica en kaliumzouten. NSAID’s remmen het antihypertensieve effect. De lithiumspiegel kan worden verhoogd.

Lisinopril (Novatec®, Zestril®) Tabl 5 mg, 10 mg, 20 mg Start 1 dd 10 mg; max 80 mg

135

O: In combinatie met een diureticum, renovasculaire hypertensie, hartfalen of ondervulling starten met een lage dosis (1 dd 2.5-5 mg). Hoge dosering diuretica eventueel (tijdelijk) verlagen. B: Kriebelhoest, angioneurotisch oedeem, hyperkaliëmie. C: Zwangerschap, lactatie. V: Voorzichtigheid is geboden bij nierarteriestenose en nierfunctiestoornissen. Kans op hyperkaliëmie bij combinatie met kaliumsparende diuretica en kaliumzouten. NSAID’s remmen het anti-hypertensieve effect. De lithiumspiegel kan worden verhoogd.

Quinapril (Acupril®) Tabl 5 mg, 10 mg, 20 mg, 40 mg Start 1 dd 10 mg; max 40 mg O: In combinatie met een diureticum, renovasculaire hypertensie, hartfalen of ondervulling starten met een lage dosis (1 dd 2.5-5 mg). Hoge dosering diuretica eventueel (tijdelijk) verlagen. Sterke weefselbinding. B: Kriebelhoest, angioneurotisch oedeem, hyperkaliëmie. C: Zwangerschap, lactatie. V: Voorzichtigheid is geboden bij nierarteriestenose en nierfunctiestoornissen. Kans op hyperkaliëmie bij combinatie met kaliumsparende diuretica en kaliumzouten. NSAID’s remmen het anti-hypertensieve effect. De lithiumspiegel kan worden verhoogd.

Ramipril (Tritace ®) caps 1,25 mg, 2,5 mg, 5 mg, 10 mg; tabl 2,5 mg, 5 mg Start 1 dd 2.5 mg; max 10 mg O: In combinatie met een diureticum, renovasculaire hypertensie, hartfalen of ondervulling starten met een lage dosis (1 dd 2.5-5 mg). Hoge dosering diuretica eventueel (tijdelijk) verlagen. B: Kriebelhoest, angioneurotisch oedeem, hyperkaliëmie. C: Zwangerschap, lactatie. V: Voorzichtigheid is geboden bij nierarteriestenose en nierfunctiestoornissen. Kans op hyperkaliëmie bij combinatie met kaliumsparende diuretica en kaliumzouten. NSAID’s remmen het anti-hypertensieve effect. De lithiumspiegel kan worden verhoogd.

CALCIUM-ENTRY BLOCKERS DIHYDROPYRIDINES Amlodipine (Norvasc®) tabl 5 mg, 10 mg 1dd 5-10 mg B: Hoofdpijn, blozen, enkeloedeem. C: Hypotensie. Lactatie. V: Voorzichtigheid is geboden bij leverproefstoornissen, porfyrie. Monotherapie kan bij angina pectoris een aanval uitlokken.

136

Nifedipine (Adalat OROS®) tabl mga 30 mg, 60 mg 1 dd 30-60 mg; maximaal 1 dd 120 mg O: B: C: V:

Kan gecombinnerd worden met een beta-blokker. Hoofdpijn, blozen, enkeloedeem. Hypotensie. Lactatie. Voorzichtigheid is geboden bij leverproefstoornissen, hartfalen, porfyrie. Cimetidine en grapefruitsap kunnen de spiegel van nifedipine verhogen. Nifedipine kan de bloedspiegel van kinine verlagen. Fenobarbital kan de bloedspiegel van nifedipine verlagen. Monotherapie kan bij angina pectoris een aanval uitlokken.

Felodipine (Plendil®, Renedil®) tabl mga 2.5 mg, 5 mg, 10 mg 1 dd 2,5-10 mg; max 1 dd 20 mg C: Hypotensie. Levercirrhose.

