2. Building an infrastructure to improve
cardiac rehabilitation:
from guidelines to audit and feedback
Mariëtte M. van Engen-Verheul

3. COLOFON
Building an infrastructure to improve cardiac rehabilitation: from guidelines to audit and
feedback.
PhD thesis, University of Amsterdam, Amsterdam, the Netherlands.
ISBN 978-94-91602-43-6.
Lay out and printed by Print Service Ede BV (www.proefschriftenprinten.nl).
Cover design by Studio Kinrooi (http://studiokinrooi.nl).
Photo at back of the cover by Minke Kersten.
Financial support by the Dutch Heart Foundation for the publication of this thesis is gratefully
acknowledged. Furthermore we are very grateful for the financial support provided by Medecs
BV, and Furore BV towards the publication of this thesis.
Copyright © 2016, Mariëtte M. van Engen-Verheul, Amsterdam, the Netherlands.
All rights reserved. No part of this thesis may be reproduced, stored or transmitted in any form
or by any means without prior written permission of the author. A digital version of this thesis
can be found at http://dare.uva.nl.
The research described in this thesis was carried out at the Department of Medical Informatics,
Academic Medical Center/University of Amsterdam, Amsterdam, the Netherlands. The work
was financially supported by ZonMw (The Netherlands Organisation for Health Research and
Development) for the CARDSS-II project number 170883002, by SAG (Stichting Achemea
Gezondheid) for the CARDSS Online project number 3200606 and by the Department of
Medical Informatics, Academic Medical Center/ University of Amsterdam.

4. Building an infrastructure to improve
cardiac rehabilitation:
from guidelines to audit and feedback
ACADEMISCH PROEFSCHRIFT
ter verkrijging van de graad van doctor
aan de Universiteit van Amsterdam
op gezag van de Rector Magnificus
prof. dr. D.C. van den Boom
ten overstaan van een door het College voor Promoties ingestelde commissie,
in het openbaar te verdedigen in de Aula der Universiteit
op woensdag 30 maart 2016, te 13:00 uur
door Mariëtte Mijntje Verheul
geboren te Maarssen

5. Promotiecommissie
Promotores: Prof. dr. N.F. de Keizer Universiteit van Amsterdam
Prof. dr. M.W.M. Jaspers Universiteit van Amsterdam
Copromotores: Dr. N.B. Peek University of Manchester
Dr. H.M.C. Kemps Máxima Medisch Centrum
Overige leden: Prof. dr. A. Abu Hanna Universiteit van Amsterdam
Prof. dr. R.J.G. Peters Universiteit van Amsterdam
Prof. dr. F. Nollet Universiteit van Amsterdam
Prof. dr. M.J. Schalij Universiteit Leiden
Dr. A. de Rijk Universiteit Maastricht
Faculteit der Geneeskunde

6. “Het hart van de mens overdenkt zijn weg,
maar de Heer bepaalt de richting die hij gaat”
Spreuken 16:9
Voor mijn ouders

7. TABLE OF CONTENTS
Chapter 01. Introduction, aims and outline
PART I Improvement challenges in the field of cardiac rehabilitation
Chapter 02. The effect of computerized decision support on barriers to guideline
implementation: a qualitative study in outpatient cardiac rehabilitation
Chapter 03. Design of a continuous multifaceted guideline-implementation strategy
based on computerized decision support
Chapter 04. Cardiac rehabilitation uptake and its determinants in the Netherlands
PART II An infrastructure to facilitate continuous improvement
Chapter 05. Optimizing the user Interface of a data entry module for an electronic
patient record for cardiac rehabilitation: a mixed method usability approach
Chapter 06. Revision of the Dutch clinical algorithm for assessing patient needs in
cardiac rehabilitation based on identified implementation problems
Chapter 07. Modified rand method to derive quality indicators: a case study in cardiac
rehabilitation
Chapter 08. A web-based system to facilitate local, systematic quality improvement by
multidisciplinary care teams: development and first experiences of CARDSS
Online
PART III Effect of a web-based audit and feedback system with outreach visits
Chapter 09. 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.
Chapter 10. Improving guideline concordance in multidisciplinary teams: preliminary
results of a cluster-randomized trial evaluating the effect of a web-based
audit and feedback intervention with outreach visits
Chapter 11. Effect of a web-based audit and feedback intervention with outreach
visits on clinical performance of multidisciplinary teams: a cluster-
randomized trial in cardiac rehabilitation
Chapter 12. What is needed to implement a web-based audit and feedback intervention
with outreach visits to improve care quality: a concept mapping study
among cardiac rehabilitation teams
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Chapter 13. Summary and General discussion
Chapter 14. Samenvatting
PhD portfolio & Publications
Curriculum Vitae
Dankwoord