Related Articles

Background

Primary care nurses play an important role in diabetes care, and were introduced in GP-practice partly to shift care from hospital to primary care. The aim of this study was to assess whether the referral rate for hospital treatment for diabetes type II (T2DM) patients has changed with the introduction of primary care nurses, and whether these changes were related to the number of diabetes-related contacts in a general practice.

Methods

Healthcare utilisation was assessed for a period of 365 days for 301 newly diagnosed and 2124 known T2DM patients in 2004 and 450 and 3226 patients in 2006 from general practices that participated in the Netherlands Information Network of General Practice (LINH). Multilevel logistic and linear regression analyses were used to analyse the effect of the introduction of primary care nurses on referrals to internists, ophthalmologists and cardiologists and diabetes-related contact rate. Separate analyses were conducted for newly diagnosed and known T2DM patients.

Results

Referrals to internists for newly diagnosed T2DM patients decreased between 2004 and 2006 (OR:0.44; 95%CI:0.22-0.87) in all practices. For known T2DM patients no overall decrease in referrals to internists was found, but practices with a primary care nurse had a lower trend (OR:0.59). The number of diabetes-related contacts did not differ between practices with and without primary care nurses. Cardiologists' and ophthalmologists' referral rate did not change.

Conclusions

The introduction of primary care nurses seems to have led to a shift of care from internists to primary care for known diabetes patients, while the diabetes-related contact rate seem to have remained unchanged.

Objective

In the field of mental health care, a major role for general practice is advocated. However, not much is known about the treatment and referral of mental health problems in general practice. This study aims at the volume and nature of treatment of mental health problems in general practice; the degree to which treatment varies according to patients’ gender, age, and social economic status; and trends in treatment and referral between 2004 and 2008.

Design/setting

Descriptive study with trends in time in general practice in the Netherlands.

Subjects

350,000 patients enlisted in general practice, whose data from the Netherlands Information Network of General Practice were routinely collected from 1 January 2004 to 31 December 2008.

Main outcome measures

For all episodes of mental health problems recorded by the GP, the proportion of patients receiving prolonged attention, medication, and referral during each year have been calculated.

Results

More than 75% of patients with a recorded mental health problem received some kind of treatment, most often medication. In 15–20% of cases medication was accompanied by prolonged attention; 9–13% of these patients were referred (given referrals), the majority to specialized mental health care. Age is the most important variable associated with treatment received. During the period 2004–2008, treatment with medication declined slightly and referrals increased slightly.

Conclusion

Treatment for psychological disorders is mostly delivered in general practice. Although in recent years restraint has been advocated in prescribing medication and collaboration between primary and secondary care has been recommended, these recommendations are only partially reflected in the treatment provided.

Background

The continuity of care is one of the cornerstones of general practice. General practitioners find personal relationships with their patients important as they enable them to provide a higher quality of care. A long-lasting relationship with patients is assumed to be a prior condition for attaining this high quality. We studied the differences in use of care between recently enlisted patients and those patients who have been enlisted for a longer period.

Methods

104 general practices in the Netherlands participated the study. We performed a retrospective cohort study in which patients who have been enlisted for less than 1 year (n = 10,102) were matched for age, sex and health insurance with patients who have been enlisted for longer in the same general practice. The two cohorts were compared with regard to the number of contacts with the general practice, diagnoses, rate of prescribing, and the referral rate in a year. These variables were chosen as indicators of differences in the use of care.

Results

In the year following their enlistment, a higher percentage of recently enlisted patients had at least one contact with the practice, received a prescription or was referred. They also had a higher probability of receiving a prescription for an antibiotic. Furthermore, they had a higher mean number of contacts and referrals, but not a higher mean number of prescriptions.

Conclusion

Recently enlisted patients used more health care resources in the first year after their enlistment compared to patients enlisted longer. This could not be explained by differences in health.

Background

Strengthening primary care is the focus of many countries, as national healthcare systems with a strong primary care sector tend to have lower healthcare costs. However, it is unknown to what extent general practitioners (GPs) that perform more services generate fewer hospital referrals. The objective of this study was to examine the association between the number of surgical interventions and hospital referrals.