Nitrendipine (Baypress®) tabl 10 mg, 20 mg 1-2 dd 10-20 mg C: Hypotensie. Levercirrhose. BENZOTHIAZEPINES

Dilthiazem Diloc ® Diltiazem ® 3 dd 120 mg Diltiazem ® Surazem ® Surazem ® 3 dd 120 mg Tildiem CR® Tildiem ® 3 dd 120 mg Tildiem XR® O: B: C: V:

137

caps 120/180/240 mg tabl 60 mg

1 dd 120-240 mg 3 dd 60 mg; maximaal

tabl mga 90/120 mg caps mga 120/180/240 mg tabl 60 mg

1 dd 90-120 mg 1 dd 120-240 mg 3 dd 60 mg; maximaal

tabl mga 90/120 mg tabl 60 mg

1 dd 90-120 mg 3 dd 60 mg; maximaal

caps mga 200/300 mg

1 dd 200-300 mg

Dank “Dankbaarheid is een bloem die in weinig tuinen bloeit”

138

Dankwoord Op het moment dat ik dit dankwoord schrijf is het precies 6 jaar geleden dat ik aan mijn promotietraject begon. Nu, aan het einde van de rit, lig ik in een hangmat in Brazilië deze 6 jaar te overdenken. Van Europees project naar regionaal project tot internationale reis, de afgelopen 6 jaren waren vol afwisseling. Vele mensen hebben bijgedragen aan dit project en zonder hen zou het onmogelijk voor mij zijn om mijn proefschrift nu te kunnen verdedigen. Met een groot woord van dank op de vorige pagina wil ik een ieder die mij heeft geholpen, ondersteund of op een andere manier heeft bijgedragen aan de totstandkoming van dit proefschrift heel hartelijk danken. Een aantal van deze mensen of groepen mensen wil ik speciaal in het zonnetje zetten met een persoonlijk woord van dank. Allereerst wil ik bedanken mijn eerste promotor, prof. dr F.M. Haaijer-Ruskamp voor haar enorme inzet in dit proefschrift. Floor, zonder jou zou ik hier nu niet zitten. Dankzij jouw enthousiasme voor onderzoek kwam ik altijd weer gemotiveerd en vol werklust terug naar mijn computer. Verder was je de ideale promotor waarbij ik altijd kon binnenstappen en wist je me altijd terug te brengen tot de wetenschappelijke kant van het onderzoek. Daarnaast was je tijdens congressen als een moeder voor ons en wist je ervoor te zorgen dat we altijd iemand kenden om mee van gedachten te kunnen wisselen. Voor zijn bijdrage in de laatste fase van het proefschrift wil ik bedanken prof. dr. P.A. de Graeff. Pieter, niet alleen je medische kennis maar ook je voorkeur voor bondigheid gaven mijn artikelen meer duidelijkheid en leesbaarheid. Ook wil ik je bedanken voor de manier waarop je je hebt ingezet om een groep internisten in het AZG te motiveren om tijd vrij te maken om met ons te discussiëren over het nut en gebruik van richtlijnen en de nieuwe transmurale richtlijn in het bijzonder. Daarnaast wist je vanuit jouw perspectief als specialist en klinisch farmacoloog mijn bevindingen in een ander daglicht te plaatsen. De grote motor van dit proefschrift is zonder twijfel mijn copromotor dr. P. Denig geweest. Petra, dankzij jouw ‘pietluttigheid’ heb ik heel veel geleerd over hoe je grondig onderzoek uitvoert en je n immer aflatende energie gaf mij en dit proefschrift de voortgang die het nodig had. Altijd wist je me de juiste weg op te sturen en je hebt me nooit laten afdalen of verdwalen. Ook bij jou stond altijd de deur voor mij open om een kleine of grote vraag te kunnen stellen en ik heb dat altijd zeer gewaardeerd. De leden van de leescommissie, prof. dr. Richard Grol, prof. dr. Betty Meyboom, prof. dr. Herre Kingma en prof. dr. Dirk-Jan van Veldhuizen, wil ik graag bedanken voor het beoordelen van dit proefschrift. 139

