Labour intensity of guidelines may have a greater effect on adherence than GPs' workload

Perceived adherence and associated barriers to the national atopic dermatitis guideline: A survey among general practitioners

BACKGROUND

General practitioners (GPs) have an important role in managing patients with atopic dermatitis (AD). Although pivotal, adherence to dermatological guidelines in general practice has not been assessed.

OBJECTIVES

To assess GPs' perceived adherence and barriers to the Dutch AD guideline.

METHODS

A survey was conducted among 391 GPs in the Netherlands between December 2021 and May 2022. GPs rated their perceived adherence and perceived barriers concerning five key recommendations of the AD guideline, following an existing framework. The correlation between perceived adherence and barriers was investigated using Spearman's rank correlation.

RESULTS

A total of 213 GPs (54%) participated. Perceived adherence rates varied across recommendations (43.7% to 98.1%). Lowest adherence was reported for recommendations concerning topical corticosteroids (TCS). Across all recommendations, patient factors (65.6%; SD 11.6) and lack of applicability to specific patient groups (29.5%; SD 10.5) were reported most frequently as barriers. The overall correlation between adherence and barriers was strongest for knowledge (ρ .55; SD .10) and attitude-related factors (range: ρ .40--.62).

CONCLUSION

GPs' perceived adherence and barriers vary substantially across recommendations of the AD guideline. In particular, GPs reported lower adherence to recommendations concerning TCS. Next to patient-related factors, strong correlations between adherence perceived by GPs and knowledge and attitude-related barriers suggest the importance of addressing these factors as well to improve adherence.

Relationship between generic and occupation-specific job demands and resources, negative work−home interference and burnout among GPs

Scholars often examine the effect of generic job demands and resources on burnout, yet to increase ecological validity, it is important to examine the effects of occupation-specific characteristics. An extended version of the job demands-resources model with work−home interference as a mediator is examined among a cross-sectional sample of 178 general practitioners (GPs). Interviews with GPs were used to develop questions on occupation-specific work characteristics. Hypotheses were tested in MEDIATE. Both generic and occupation-specific job demands positively affected emotional exhaustion, while only occupation-specific job demands affected depersonalization. Only strain-based work−family interference mediated the relationship between generic and occupation-specific job demands, emotional exhaustion and depersonalization. This study offers an important extension of the job demands-resources model by including occupation-specific job characteristics. This broader perspective can aid in more targeted job design to reduce burnout among GPs.

The association between the workload of general practitioners and patient experiences with care: results of a cross-sectional study in 33 countries

BACKGROUND

The workload of general practitioners (GPs) and dissatisfaction with work have been increasing in various Western countries over the past decades. In this study, we evaluate the relation between the workload of GPs and patients' experiences with care.

METHODS

We collected data through a cross-sectional survey among 7031 GPs and 67,873 patients in 33 countries. Dependent variables are the patient experiences on doctor-patient communication, accessibility, continuity, and comprehensiveness of care. Independent variables concern the workload measured as the GP-reported work hours per week, average consultation times, job satisfaction (an indicator of subjective workload), and the difference between the workload measures of every GP and the average in their own country. Finally, we evaluated interaction effects between workload measures and what patients find important in a country and the presence of a patient-list system. Relationships were determined through multilevel regression models.

RESULTS

Patients of GPs who are happier with their work were found to experience better communication, continuity, access, and comprehensiveness. When GPs are more satisfied compared to others in their country, patients also experience better quality. When GPs work more hours per week, patients also experience better quality of care, but not in the area of accessibility. A longer consultation time, also when compared to the national average, is only related to more comprehensive care. There are no differences in the relationships between countries with and without a patient list system and in countries where patients find the different quality aspects more important.

CONCLUSIONS

Patients experience better care when their GP has more work hours, longer consultation times, and especially, a higher job satisfaction.

Is there a conflict between general practitioners applying guidelines for antibiotic prescribing and including their patients' preferences?

OBJECTIVES

One perceived barrier to guideline adherence is the existence of conflicting patient preferences. We examined whether patient preferences influence the prescription of antibiotics in general practice, and how this affects guideline adherence. We hypothesized that preferences play a larger role in prescribing antibiotics if the guideline allows for preferences to be taken into account, ie, if prescribing antibiotics is an option which can be considered rather than a clear recommendation to prescribe or not. We included three guidelines: acute cough, acute rhinosinusitis, and urinary tract infections.

