title: Do patients matter? Contribution of patient and care provider characteristics to the adherence of general practitioners and midwives to the Dutch national guidelines on imminent miscarriage.
abstract: OBJECTIVE
  To assess the relative contribution of patient and care provider characteristics to the adherence of general practitioners (GPs) and midwives to two specific recommendations in the Dutch national guidelines on imminent miscarriage. The study focused on performing physical examinations at the first contact and making a follow up appointment after 10 days because these are essential recommendations and there was much variation in adherence between different groups of providers.
  
  
  METHODS
  Prospective recording by GPs and midwives of care provided for patients with symptoms of imminent miscarriage.
  
  
  METHODS
  General practices and midwifery practices in the Netherlands.
  
  
  METHODS
  73 GPs and 38 midwives who agreed to adhere to the guidelines; 391 patients were recorded during a period of 12 months.
  
  
  METHODS
  Adherence to physical examinations and making a follow up appointment were measured as part of a larger prospective recording study on adherence to the guidelines on imminent miscarriage. Patient and care provider characteristics were obtained from case recordings and interviews, respectively. Multilevel analysis was performed to assess the contribution of several care provider and patient characteristics to adherence to two selected recommendations: the number of recommended physical examinations at the first contact and the number of days before a follow up appointment took place.
  
  
  RESULTS
  In the multilevel model explaining variance in adherence to physical examinations, the care provider's acceptance of the recommendations was the most important factor. Severity of symptoms and referral to an obstetrician were significant factors at the patient level. In the model for follow up appointments the characteristics of the care provider were less important. Referral to an obstetrician and probability diagnosis were significant factors at the patient level.
  
  
  CONCLUSIONS
  The study showed that characteristics of both the patient and care provider contribute to the variability in adherence. Furthermore, the contribution of the characteristics differed per recommendation. It is therefore advised that the contribution of both patient and care provider characteristics per recommendation should be carefully examined. If implementation is to be successful, strategies should be developed to address these specific contributions.
authors.affiliation: Public Health Division, TNO Prevention and Health, Leiden, The Netherlands. MAH.Fleuren@pg.tno.nl
authors.forename: M
authors.initials: M
authors.lastname: Fleuren
authors.forename: M
authors.initials: M
authors.lastname: van der Meulen
authors.forename: D
authors.initials: D
authors.lastname: Wijkel
mesh_terms: D000022:Abortion, Spontaneous / Q000517:prevention & control; D000033:Abortion, Threatened / Q000000981:diagnostic imaging / Q000517:prevention & control; D000293:Adolescent; D000328:Adult; D005194:Family Practice / Q000592:standards*; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008880:Midwifery / Q000592:standards*; D009426:Netherlands; D010349:Patient Compliance; D010353:Patient Education as Topic; D010808:Physical Examination; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D018084:Ultrasonography, Interventional