Dankwoord

Het evalueren van een nascholingsprogramma in de huisartspraktijk betekent dat er vele patiëntengegevens uit computerbestanden van de huisartsen moeten worden gehaald, zowel voor de voormeting als voor de nameting. Dit is een enorme logistieke klus en zonder Ellen la Bastide en Wessel Sloof was het mij niet gelukt om de vele huisartsen op een efficiënte en overzichtelijke manier te benaderen. Ellen, je hebt me veel werk uit handen genomen met het bellen van de huisartsen. Door het mede opzetten en verfijnen van het volgsysteem door Wessel kon ik snel en gemakkelijk zien welke huisarts al bezocht was of nog een telefoontje moest krijgen. Daarnaast hebben we ook een aantal tochtjes gemaakt in Stad en Ommelanden om huisartsen te bezoeken en dat was altijd gezellig. Wessel, dat standbeeld komt eraan! Roy Stewart wil ik bedanken voor zijn bijdrage en hulp bij de multilevel analyses. Roy, de uurtjes bij jou waren altijd gezellig en je kennis over multilevel wist je altijd helder over te brengen. Collega’s zijn enorm belangrijk, zeker de collega’s waarmee je een nieuwe baan start. Zij delen dezelfde beginproblemen en samen nieuw zijn is altijd leuker dan alleen. Andere ervaren collega’s maken je wegwijs in deze nieuwe wereld en staan altijd klaar voor een goed advies. Hiervoor wil ik de ‘meisjes van Floor’ hartelijk bedanken. Iris Kindt, mijn eerste kamergenote met wie ik in de gezelligste werkkamer van de universiteit mijn eerste schreden op het wetenschappelijke pad heb gezet. Dank ook aan mijn paranimf, Nynke Schuling, je hebt je over ons ontfermd en je had het geduld om voor de zoveelste keer uit te leggen hoe de fax werkte. Extra dank ben ik je verschuldigd dat je mijn manuscript voor de leescommissie hebt klaargemaakt tijdens mijn afwezigheid. Een betere paranimf en vriendin kan niemand zich wensen. Ceciel Aarnoudse, jou wil ik bedanken voor alle gezelligheid die je hebt gegeven vanaf de allereerste dag dat we samen tegelijkertijd begonnen. Jammer dat je aan het eind niet aan mijn zijde zult staan. Toch ben je mijn derde paranimf en ik ben blij dat we al die tijd contact met elkaar hebben gehouden. Met Lisa Pont heb ik ruim vier jaar een onafscheidelijk werkleven geleidt. Lisa, not only during working hours but also after hours we’ve spent many ‘gezellige’ hours together and I learnt a great deal from you, in particular how to give a good presentation. I hope we’ll see each other soon somewhere in the world. Mijn huidige collega’s, Peter Mol, Heidrun Sturm, Larissa Grigoryan en Jacoba Greving wil ik bedanken voor de voortdurende gezellige werksfeer en de hulp die iedereen op zijn eigen specifieke gebied geboden heeft. Jacoba, ik vind het fijn dat je zo op het laatste moment bij wilde springen en mijn paranimf wilde zijn. Met jouw nuchtere kijk op het leven zal ik mij een stuk minder gespannen voelen in het ‘zweetkamertje’. Daarnaast wil ik nog een ex-collega noemen die met mijn data onderzoek heeft verricht en dat is Carel Schaars. Carel, bedankt voor je bijdrage aan dit proefschrift in de vorm van hoofdstuk 6. 140

Dankwoord

De vele collega’s van de Klinische Farmacologie wil ik graag bedanken voor de behulpzame discussies tijdens de maandagochtend besprekingen ondanks dat onze onderwerpen wat ver van elkaar afstaan en de altijd gezellige labdag. De collega’s van het Noordelijk Centrum voor Gezondheidsvraagstukken (NCG) en met name de (ex-)leden van de promovendiraad wil ik bedanken voor hun steun en prettige samenwerking. De collega’s van sociale farmacie wil ik graag bedanken voor de tweewekelijkse dRugs bijeenkomsten en de nuttige en leerzame discussies over onderzoek doen. Om de huisartsen in de provincie Groningen tweemaal te kunnen bezoeken om gegevens te verzamelen heb ik veel hulp gehad van derde- en vierdejaars geneeskundestudenten. Veel dank, zonder jullie had ik niet zoveel gegevens kunnen verzamelen. De huisartsen die hebben meegewerkt aan het onderzoek wil ik hierbij nogmaals heel hartelijk danken en met name één van hen, Bert Tent die samen met Jellie Meindersma ervoor heeft gezorgd dat de huisartsen wilden meewerken aan dit onderzoek. Werken gaat beter als je ontspannen bent en mijn vrienden hebben in de afgelopen 6 jaren voor deze afleiding en ontspanning gezorgd. Bovendien hebben jullie met je interesse voor mijn onderzoek ervoor gezorgd dat ik over de juis te hoeveelheid motivatie en energie beschikte om het proefschrift af te kunnen ronden. Lieve ouders, Heit en Mem, jullie hebben me de discipline bijgebracht die nodig was om dit proefschrift af te kunnen ronden. Dank voor alles wat jullie voor mij gedaan hebben. Aan het einde van een lange reeks mensen wil ik als laatste Henk-Jan bedanken. Lieve Henk-Jan, je hebt me door dik en dun gesteund de afgelopen 5 jaren. Je bent altijd geduldig en rustig gebleven waardoor mijn frustraties als sneeuw voor de zon verdwenen. Jij hebt me de juiste weg gewezen en ik hoop nog lang op deze weg door te mogen blijven lopen.