METHODS

Data from NIVEL (the Netherlands Institute for Health Services Research) Primary Care Database (NIVEL-PCD) were used to assess antibiotic indications and prescriptions. These data were combined with a questionnaire among members of NIVEL's Dutch Health Care Consumer Panel to examine patient preferences. According to NIVEL-PCD, 286 of these members contacted their general practitioner (GP) in 2015 for acute cough, acute rhinosinusitis or urinary tract infections. A logistic multilevel regression analysis was performed to test our hypothesis.

RESULTS

Patient preferences do play a role in GPs' prescribing of antibiotics only in situations where, in accordance with the guideline, their use is an option which could be considered (interaction between indication and preference: p=0.049). If patients ask for antibiotics themselves in such situations, then GPs prescribe antibiotics more often.

CONCLUSION

Patient preferences only play a role if the guideline provides room to take preferences into account. Therefore, our results do not suggest a conflict between applying guidelines and including patient preferences. Further research is recommended to examine this possible conflict in other situations.

Guideline adherence for diagnostic faeces testing in primary care patients with gastroenteritis

BACKGROUND

Gastroenteritis (GE) is a common reason for primary care consultation. Dutch clinical practice guidelines (CPG) recommend diagnostic faeces testing (DFT) only in primary care patients with severe illness, comprised immunity or increased transmission risk. For its superior accuracy, shorter turnaround time and ease of use, polymerase chain reaction (PCR)-based DFT has largely replaced conventional techniques. It is unknown whether this changed CPG adherence.

OBJECTIVE

To quantify the effect of PCR introduction on adherence to CPG indications for DFT in primary care patients with GE.

METHODS

We performed a cohort study using routine care data of 225 GPs. Episodes of GE where DFT was performed were extracted from electronic patient records. Presenting symptoms were identified and adherence to CPG indications for DFT assessed in two randomly drawn samples of each 500 patients, one from the period before PCR introduction (2010-11) and one after (2013). The association between PCR introduction and adherence was estimated using multivariable regression analysis.

RESULTS

In 88% of all episodes relevant presenting symptoms were reported, most often 'frequent watery stool' (58%) and 'illness duration >10 days' (40%). DFT was performed in 15% of episodes before PCR introduction and in 18% after. Overall, in 17% the DFT request was considered adherent to the CPG, 16% before PCR introduction and 18% after (adjusted OR 1.2, 95% CI 0.9-1.7).

CONCLUSION

Overall adherence to CPG indications when requesting DFT in primary care patient with GE was 17%. Implementation of PCR-based DFT was not associated with a change in CPG adherence.

Development and validation of a new instrument measuring guideline adherence in clinical practice

BACKGROUND

Education in evidence-based medicine (EBM) is an important part of the postgraduate training of GPs. Evaluation of its effect on EBM behaviour in daily clinical practice is difficult and instruments are scarce. Working in accordance with guidelines is considered as one of the key indicators of EBM behaviour.

OBJECTIVE

To develop and validate an instrument assessing guideline adherence of GP trainees in clinical practice.

METHODS

We developed an instrument that assesses guideline adherence, taking conscious deviation into account. The instrument assesses guideline adherence on 59 different management decisions (diagnosis N = 17, therapy N = 20, referral N = 22) for 23 conditions as described in 27 different clinical practice guidelines. We validated this instrument using performance data as collected by third-year GP trainees on three important properties: validity, reliability and feasibility.

RESULTS

Performance data were collected by 76 GP trainees on 12106 patient consultations with 12587 different reasons for encounter. Overall, guideline adherence was 82% (95% confidence interval 77-88%). The significant correlation with the national GP knowledge test (r 0.33, P 0.004) showed the instrument to be a valid instrument. Interrater reliabilities (intraclass correlation coefficient) varied between moderate and excellent (0.64-1.00, P < 0.001). The instrument proved feasible with coverage of 24% (N = 3082) of reasons for encounter presented to GP trainees and a mean and median time of 1 minute to score a patient consultation.

