Table 2

Summary of selected Dutch guideline studies addressing the effects on quality of care

First author; yearClinical areaStudy designInterventionEffects on process/structure of careEffects on patient health outcomes
Engers et al, 200524Management of low-back painCluster RCT; GPs were randomly assigned (67 GPs, 616 consultations; 531 patients).Multifaceted tailored implementation strategy (distribution of guideline, educational workshop, a tool for patient education, a tool for reaching agreement with other healthcare providers) vs no interventionFewer referrals to a therapist during follow-up in IG compared with CG (36% vs 76%; OR 0.2; 95% CI 0.1 to 0.6). No sign. differences in 3 other outcome measures (eg, prescription of pain medication on a time-contingent basis) (partly effective)Not measured
Frijling et al, 200325+200426Preventive cardiovascular careControlled before and after study (617 general practices: IG: 316/CG: 301).Multifaceted intervention (conferences, dissemination of manuals and support from trained non-physicians during outreach visits) vs no intervention.Improvement in all 8 structure-of-care indicators in IG (varying from 12.5% for reminder for assessment of cardiovascular risk-factor profiles to 39.3% for reminder for BP measurement) and in 2 of 7 process-of-care indicators (varying from 9.7% for smoking cessation to 35.3% for measuring BP) compared with CG. OR from 1.45 (95% CI 1.02 to 2.07) to 27.13 (95% CI 12.86 to 57.24). (mostly effective)Not measured
Hak et al, 200027Influenza and influenza vaccinationUncontrolled before and after study (988 general practices).Multifaceted intervention (employment of facilitators, information-based methods, small-group consensus meetings, individual instructions and supportive computer software).Improvement in vaccine uptake (7.2%) and all 7 aspects of influenza immunisation practice (varying from 9% for immunisation by practice assistant to 37% for sending personal reminders). (mostly effective)Not measured
Hermens et al, 199928+200129Effective cervical cancer screeningUncontrolled before and after study (988 general practices).Multifaceted intervention (educational materials, a computerised module, small group education meetings, consultations, outreach visits).Improvement in 9 of 10 indicators (varying from 5% for presence of a sex-age register to 33% for sending a reminder to non-compliers). (mostly effective)Not measured
Hulscher et al, 199730Organisational guidelines for cardiovascular disease preventionControlled before and after study (95 general practices: outreach visit: 33; feedback: 31, CG: 31).Outreach visit method (visiting of practices by trained nurses), a feedback method (provision of feedback report with advice) vs no intervention.Outreach visit group improved in 6 of 10 indicators (varying from 12% for sex-age register available to 88% for written protocols available). No improvements in feedback group. (mostly effective)Not measured
Jans et al, 200031+200132Management of asthma and COPDControlled before and after study (19 practices (IG: 14/CG: 5)/370 patients (IG: 280/CG: 90).Multifaceted intervention (identification of barriers, documentation of the care provided, specific education, feedback and peer review) vs no intervention.Improvement in 4 of 8 aspects in IG (varying from 36% for monitoring of medication compliance to 74% for measurement of PEFR) compared with CG. (partly effective)1 of 4 outcomes improved in IG compared with CG (mean PEFR from 78.5 to 81.0). (partly effective)
Kasje et al, 200633Treatment of CHF and DM2Cluster RCT, balanced incomplete block design, peer groups were randomised (16 peer groups: 10 CHF, 6 T2DM; 85 GPs; 979 patients).Interactive educational programme for small peer groups (one arm received a programme on treatment of CHF, the other arm on hypertension treatment in DM2).No effect on both outcome measures (prescribing of ACE inhibitors and antihypertensive treatment) in both groups compared with CG. (not effective)Not measured