Willeke

141

Dankwoord

142

Northern Centre for Healthcare Research (NCH) and previous dissertations The Northern Centre for Healthcare Research (NCH) was founded in 1986 as a research institute of the University of Groningen (RUG), The Netherlands. Researchers from both the Medical and Social Faculty, with various professional backgrounds, are members of the NCH. These include medical sociologists, medical doctors, psychologists and human movement scientists. Research of the NCH is aimed at optimising quality of life of patients and quality of healthcare, and focuses on (a) determinants of health and illness, (b) consequences of illness, (c) the effects of medical treatment and decision making, and (d) the evaluation of health services and various types of interventions. At the time that this thesis is published, the NCH comprises five research programs. Until 1998, the NCH covered two research programs, i.e. ‘Determinants of Health’ and ‘Medical Decision Making and Evaluation of Healthcare’. The first program was reformulated in 1996 and was continued as ‘Disorder, Disability and Quality of Life’ (DDQ). Hence, previous dissertations in this area are listed as part of the present DDQ-programme. The second program was subdivided in 1998 into two new programs, i.e. ‘Public Health and Public Health Services Research’ and ‘Rational Drug Use’. Dissertations published earlier within the second program are listed retrospectively under these new headings. In 1998, two new programs, ‘Rehabilitation Programs Research’ and ‘Research in Motor Behaviour’, were formulated and officially integrated in the NCH in January 1999. The accomplished dissertations since the start of the programs in 1998 are included in the list. In 2000 the Department of General Practice joined the NCH and together with the Rational Drug Use group initiated a new research program, i.e. ‘Research in Evidence Based Medicine’. More information regarding the institute and its research can be obtained from our internet site: http://coo.med.rug.nl/nch.

Disorder, Disability and Quality of Life Arnold R (2004) Quality of life in chronic obstructive pulmonary disease and chronic heart failure PROMOTORES: prof dr R Sanderman, prof dr GH Koëter. COPROMOTORES: dr AV Ranchor, dr MJL De Jongste Keers JC (2004) Diabetes rehabilitation; effects and utilisation of a multidisciplinary education programme PROMOTORES: prof dr R Sanderman, prof dr ROB Gans. COPROMOTORES: dr J Bouma, dr TP Links Pool G (2003) Surviving testicular cancer; sexuality and other existential issues. PROMOTORES: prof dr HBM van de Wiel, prof dr DTh Sleijfer, prof dr HJ Hoekstra. CO-PROMOTOR: dr MF van Driel 143