CONCLUSION

This instrument proved valid, reliable and feasible to assess guideline adherence among trainees in the clinical primary care setting.

Does integrated training in evidence-based medicine (EBM) in the general practice (GP) specialty training improve EBM behaviour in daily clinical practice? A cluster randomised controlled trial

OBJECTIVES

Evidence-based medicine (EBM) is an important element in the general practice (GP) specialty training. Studies show that integrating EBM training into clinical practice brings larger benefits than stand-alone modules. However, these studies have neither been performed in GP nor assessed EBM behaviour of former trainees in daily clinical practice.

SETTING

GP specialty training in the Netherlands.

PARTICIPANTS

All 82 third year GP trainees who started their final third year in 2011 were approached for inclusion, of whom 79 (96%) participated: 39 in the intervention group and 40 in the control group.

INTERVENTION

Integrated EBM training, in which EBM is embedded closely within the clinical context by joint assignments for the trainee and supervisor in daily practice, and teaching sessions based on dilemmas from actual patient consultations.

COMPARISON

Stand-alone EBM training at the institute only.

PRIMARY AND SECONDARY OUTCOMES

Our primary outcome was EBM behaviour, assessed by measuring guideline adherence (incorporating rational, motivated deviation) and information-seeking behaviour. Our secondary outcomes were EBM attitude and EBM knowledge. Data were acquired using logbooks and questionnaires, respectively. Analyses were performed using mixed models.

RESULTS

Logbook data were available from 76 (96%) of the participating trainees at baseline (7614 consultations), 60 (76%) at the end of the third year (T1, 4973 consultations) and 53 (67%) 1 year after graduation (T2, 3307 consultations). We found no significant differences in outcomes between the 2 groups, with relative risks for guideline adherence varying between 0.96 and 0.99 (95% CI 0.86 to 1.11) at T1, and 0.99 and 1.10 (95% CI 0.92 to 1.25) at T2, and for information-seeking behaviour between 0.97 and 1.16 (95% CI 0.70 to 1.91) and 0.90 and 1.10 (95% CI 0.70 to 1.32), respectively.

CONCLUSIONS

Integrated EBM training compared with stand-alone EBM training does not improve EBM behaviour, attitude or knowledge of (future) GPs.

General practitioners’ attitudes towards decision-supported prescribing: An analysis of the Dutch primary care sector

The use of multiple drugs by patients increases the risk of medical problems. Clinical decision support could assist general practitioners with prescribing but is underused. This article aims to investigate the attitudes of general practitioners towards using decision support systems. A survey was distributed among 500 Dutch general practitioners. Virtually all 184 respondents indicated having a clinical information system, while only 21 percent indicated having a decision support plug-in; this correlated with their use of medical formularies. Only use of one of the medical formularies correlated with the number of recognized underprescription problems. General practitioners’ attitudes toward a newly proposed system aiding them with polypharmacy prescribing were mainly positive (57%); the perceived usefulness correlated with output quality (p = .000), time investment (p = .000), and financial stimuli (payability: p = .000 and reimbursement: p = .015) but not with job relevance. Dutch general practitioners are thus likely to adopt the proposed system under the conditions that it improves prescription quality and does not require extensive investments of time or money.

Patient complaint cases in primary health care: what are the characteristics of general practitioners involved?

Background. Limited knowledge exists about factors increasing the risk of general practitioners becoming involved in a complaint case or getting disciplined in connection with a complaint case. Aim. The present study aimed to identify the general practitioner and practice characteristics associated with complaint cases and discipline. Methods. Information on general practitioners involved in complaint case decisions during one year (2007) was linked to Danish National register data on all general practitioners (n = 3,765). Logistic regression was used for statistical analysis. Results. With regard to complaints concerning daytime services (n = 265), the professional seniority of the general practitioner was positively associated with the odds of receiving a complaint decision (OR = 1.44 per 20 years of seniority; CI 95%, 1.04–1.98). Likewise, having more consultations per day was associated with increased odds (OR = 1.29 per 10 extra consultations per day; CI 95%, 1.07–1.54). No statistically significant association could be demonstrated between being disciplined and general practitioner or practice characteristics. Conclusion. The possible relationship between professional seniority, rate of consultations, and complaint cases merits further studies to clarify the impact of professional seniority and workload on professional performance and to furthermore consider the role of factors such as job content and communication styles.

