title: Out-of-hours primary care: development of indicators for prescribing and referring.
abstract: BACKGROUND
  Dutch general practitioners have reorganized their out-of-hours primary health care to general practice cooperatives. Good insight into the quality of delivered medical care is important to make the accountability of health practitioners and managers transparent to society and to identify and minimize medical errors.
  
  
  OBJECTIVE
  Development of a set of quality indicators for internal quality improvement in out-of-hours primary clinical care.
  
  
  METHODS
  A systematic approach combining the opinion of three different general practitioner expert panels, and an empirical test in daily practice. The indicators were based on clinical, evidence-based, national guidelines. We tested the validity, feasibility, reliability and opportunity for quality improvement.
  
  
  RESULTS
  Of the 80 available national clinical guidelines, 29 were approved and selected by the first general practitioner expert panel. Out of these 29 guidelines, 73 indicators concerning prescribing and referring were selected by the second panel. In an empirical test on 36 254 patient contacts, 7344 patient contacts (22.7%) were relevant for the assessment of these 73 indicators. Six indicators were excluded because they scored more than 15% missing values. In total, 38 indicators were excluded because the opportunity for quality improvement was limited (performance score > or =90%). In the final meeting, the third general practitioner expert panel excluded five indicators, leading to a final set of 24 indicators.
  
  
  CONCLUSIONS
  This study shows the importance of subjecting indicators to an empirical test in practice. The national clinical guidelines are only partially applicable in the assessment of out-of-hours primary care. They need to be expanded with topics that are related to general practitioner care in an out-of-hours setting and acute medical problems.
authors.affiliation: Centre for Quality of Care Research (WOK), KWAZO 114 Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands. p.giesen@voha.umcn.nl
authors.forename: Paul
authors.initials: P
authors.lastname: Giesen
authors.forename: M
authors.initials: M
authors.lastname: Willekens
authors.forename: H
authors.initials: H
authors.lastname: Mokkink
authors.forename: Jozé
authors.initials: J
authors.lastname: Braspenning
authors.forename: W
authors.initials: W
authors.lastname: Van Den Bosch
authors.forename: Richard
authors.initials: R
authors.lastname: Grol
mesh_terms: D039602:After-Hours Care / Q000458:organization & administration* / Q000592:standards; D003430:Cross-Sectional Studies; D004363:Drug Utilization / Q000592:standards; D036262:Empirical Research; D019317:Evidence-Based Medicine; D019983:Guideline Adherence / Q000706:statistics & numerical data; D006801:Humans; D016347:Medical Records Systems, Computerized; D009426:Netherlands; D017410:Practice Guidelines as Topic; D011320:Primary Health Care / Q000458:organization & administration* / Q000592:standards; D016730:Program Development / Q000379:methods; D011785:Quality Assurance, Health Care / Q000379:methods*; D019984:Quality Indicators, Health Care / Q000592:standards*; D012017:Referral and Consultation