Stiegelis HE (2003) A life less ordinary; cognitive adaptation and psychological functioning among cancer patients treated with radiotherapy. PROMOTORES: prof dr R Sanderman, prof dr AP Buunk. COPROMOTOR: dr M Hagedoorn Heuvel ETP van den (2002) Supporting caregivers of stroke patients; an intervention study. PROMOTORES : prof dr B Meyboom-de Jong, prof dr R Sanderman. CO- PROMOTOR: dr LP de Witte. REFERENT: dr LM Schure Schroevers MJ (2002) Short- and long-term adaptation to cancer; a comparison of patients with the general population. PROMOTOR: prof dr R Sanderman. REFERENT: dr AV Ranchor Hoekstra-Weebers JEHM (2000) Parental adaptation to pediatric cancer. PROMOTORES: prof dr EC Klip, prof dr WA Kamps. REFERENT: dr JPC Jaspers Doeglas DM (2000) Functional ability, social support and quality of life: a longitudinal study in patients with early rheumatoid arthritis. PROMOTORES: prof dr WJA van den Heuvel, prof dr R Sanderman. COPROMOTOR: dr ThPBM Suurmeijer Nijboer C (2000) Caregiving to patients with colorectal cancer: a longitudinal study on caregiving by partners. PROMOTORES: prof dr GAM van den Bos, prof dr R Sanderman. CO-PROMOTOR: dr AHM Triemstra Tiesinga LJ (1999) Fatigue and Exertion Fatigue: from description through validation to application of the Dutch Fatigue Scale (DUFS) and the Dutch Exertion Fatigue Scale (DEFS). PROMOTORES: prof dr WJA van den Heuvel, prof dr ThWN Dassen. COPROMOTOR: dr RJG Halfens Jong GM de (1999) Stress, stress management and issues regarding implementation. PROMOTORES: prof dr PMG Emmelkamp, prof dr JL Peschar. REFERENT: dr R Sanderman

Alberts JF (1998) The professionalized patient: sociocultural determinants of health services utilization. PROMOTOR: prof dr WJA van den Heuvel. REFERENT: dr R Sanderman Eijk LM van (1997) Activity and well-being in the elderly. PROMOTORES: prof dr WJA van den Heuvel, prof dr SM Lindenberg. REFERENT: dr GIJM Kempen Nieboer AP (1997) Life-events and well-being: a prospective study on changes in well-being of elderly people due to a serious illness event or death of the spouse. PROMOTORES: prof dr SM Lindenberg, prof dr J Ormel Scaf-Klomp W (1997) Screening for breast cancer: attendanc e and psychological consequences. PROMOTOR: prof dr WJA van den Heuvel. REFERENT: dr R Sanderman

144

Zwanikken CP (1997) Multiple sclerose: epidemiologie en kwaliteit van leven. PROMOTOR: prof dr J Minderhoud. CO- PROMOTORES: dr JW Groothoff, dr ThPBM Suurmeijer Kooiker SE (1996) Illness in everyday life: a health diary study of common symptoms and their consequences. PROMOTORES: prof dr WJA van den Heuvel, prof dr J van der Zee Krol B (1996) Quality of life in rheumatoid arthritis patients: the relation between personality, social support and depression. PROMOTOR: prof dr WJA van den Heuvel. REFERENTEN: dr R Sanderman, dr ThPBM Suurmeijer Ruiter JH de (1995) Sociale ondersteuning en kwaliteit van leven bij patiënten met kanker. PROMOTORES: prof dr WJA van den Heuvel, prof dr H Schraffordt Koops. REFERENTEN: dr FLP van Sonderen, dr R Sanderman Steverink N (1995) Zo lang mogelijk zelfstandig: naar een verklaring van verschillen ten aanzien van opname in een verzorgingstehuis onder fysiek kwetsbare ouderen. PROMOTORES: prof dr WJA van den Heuvel, prof dr TAB Snijders, prof dr J Ormel Uitenbroek DG (1995) Exercise behaviour. PROMOTOR: prof dr WJA van den Heuvel Linden-van den Heuvell GFEC van (1994) Voorbereiding op medische ingrepen. PROMOTOR: prof dr EC Klip Linschoten CP van (1994) Gezondheidsbeleving van ouderen: een Iongitudinale studie. PROMOTOR: prof dr WJA van den Heuvel. CO-PROMOTOR: dr J Ormel Oosterhuis A (1994) De gedragstherapeutische behandeling van slaapklachten. PROMOTOR: prof dr EC Klip Ranc hor AV (1994) Social class, psychosocial factors and disease: from description towards explanation. PROMOTORES: prof dr WJA van den Heuvel, prof dr AP Buunk. REFERENTEN: dr R Sanderman, dr J Bouma Reitsma B (1994) The end of the line? Evaluation of a multidisciplinary team approach to chronic pain. PROMOTORES: prof dr EC Klip, prof dr JWF Beks, prof dr JP Hennis Gerritsen JC (1993) Onafhankelijkheid van ouderen: mogelijkheden en voorwaarden. PROMOTOR: prof dr WJA van den Heuvel Heyink JW (1992) Levertransplantatie: psycho-sociale aspecten. PROMOTORES : prof dr WJA van den Heuvel, prof dr MJH Slooff. REFERENT: dr Tj Tijmstra