Lobo et al, 200234+200437+Frijling et al, 200236+200335Prevention and treatment of cardiovascular careCluster RCT; practices were randomised (124 practices/185 GPs/2268 patients; 537 diabetes/617 cardiovascular disease/1114 hypertension).Multifaceted intervention (feedback reports and support from facilitators including discussion of feedback reports, selection of clinical issues for improvement, selection of methods for change and evaluation during 15 outreach visits per practice) vs no intervention.Improvement in all 6 aspects of organising preventive cardiovascular care, such as the nr. of preventive tasks performed by practice assistant in IG compared with CG. Improvement in process of cardiovascular care in 5 of 12 indicators: OR from 1.55 (95% CI 1.35 to 1.77) for risk factors in patients with hypertension to 4.11 (95% CI 2.17 to 7.77) for checking for clinical signs of deterioration in patients with heart failure. Improvement in 2 of 7 indicators of process of diabetes care. OR from 1.52 (95% CI 1.07 to 2.16) for eye examination to 1.68 (95% CI 1.19 to 2.39) for foot examination. (mostly effective)Improvement in 2 of 8 aspects of HRQL in diabetes patients compared with CG (mean change from 3.71 (95% CI 0.73 to 6.68; scale 0–100) for mental health to 3.93 (95% CI 1.08 to 6.78) for vitality) and in 3 of 8 aspects in patients with cardiovascular disease (from 3.01 (95% CI 0.72 to 5.30) for vitality to 3.96 (95% CI 0.50 to 7.42) for social functioning). No improvement in patients with hypertension. (partly effective)
Renders et al, 200138+200239DM2Controlled before and after study (27 GPs (IG: 22/CG: 5) and 389 patients (IG: 312/CG: 77).Multifaceted intervention (distribution of guidelines, postgraduate education, audit and feedback, templates to register diabetes care; a recall system) vs no intervention.Improvement in all 9 indicators (varying from 16% for measurement of BP to 44.7% for measurement of HDL cholesterol) compared with CG. OR from 2.43 (95% CI 1.01 to 5.82) to 12.08 (95% CI 4.70 to 31.01). (mostly effective)The intervention did not improve any of the 14 patient outcomes, such as BP and HbA1c. (not effective)
Smeele et al, 199940Treatment of asthma/COPDCluster RCT; GPs were randomised (34 GPs (IG: 17/CG: 17) 433 patients (IG: 210/CG:223).Multifaceted intervention (an intensive, interactive group education and peer review programme) vs no intervention.Improvement in 2 structure-of-care aspects (varying from 16% for skills to 18% for presence of peak flow meters) in IG compared with CG. None of the 6 process-of care aspects showed sign. changes. (partly effective)No changes in any of the 3 patient outcomes (symptoms, smoking habit, disease specific quality of life) compared with CG. (not effective)
Van der Weijden et al, 200541Cholesterol for screening and management of hypercholesterolemiaCluster RCT; practices were randomised (32 GPs (IG: 16/CG: 16); 20 general practices; 3950 patient records).Multifaceted intervention (guideline dissemination, group education, supportive materials, feedback and face-to-face instruction on location) vs guideline dissemination.No improvement in 2 outcome measures (quality of selective case finding and quality of diagnostic procedures) in both groups. (not effective)Not measured
Van Essen et al, 199742Influenza vaccinationControlled before and after study (2 regions; 79 practices (IR: 82/CR: 97); 242 GPs (IR: 118/CG: 124); 550.000 patients).Multifaceted intervention (distribution of educational materials, educational meetings; distribution of vaccines, information on practice routines, etc) vs no intervention.Improvement in IR on vaccine rate (21%) and 3 of 5 organisational aspects (varying from 16% for special vaccination hours to 29% for vaccine in stock) compared with CR. (mostly effective)Not measured
Wolters et al, 200543+200644Management of lower urinary tract symptomsCluster RCT; GPs were randomised (142 GPs (IG: 70/CG: 72); 187patients).A distance learning programme (evidence-based information, assessment of learning needs, knowledge test; patient education materials) vs written guidelines.Lower referral rate to an urologist in distance learning group (OR 0.08; 95% CI 0.02 to 0.40). No effect on other 2 primary outcomes (PSA testing, prescription of medication). (partly effective)No difference between groups. In both groups urinary symptoms sign. decreased. (mostly effective)
Kamphuisen et al, 200245Diagnosis of pulmonary embolismUncontrolled before and after study (117 patients before and 119 patients after)Physicians were asked to strictly follow the diagnostic protocol after a non-high-probability perfusion-ventilation scan.Improvement of 26% in adherence to the guideline (20% before and 46% after the implementation of the guideline). (mostly effective)Not measured