Impact of remuneration on guideline adherence: empirical evidence in general practice

BACKGROUND AND OBJECTIVE

Changes in the Dutch GP remuneration system provided the opportunity to study the effects of changes in financial incentives on the quality of care. Separate remuneration systems for publicly insured patients (capitation) and privately insured patients (fee-for-service) were replaced by a combined system of capitation and fee-for-service for all in 2006. The effects of these changes on the quality of care in terms of guideline adherence were investigated.

DESIGN AND SETTING

A longitudinal study from 2002 to 2009 using data from patient electronic medical records in general practice. A multilevel (patient and practice) approach was applied to study the effect of changes in the remuneration system on guideline adherence.

SUBJECTS

21 421 to 39 828 patients from 32 to 52 general practices (dynamic panel of GPs).

MAIN OUTCOME MEASURES

Sixteen guideline adherence indicators on prescriptions and referrals for acute and chronic conditions.

RESULTS

Guideline adherence increased between 2002 and 2008 by 7% for (formerly) publicly insured patients and 10% for (formerly) privately insured patients. In general, no significant differences in the trends for guideline adherence were found between privately and publicly insured patients, indicating the absence of an effect of the remuneration system on guideline adherence. Adherence to guidelines involving more time investment in terms of follow-up contacts was affected by changes in the remuneration system. For publicly insured patients, GPs showed a higher trend for guideline adherence for guidelines involving more time investment in terms of follow-up contacts compared with privately insured patients.

CONCLUSION

The change in the remuneration system had a limited impact on guideline adherence.

Variation in formulary adherence in general practice over time (2003-2007)

OBJECTIVE

To study trends and variation in adherence to the main national formulary for the 20 most prevalent health problems in Dutch general practice over a 5-year period (2003-07).

METHODS

Routine electronic medical records from a pool of 115 representative general practices were linked to the main national formulary. Analyses included over 2 million prescriptions for 246 391 patients. The outcome variable was whether or not the prescribed medication was congruent with recommendations in the national formulary. Trends and variation were analysed using three-level multilevel logistic regression analyses (general practice, patient, and prescription).

RESULTS

The percentage of formulary adherent prescriptions for the 20 most prevalent health problems was 73-76% between 2003 and 2007. The percentage varied considerably between guidelines. Lowest adherence rates were found for acute bronchitis and acute upper respiratory infection. Interpractice variation was constant over time.

CONCLUSIONS

General practice information networks are useful for monitoring general patterns of formulary on a year-to-year basis. Formulary adherence is stable over time but varies across diagnoses, patients and general practices. In the past decade, efforts have been made to increase the level of formulary adherent prescribing. These general efforts managed to stabilize (variation in) adherence in a field where many other initiatives (e.g. by pharmaceutical companies) are undertaken to influence prescribing behaviour.

Effect of CYP2C9 polymorphisms on prescribed dose and time-to-stable dose of sulfonylureas in primary care patients with Type 2 diabetes mellitus

AIMS

Sulfonylureas are mainly metabolized by the enzyme CYP2C9. Two allelic variants, CYP2C9*2 and CYP2C9*3, result in decreased metabolic capacity and have been associated with elevated sulfonylurea serum levels. However, most of the available data originates from pharmacokinetic analyses performed in healthy individuals. In this study, the effect of CYP2C9*2 and CYP2C9*3 alleles on prescribed dose and time-to-stable dose of sulfonylureas was investigated.

MATERIALS & METHODS

A group of 207 incident sulfonylurea users treated in four university affiliated primary care centers were identified. The effect of the CYP2C9*2 and CYP2C9*3 alleles on prescribed dose and time-to-stable dose was then assessed.

RESULTS

No significant effects of the CYP2C9*2 and CYP2C9*3 alleles were found. However, a trend towards a lower stable glimepiride dose for carriers of the CYP2C9*3 allele was observed.

CONCLUSION

Genotyping for the CYP2C9*2 and CYP2C9*3 alleles currently appears to have no clinical implications for dosing of sulfonylureas in primary care patients with Type 2 diabetes mellitus.