145

Sonderen FLP van (1991) Het meten van sociale steun. PROMOTORES: prof dr WJA van den Heuvel, prof dr FN Stokman. REFERENT: dr J Ormel Kempen GIJM (1990) Thuiszorg voor ouderen: een onderzoek naar de individuele determinanten van het gebruik van wijkverpleging en/of gezinsverzorging op verzorgend en huishoudelijk gebied. PROMOTORES: prof dr WJA van den Heuvel, prof dr W Molenaar. REFERENT: dr ThPBM Suurmeijer Sanderman R (1988) Life events, mediating variables and psychological distress: a longitudinal study. PROMOTORES: prof dr WJA van den Heuvel, prof dr PE Boeke, prof dr PMG Emmelkamp. REFERENT: dr J Ormel

Public Health and Public Health Services Research Post J (2004) Grootschalige huisartsenzorg buiten kantooruren PROMOTORES: prof dr J de Haan. Reneman MF (2004) Functional capacity evaluation in patients with chronic low back pain; reliability and validity. PROMOTORES: prof dr JW Groothoff, prof dr JHB Geertzen. COPROMOTOR: dr PU Dijkstra Bâra-Ionilã C-A (2003) The Romanian health care system in transition from the users’ perspective. PROMOTORES: prof dr WJA van den heuvel, prof dr JAM Maarse. CO- PROMOTOR: dr JP van Dijk Lege W de (2002) Medische consumptie in de huisartspraktijk op Urk. PROMOTORES: prof dr D Post, prof dr JW Groothoff Hoekstra EJ (2002) Arbeidsbemiddeling met behulp van Supported Employment als interventie bij de reïntegratie van chronisch zieken; de rol van de arbeidsbemiddelaar, chronisch zieke en werkgever. PROMOTORES: prof dr JW Groothoff, prof dr K Sanders, prof dr WJA van den Heuvel, prof dr D Post Enk JG van (2002) Determinants of use of healthcare services in childhood. PROMOTORES: prof dr D Post, prof dr AJP Veerman, prof dr WJA van den Heuvel Gecková A (2002) Inequality in health among Slovak adolescents. PROMOTORES: prof dr D Post, prof dr JW Groothoff. REFERENT: dr JP van Dijk Dijk JP van (2001) Gemeentelijk gezondheidsbeleid; omvang en doelgerichtheid. PROMOTORES: prof dr D Post, prof dr M Herweijer, prof dr JW Groothoff Middel LJ (2001) Assessment of change in clinical evaluation.

146

PROMOTOR: prof dr WJA van den Heuvel. REFERENT: dr MJL de

Jongste Bijsterveld HJ (2001) Het ouderenperspectief op thuiszorg; wensen en behoeften van ouderen ten aanzien van de thuis(zorg)situatie in Friesland PROMOTORES: prof dr D Post, prof dr B Meyboom-de Jong. REFERENT: dr J Greidanus Dijkstra GJ (2001) De indicatiestelling voor verzorgingshuizen en verpleeghuizen. PROMOTORES: prof dr D Post, prof dr JW Groothoff Dalen IV van (2001) Second opinions in orhopaedic surgery: extent, motives, and consequences. PROMOTORES: prof dr JR van Horn, prof dr PP Groenewegen, prof dr JW Groothoff Beltman H (2001) Buigen of barsten? Hoofdstukken uit de geschiedenis van de zorg aan mensen met een verstandelijke handicap in Nederland 1945-2000. PROMOTORES: prof dr D Post, prof dr AThG van Gennep Pal TM (2001) Humidifiers disease in synthetic fiber plants: an occupational health study. PROMOTORES: prof dr JGR de Monchy, prof dr D Post, prof dr JW Groothoff Goossen WTF (2000) Towards strategic use of nursing information in the Netherlands. PROMOTORES: prof dr WJA van den Heuvel, prof dr ThWN Dassen, prof dr ir A Hasman Hospers JJ (1999) Allergy and airway hyperresponsiveness: risk factors for mortality. PROMOTORES: prof dr D Post, prof dr DS Postma, prof dr ST Weiss