Methods

Data were derived from electronic medical records of 48 practices that participated in the Netherlands Information Network of General Practice (LINH) in 2006-2007. For each care-episode of benign neoplasm skin/nevus, sebaceous cyst or laceration/cut it was determined whether the patient was referred to a medical specialist and/or minor surgery was performed. Multilevel multinomial regression analyses were used to determine the relation between minor surgery and hospital referrals on the level of the GP-practice.

Results

Referral rates differed between diagnoses, with 1.0% of referrals for a laceration/cut, 8.2% for a sebaceous cyst and 10.2% for benign neoplasm skin/nevus. The GP practices performed minor surgery for a laceration/cut in 8.9% (SD:14.6) of the care-episodes, for a benign neoplasm skin/nevus in 27.4% (SD:14.4) of cases and for a sebaceous cyst in 26.4% (SD:13.8). GP practices that performed more minor surgery interventions had a lower referral rate for patients with a laceration/cut (-0.38; 95%CI:-0.60- -0.11) and those with a sebaceous cyst (-0.42; 95%CI:-0.63- -0.16), but not for people with benign neoplasm skin/nevus (-0.26; 95%CI:-0.51-0.03). However, the absolute difference in referral rate appeared to be relevant only for sebaceous cysts.

Conclusions

The effects of minor surgery vary between diagnoses. Minor surgery in general practice appears to be a substitute for specialist medical care only in relation to sebaceous cysts. Measures to stimulate minor surgery for sebaceous cysts may induce substitution.

Background

Optimal clinical management of childhood urinary tract infections (UTI) potentiates long-term positive health effects. Insight into the quality of care in Dutch family practices for UTIs was limited, particularly regarding observation periods of more than a year. Our aim was to describe the clinical management of young children's UTIs in Dutch primary care and to compare this to the national guideline recommendations.

Methods

In this cohort study, all 0 to 6-year-old children with a diagnosed UTI in 2001 were identified within the Netherlands Information Network of General Practitioners (LINH), which comprises 120 practices. From the Dutch guideline on urinary tract infections, seven indicators were derived, on prescription, follow-up, and referral.

Results

Of the 284 children with UTI who could be followed for three years, 183 (64%) were registered to have had one cystitis episode, 52 (18%) had two episodes, and 43 (15%) had three or more episodes. Another six children were registered to have had one or two episodes of acute pyelonephritis. Overall, antibiotics were prescribed for 66% of the children having had ≤ 3 cystitis episodes, two-thirds of whom received the antibiotics of first choice. About 30% of all episodes were followed up in general practice. Thirty-eight children were referred (14%), mostly to a paediatrician (76%). Less than one-third of the children who should have been referred was actually referred.

Conclusion

Treatment of childhood UTIs in Dutch family practice should be improved with respect to prescription, follow-up, and referral. Quality improvement should address the low incidence of urinary tract infections in children in family practice.

Background

To study the influence of a nationwide albuminuria self-test program on the number of GP contacts for urinary complaints and/or kidney diseases and the number of newly diagnosed patients with kidney diseases by the GP.

Methods

Data were used from the Netherlands Information Network of General Practice (LINH), including a representative sample of general practices with a dynamic population of approximately 300.000 listed patients. Morbidity data were retrieved from electronic medical records, kept in a representative sample of general practices. The incidence of kidney diseases and urinary complaints before and after the albuminuria self-test program was compared with logistic regression analyses.

Results

Data were used from 139 general practices, including 444,220 registered patients. The number of GP consultations for kidney diseases and urinary complaints was increased in the year after the albuminuria self-test program and particularly shortly after the start of the program. Compared with the period before the self-test program, more patients have been diagnosed by the GP with symptoms/complaints of kidney disease and urinary diseases (OR = 1.7 (CI 1.4 - 2.0) and OR = 2.1 (CI 1.9 - 2.3), respectively). The odds on an abnormal urine-test in the period after the self-test program was three times higher than the year before (OR = 3.0 (CI 2.4 - 3.6)). The effect of the self-test program on newly diagnosed patients with an abnormal urine test was modified by both the presence of the risk factors hypertension and diabetes mellitus. For this diagnosis the highest OR was found in patients without both conditions (OR = 4.2 (CI 3.3 - 5.4)).

Conclusions

A nationwide albuminuria self-test program resulted in an increasing number of newly diagnosed kidney complaints and diseases the year after the program. The highest risks were found in patients without risk factors for kidney diseases.

