title: Understanding factors that influence the use of risk scoring instruments in the management of patients with unstable angina or non-ST-elevation myocardial infarction in the Netherlands: a qualitative study of health care practitioners' perceptions.
abstract: BACKGROUND
  Cardiac risk scores estimate a patient's risk of future cardiac events or death. They are developed to inform treatment decisions of patients diagnosed with unstable angina or non-ST-elevation myocardial infarction. Despite recommending their use in guidelines and evidence of their prognostic value, they seem underused in practice. The purpose of the study was to gain insight in the motivation for implementing cardiac risk scores, and perceptions of health care practitioners towards the use of these instruments in clinical practice.
  
  
  METHODS
  This qualitative study involved semi-structured interviews with 31 health care practitioners at 11 hospitals throughout the Netherlands. Participants were approached through purposive sampling to represent a broad range of participant- and hospital characteristics, and included cardiologists, medical residents, medical interns, nurse practitioners and an emergency physician. The Pettigrew and Whipp Framework for strategic change was used as a theoretical basis. Data were initially analysed through open coding to avoid forcing data into categories predetermined by the framework.
  
  
  RESULTS
  Cardiac risk score use was dependent on several factors, including IT support, clinical relevance for daily practice, rotation of staff and workload. Both intrinsic and extrinsic drivers for implementation were identified. Reminders, feedback and IT solutions were strategies used to improve and sustain the use of these instruments. The scores were seen as valuable support systems in improving uniformity in treatment practices, educating interns, conducting research and quantifying a practitioner's own risk assessment. However, health care practitioners varied in their perceptions regarding the influence of cardiac risk scores on treatment decisions.
  
  
  CONCLUSIONS
  Health care practitioners disagree on the value of cardiac risk scores for clinical practice. Practitioners driven by intrinsic motivations predominantly experienced benefits in policy-making, education and research. Practitioners who were forced to use cardiac risk scores were less likely to take into account the risk score in their treatment decisions. The results of this study can be used to develop strategies that stimulate or sustain cardiac risk score use in practice, while taking into account barriers that affect cardiac risk score use, and possibly reduce practice variation in the management of unstable angina and non-ST-elevation myocardial infarction patients.
authors.affiliation: EMGO Institute for Health and Care Research, Department of Public and Occupational Health, VU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands. j.engel1@vumc.nl.
authors.forename: Josien
authors.initials: J
authors.lastname: Engel
authors.forename: Marie-Julie
authors.initials: MJ
authors.lastname: Heeren
authors.forename: Ineke
authors.initials: I
authors.lastname: van der Wulp
authors.forename: Martine C
authors.initials: MC
authors.lastname: de Bruijne
authors.forename: Cordula
authors.initials: C
authors.lastname: Wagner
mesh_terms: D000328:Adult; D000789:Angina, Unstable / Q000628:therapy*; D019468:Disease Management; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000628:therapy*; D009426:Netherlands; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011379:Prognosis; D036301:Qualitative Research; D018570:Risk Assessment / Q000379:methods*