Wijk P van der (1999) Economics: Charon of Medicine? PROMOTORES: prof dr WJA van den Heuvel, prof dr L Koopmans, prof dr FFH Rutten. REFERENT: dr J Bouma Dijkstra A (1998) Care dependency: an assessment instrument for use in long-term care facilities. PROMOTORES: prof dr WJA van den Heuvel, prof dr ThWN Dassen Tuinstra J (1998) Health in adolescence: an empirical study of social inequality in health, health risk behaviour and decision making styles. PROMOTORES: prof dr D Post, prof dr WJA van den Heuvel. COPROMOTOR: dr JW Groothoff Mink van der Molen AB (1997) Carpale letsels: onderzoek naar de verzuimaspecten ten gevolge van carpale letsels in Nederland 1990-1993. PROMOTORES: prof dr PH Robinson, prof WH Eisma. CO- PROMOTOR: dr JW Groothoff. REFERENT: dr GJP Visser 147

Mulder HC (1996) Het medisch kunnen: technieken, keuze en zeggenschap in de moderne geneeskunde. PROMOTOR: prof dr WJA van den Heuvel Dekker GF (1995) Rugklachten-management-programma bij de Nederlandse Aardolie Maatschappij B.V.: ontwerp, uitvoering en evaluatie. PROMOTORES: prof dr D Post, prof WH Eisma. CO-PROMOTOR: dr JW Groothoff Puttiger PHJ (1994) De medische keuring bij gebruik van persluchtmaskers. PROMOTORES: prof dr D Post,prof dr WJA Goedhard. CO-PROMOTOR: dr JW Groothoff Engelsman C & Geertsma A (1994) De kwaliteit van verwijzingen. PROMOTORES: prof dr WJA van den Heuvel, prof dr FM HaaijerRuskamp, prof dr B Meyboom-de Jong Lucht F van der (1992) Sociale ongelijkheid en gezondheid bij kinderen. PROMOTOR : prof dr WJA van den Heuvel. REFERENT: dr JW Groothoff

Research in Evidence Based Medicine Groenier KH (2004) Empirical classification of shoulder complaints. PROMOTOR: prof dr B Meyboom-de Jong. CO-PROMOTORES: dr WH van Schiur, dr JC Winters Wachters-Kaufmann CSM (2004) Voorlichting aan CVA-patiënten en hun centrale verzorgers. PROMOTORES: prof dr B Meyboom-de Jong, prof dr TH The. COPROMOTOR: dr J Schuling Pont LG (2002) Assessing the quality of prescribing in general practice. PROMOTORES: prof dr FM Haaijer-Ruskamp, prof dr WH van Gilst, prof dr T van der Molen Bemelmans WJE (2001) Prevention of coronary heart disease by nutritional interventions. Impact of nutritional education in groups and supplementation with alpha-linolenic acid. PROMOTOR: prof dr B Meyboom-de Jong. CO- PROMOTOR: dr JF May. REFERENTEN: dr J Broer, dr EJM Feskens, dr FW Siero, dr AJ Smit Veninga CCM (2000) Improving prescribing in general practice. PROMOTOR: prof dr FM Haaijer-Ruskamp. REFERENT: dr P Denig Veehof LJG (1999) Polypharmacy in the elderly. PROMOTORES: prof dr B Meyboom-de Jong, prof dr FM HaaijerRuskamp Vries SO de (1998) Management strategies for intermittent claudication. PROMOTOR: prof dr MGM Hunink. REFERENT: dr JB Wong Bosch JL (1997) Outcome assessment of the percutaneous treatment of lilac artery occlusive disease.