Background

Midwives and obstetricians are the key providers of care during pregnancy and postpartum. Information about the consultations with a general practitioner (GP) during this period is generally lacking.

The aim of this study is to compare consultation rates, diagnoses and GP management of pregnant women with those of non-pregnant women.

Methods

Data were retrieved from the Netherlands Information Network of General Practice (LINH), a nationally representative register. This register holds longitudinal data on consultations, prescriptions and the referrals of all patients listed at 84 practices in the Netherlands in 2007–2009, including 15,123 pregnant women and 102,564 non-pregnant women in the same age-range (15 to 45 years). We compared consultation rates (including all contacts with the practice), diagnoses (ICPC-1 coded), medication prescriptions (coded according to the Anatomical Therapeutic Chemical classification system), and rate and type of referrals from the start of the pregnancy until six weeks postpartum (336 days).

Results

Pregnant women contacted their GP on average 3.6 times, compared to 2.2 times for non-pregnant women. The most frequently recorded diagnoses for pregnant women were ‘pregnancy’ and ‘cystitis/urinary infection’, and ‘cystitis/urinary infection’ and ‘general disease not otherwise specified’ for non-pregnant women. The mean number of prescribed medications was lower in pregnant women (2.1 against 4.4). For pregnant women, the most frequent referral indication concerned obstetric care, for non-pregnant women this concerned physiotherapy.

Conclusions

GP consultation rates in pregnancy and postpartum shows that GPs are important providers of care for pregnant women. Therefore, the involvement of GPs in collaborative care during pregnancy and postpartum should be reinforced.

Background

Patients suffering from psychotic disorders have an increased risk of comorbid somatic diseases such as cardiovascular disorders and diabetes mellitus. Doctor-related factors, such as unfamiliarity with these patients, as well as patient-related factors, such as cognitive disturbance and negative symptoms, contribute to suboptimal health care for these patients.

General practitioners (GPs) could play a key role in diagnosing and treating this somatic comorbidity as in the Netherlands, almost all residents are registered at a general practice. This study aims to find out whether there are any differences between the levels of health care provided by GPs to patients with psychotic disorders, compared to other types of patients.

Methods

A cohort of patients with an ICPC code of psychosis and two matched control groups, one consisting of patients with other mental problems and the other one of patients without any mental problems, were followed over a period of 5 years.

Results

Patients with psychotic disorders (N = 734) contacted the GP practice more often than patients in the control groups. These patients, both adults (p = 0.051) and the elderly (p < 0.005), received more home visits from their GPs. In the adult group (16 to 65 years old inclusive), the number of consultations was significantly higher among both psychosis patients and the group of patients with other mental problems (p < 0.0005). The number of telephone consultations was significantly higher in both age categories, adult group (p < 0.0005), and > 65 years old (p = 0.007). With regard to chronic illnesses, elderly psychosis patients had fewer contacts related to cardiovascular diseases or chronic lung diseases.

Conclusion

Patients with psychotic disorders contact the GP practice more frequently than other types of patients. Adult psychosis patients with diabetes mellitus, cardiovascular diseases or chronic lung diseases receive the same amount of health care for these diseases as other primary care patients. The finding that older patients with psychotic disorders are diagnosed with cardiovascular diseases and obstructive lung diseases less frequently than other types of elderly patients requires further study.

Background

Previous studies of inter-practice variation of the prevalence of hypertension and diabetes mellitus showed wide variations between practices. However, in these studies inter-practice variation was calculated without controlling for clustering of patients within practices and without adjusting for patient and practice characteristics. Therefore, in the present study inter-practice variation of diagnosed hypertension and diabetes mellitus prevalence rates was calculated by 1) using a multi-level design and 2) adjusting for patient and practice characteristics.

Methods

Data were used from the Netherlands Information Network of General Practice (LINH) in 2004. Of all 168.045 registered patients, the presence of hypertension, diabetes mellitus and all available ICPC coded symptoms and diseases related to hypertension and diabetes, were determined. Also, the characteristics of practices were used in the analyses. Multilevel logistic regression analyses were performed.