Schouten et al, 200746Antibiotic treatment of lower respiratory tract infectionsCluster RCT; multicentre; hospitals were randomised (6 hospitals; 1906 patients).Multifaceted intervention (feedback on baseline performance and selection of interventions on the basis of analysing barriers) vs no intervention.Improvement in 2 of 5 primary outcomes in IH compared with CH (varying from 14% for antibiotic prescription; OR 2.63 (95% CI 1.57 to 4.42) to 15.7% for adaptation of antibiotic dose; OR 7.32 (95% CI 2.09 to 25.7). (partly effective)Not reported
Van Kasteren et al, 200547Optimising antibiotics policyInterrupted time series design (13 hospitals; 1763 procedures before/2050 after).Multifaceted intervention (performance feedback and implementation of national clinical practice guidelines).Improvement in all 4 outcome measures (costs excluded) (varying from 12.4% for timing to 56% for antibiotic choice). (mostly effective)No effect on overall SSI rates (not effective)
Bakker et al, 200648Treatment of DM2Uncontrolled before and after study (70 patients).Medical doctors were instructed to strictly adhere to the guideline.Not measuredImprovement in 6 of 7 outcome measures (eg, lowering HbA1c; decrease 1.7%) and body weight (decrease 3.8 kg). (mostly effective)
Bekkering et al, 2005a49+2005b50Management of low-back painCluster RCT: practices were randomised, block-randomisation (113 physiotherapists; 68 practices).A multifaceted active strategy (dissemination of guideline and active training strategy consisting of education, discussion, role playing, feedback, reminders) vs standard dissemination.Improvement in all 4 outcome measures in active strategy group compared with standard dissemination group. OR from 1.99 (95% CI 1.06 to 3.72) for setting functional treatment goals to 3.59 (95% CI 1.35 to 9.55) for giving adequate patient information. Adherence to all four criteria also improved more in active strategy group (42% vs 30%; OR 2.05; 95% CI 1.15 to 3.65). (mostly effective)No sign. difference between groups. Improvement in 2 of 3 primary outcome variables (physical functioning from 38 to 20 (scale 0–100) in active strategy group and from 40.5 to 17.5 in standard group and pain from 7.0 to 2.0 (scale 0–10) in both groups) in first 12 weeks. (mostly effective)
De Laat et al, 200651+200752Prevention and treatment of pressure ulcersUncontrolled before and after study (process of care: T0: 657; T1: 735; T2: 755 patients and patient outcomes: 399 patients).Guideline was introduced in staff meeting, announcement in several hospital media and the introduction of pressure reducing viscoelastic foam mattresses.Improvement in inadequate prevention (from 19% to 4% after 4 months and to 6% after 11 months) and in inadequate treatment (from 60% to 31%). (mostly effective)Improvement in both patient outcome measures (incidence of pressure ulcers decreased from 54 to 32 per 1000 patient days; pressure ulcer free time increased from 12 to 19 days). (mostly effective)
Van der Sanden et al, 200553Management of asymptomatic impacted lower third molarsCluster RCT; GDPs were randomised (92 GDPs: I: 46/C: 46).A multifaceted intervention (ie, feedback, reminders and an interactive meeting) vs no intervention.Increased knowledge of dentists in IG compared with CG. No improvement in other outcome measure (referral rates). (partly effective)Not measured
  • ACE inhibitors, inhibitors of angiotensin-converting enzyme; BP, blood pressure; CG, control group; CH, control hospital; CHF, chronic heart failure; CI, confidence interval; COPD, chronic obstructive pulmonary disease; CR, control region; DM2, diabetes mellitus type II; HDL cholesterol, high-density lipoprotein cholesterol; HRQL, health-related quality of life; IG, intervention group; GDP, general dental practitioner; GP, general practitioner; IH, intervention hospital; IR, intervention region; NSAIDs, non-steroidal anti-inflammatory drugs; OR, odds ratio; PEFR, peak expiratory flow rate; PSA test, prostate-specific antigen test; RCT, randomised controlled trial; sign., significant; SSI, surgical site infections.

  • Mostly effective, significant effect on more than half of the outcome measures was reported; not effective, no significant effect on any of the outcome measures was reported; partly effective, significant effect on half or less than half of the outcome measures was reported.