148

PROMOTORES: prof dr MGM Hunink, prof dr WPThM Mall, prof dr L

Koopmans Dijkers FW (1997) Repeat prescriptions: a study in general practice in the Netherlands. PROMOTORES: prof dr B Meyboom-de Jong, prof dr FM HaaijerRuskamp, prof dr AF Casparie Trigt AM van (1995) Making news about medicines. PROMOTORES: prof dr TFJ Tromp, prof dr FM Haaijer-Ruskamp Boerkamp E (1995) Assessing professional services quality: an application in health care. PROMOTORES: prof dr JC Reuijl, prof dr FM Haaijer-Ruskamp Denig P (1994) Drug choice in medical practice: rationals, routines, and remedies. PROMOTORES: prof dr FM Haaijer-Ruskamp, prof dr H Wesseling Jong-van den Berg LTW de (1992) Drug utilization studies in pregnancy: what can they contribute to safety assessment? PROMOTORES : prof dr MNG Dukes, prof dr H Wesseling. REFERENT: dr FM Haaijer-Ruskamp Zijlstra IF (1991) De regionaal klinisch farmacoloog. PROMOTORES: prof dr H Wesseling, prof dr FWJ Gribnau, prof dr C van Weel. REFERENTEN: dr FM Haaijer-Ruskamp, dr H Wollersheim Rehabilitation Programs Research (from 1998 onwards)

Brouwer S (2004) Disability in chronic low back pain. PROMOTORES: prof dr JHB Geertzen, prof dr JW Groothoff, prof dr LNH Göeken. CO- PROMOTOR: dr PU Dijkstra Dekker R (2004) Long-term outcome of sports injuries. PROMOTORES: prof dr HJ ten Duis, prof WH Eisma, prof dr JW Groothoff. CO- PROMOTOR: dr CK van der Sluis Schegget-Slaterus, MJ ter (2004) The quality of expert advice in relation to the act on facilities for the handicapped. PROMOTORES: prof dr JW Groothoff, prof WH Eisma Schonherr MC (2003) Functional outcome after spinal cord injury. PROMOTORES: prof WH Eisma, prof dr JW Groothoff Sturms LM (2003) Pediatric traffic injuries; consequences for the child and the parents. PROMOTORES: prof WH Eisma, prof dr HJ ten Duis, prof dr JW Groothoff. CO- PROMOTOR: dr CK van der Sluis Meijer JWM (2002) The diabetic foot syndrome; diagnosis and consequences. PROMOTORES: prof WH Eisma, prof dr JW Groothoff. COPROMOTORES: dr TP Links, dr AJ Smit 149

Schoppen T (2002) Functional outcome after a lower limb amputation. PROMOTORES: prof WH Eisma, prof dr JW Groothoff, prof dr LNH Göeken. REFERENTEN: dr AM Boonstra, dr J de Vries Rommers GM (2000) The elderly amputee: rehabilitation and functional outcome. PROMOTOR: prof WH Eisma. CO-PROMOTOR: dr JW Groothoff Halbertsma JPK (1999) Short hamstrings & stretching: a study of muscle elasticity. PROMOTORES: prof WH Eisma, prof dr LNH Göeken. CO-PROMOTOR: dr JW Groothoff. REFERENT: dr ir AL Hof Geertzen JHB (1998) Reflex sympathetic dystrophy: a study in the perspective of rehabilitation medicine. PROMOTORES: prof WH Eisma, prof dr HJ ten Duis. CO- PROMOTOR: dr JW Groothoff. REFERENT: dr PU Dijkstra Sluis CK van der (1998) Outcomes of major trauma. PROMOTORES: prof dr HJ ten Duis, prof WH Eisma

Research in Motor Behaviour (from 1998 onwards) Kamsma YPT (2002) Functional Reorganisation of basic motor actions in Parkinson’s disease. Problem analysis, development and evaluation of a compensatory strategy training. PROMOTORES: prof dr P Rispens, prof dr WH Brouwer Stevens M (2001) Groningen Active Living Model (GALM): development and initial validation. PROMOTOR: prof dr P Rispens. REFERENTEN: dr KAPM Lemmink, dr MHG de Greef Lettinga AT (2000) Diversity in neurological physiotherapy: a comparative analysis of clinical and scientific practices. PROMOTORES: prof dr P Rispens, prof dr PJM Helders, prof dr A Mol Heuvelen MJG van (1999) Physical activity, physical fitness and disability in older persons. PROMOTOR: prof dr P Rispens. CO-PROMOTORES: dr WH Brouwer, dr GIJM Kempen. REFERENT: dr MHG de Greef Berkhuysen MA (1999) Toward tailor-made cardiac rehabilitation: getting at the heart of the matters. PROMOTORES: prof dr AP Buunk, prof dr P Rispens. REFERENT: dr R Sanderman

150

Willeke Kasje. Implementing joint treatment guidelines to improve prescribing in general practice

Recommend Documents