title: Evaluating the effect of a web-based quality improvement system with feedback and outreach visits on guideline concordance in the field of cardiac rehabilitation: rationale and study protocol.
abstract: BACKGROUND
  Implementation of clinical practice guidelines into daily care is hampered by a variety of barriers related to professional knowledge and collaboration in teams and organizations. To improve guideline concordance by changing the clinical decision-making behavior of professionals, computerized decision support (CDS) has been shown to be one of the most effective instruments. However, to address barriers at the organizational level, additional interventions are needed. Continuous monitoring and systematic improvement of quality are increasingly used to achieve change at this level in complex health care systems. The study aims to assess the effectiveness of a web-based quality improvement (QI) system with indicator-based performance feedback and educational outreach visits to overcome organizational barriers for guideline concordance in multidisciplinary teams in the field of cardiac rehabilitation (CR).
  
  
  METHODS
  A multicenter cluster-randomized trial with a balanced incomplete block design will be conducted in 18 Dutch CR clinics using an electronic patient record with CDS at the point of care. The intervention consists of (i) periodic performance feedback on quality indicators for CR and (ii) educational outreach visits to support local multidisciplinary QI teams focussing on systematically improving the care they provide. The intervention is supported by a web-based system which provides an overview of the feedback and facilitates development and monitoring of local QI plans. The primary outcome will be concordance to national CR guidelines with respect to the CR needs assessment and therapy indication procedure. Secondary outcomes are changes in performance of CR clinics as measured by structure, process and outcome indicators, and changes in practice variation on these indicators. We will also conduct a qualitative process evaluation (concept-mapping methodology) to assess experiences from participating CR clinics and to gain insight into factors which influence the implementation of the intervention.
  
  
  CONCLUSIONS
  To our knowledge, this will be the first study to evaluate the effect of providing performance feedback with a web-based system that incorporates underlying QI concepts. The results may contribute to improving CR in the Netherlands, increasing knowledge on facilitators of guideline implementation in multidisciplinary health care teams and identifying success factors of multifaceted feedback interventions.
  
  
  BACKGROUND
  NTR3251.
authors.affiliation: Department of Medical Informatics, Academic Medical Centre/University of Amsterdam, (Room J1b-113.2), P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands. m.m.vanengen-verheul@amc.uva.nl.
authors.forename: Mariëtte M
authors.initials: MM
authors.lastname: van Engen-Verheul
authors.affiliation: Department of Medical Informatics, Academic Medical Centre/University of Amsterdam, (Room J1b-113.2), P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands. n.f.keizer@amc.uva.nl.
authors.forename: Nicolette F
authors.initials: NF
authors.lastname: de Keizer
authors.affiliation: Department of Medical Informatics, Academic Medical Centre/University of Amsterdam, (Room J1b-113.2), P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands. s.n.vanderveer@amc.uva.nl.|European Renal Best Practice (ERBP) Methods Support Team, University Hospital Ghent, Ghent, Belgium. s.n.vanderveer@amc.uva.nl.
authors.forename: Sabine N
authors.initials: SN
authors.lastname: van der Veer
authors.affiliation: Department of Medical Informatics, Academic Medical Centre/University of Amsterdam, (Room J1b-113.2), P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands. h.kemps@mmc.nl.|Department of Cardiology, Máxima Medical Centre, Veldhoven, The Netherlands. h.kemps@mmc.nl.
authors.forename: Hareld M C
authors.initials: HM
authors.lastname: Kemps
authors.affiliation: Amsterdam School of Health Professions, Amsterdam, The Netherlands. w.j.m.scholte.op.reimer@hva.nl.
authors.forename: Wilma J M
authors.initials: WJ
authors.lastname: Scholte op Reimer
authors.affiliation: Department of Medical Informatics, Academic Medical Centre/University of Amsterdam, (Room J1b-113.2), P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands. m.w.jaspers@amc.uva.nl.
authors.forename: Monique W M
authors.initials: MW
authors.lastname: Jaspers
authors.affiliation: Department of Medical Informatics, Academic Medical Centre/University of Amsterdam, (Room J1b-113.2), P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands. niels.peek@manchester.ac.uk.|Health e-Research Centre, Institute of Population Health, University of Manchester, Manchester, UK. niels.peek@manchester.ac.uk.
authors.forename: Niels
authors.initials: N
authors.lastname: Peek
mesh_terms: D000072038:Cardiac Rehabilitation; D002309:Cardiology / Q000193:education / Q000592:standards; D057286:Electronic Health Records; D005246:Feedback; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D020407:Internet; D008297:Male; D009426:Netherlands; D010348:Patient Care Team / Q000592:standards; D010353:Patient Education as Topic; D058996:Quality Improvement; D019984:Quality Indicators, Health Care; D011788:Quality of Life; D012046:Rehabilitation / Q000193:education / Q000592:standards; D011795:Surveys and Questionnaires