Results

The 95% prevalence range for the practices for the prevalence of diagnosed hypertension and diabetes mellitus was 66.3 to 181.7 per 1000 patients and 22.2 to 65.8 per 1000 patients, respectively, after adjustment for patient and practice characteristics. The presence of hypertension and diabetes was best predicted by patient characteristics. The most important predictors of hypertension were obesity (OR = 3.5), presence of a lipid disorder (OR = 3.0), and diabetes mellitus (OR = 2.6), whereas the presence of diabetes mellitus was particularly predicted by retinopathy (OR = 8.5), lipid disorders (OR = 2.8) and hypertension (OR = 2.7).

Conclusion

Although not the optimal case-mix could be used in this study, we conclude that even after adjustment for patient (demographic variables and risk factors for hypertension and diabetes mellitus) and practice characteristics (practice size and presence of a practice nurse), there is a wide difference between general practices in the prevalence rates of diagnosed hypertension and diabetes mellitus.

Background

There is accumulating evidence for an increased cardiovascular burden in inflammatory arthritis, but the true magnitude of this cardiovascular burden is still debated. We sought to determine the prevalence rate of non-fatal cardiovascular disease (CVD) in inflammatory arthritis, diabetes mellitus and osteoarthritis (non-systemic inflammatory comparator) compared to controls, in primary care.

Methods

Data on CVD morbidity (ICPC codes K75 (myocardial infarction), K89 (transient ischemic attack), and/or K90 (stroke/cerebrovascular accident)) from patients with inflammatory arthritis (n = 1,518), diabetes mellitus (n = 11,959), osteoarthritis (n = 4,040) and controls (n = 158,439) were used from the Netherlands Information Network of General Practice (LINH), a large nationally representative primary care based cohort. Data were analyzed using multi-level logistic regression analyses and corrected for age, gender, hypercholesterolemia and hypertension.

Results

CVD prevalence rates were significantly higher in inflammatory arthritis, diabetes mellitus and osteoarthritis compared with controls. These results attenuated - especially in diabetes mellitus - but remained statistically significant after adjustment for age, gender, hypertension and hypercholesterolemia for inflammatory arthritis (OR = 1.5 (1.2-1.9)) and diabetes mellitus (OR = 1.3 (1.2-1.4)). The association between osteoarthritis and CVD reversed after adjustment (OR = 0.8 (0.7-1.0)).

Conclusions

These results confirm an increased prevalence rate of CVD in inflammatory arthritis to levels resembling diabetes mellitus. By contrast, lack of excess CVD in osteoarthritis further suggests that the systemic inflammatory load is critical to the CVD burden in inflammatory arthritis.

Background

Information exchange networks for chronic illness care may influence the uptake of innovations in patient care. Valid and feasible methods are needed to document and analyse information exchange networks in healthcare settings. This observational study aimed to examine the usefulness of methods to study information exchange networks in primary care practices, related to chronic heart failure, diabetes and chronic obstructive pulmonary disease.

Methods

The study was linked to a quality improvement project in the Netherlands. All health professionals in the practices were asked to complete a short questionnaire that documented their information exchange relations. Feasibility was determined in terms of response rates and reliability in terms of reciprocity of reports of receiving and providing information. For each practice, a number of network characteristics were derived for each of the chronic conditions.

Results

Ten of the 21 practices in the quality improvement project agreed to participate in this network study. The response rates were high in all but one of the participating practices. For the analysis, we used data from 67 health professionals from eight practices. The agreement between receiving and providing information was, on average, 65.6%. The values for density, centralization, hierarchy, and overlap of the information exchange networks showed substantial variation between the practices as well as between the chronic conditions. The most central individual in the information exchange network could be a nurse or a physician.

Conclusions

Further research is needed to refine the measure of information networks and to test the impact of network characteristics on the uptake of innovations.

Objectives

To compare outcome and resource utilisation among patients referred to the Amalthea Project, a liaison organisation that facilitates contact between voluntary organisations and patients in primary care, with patients receiving routine general practitioner care.

Design

Randomised controlled trial with follow up at one and four months.

Setting

26 general practices in Avon.

Participants

161 patients identified by their general practitioner as having psychosocial problems.

Main outcome measures

Primary outcomes were psychological wellbeing (assessed with the hospital anxiety and depression scale) and social support (assessed using the Duke-UNC functional social support questionnaire). Secondary outcomes were quality of life measures (the Dartmouth COOP/WONCA functional health assessment charts and the delighted-terrible faces scale), cost of contacts with the primary healthcare team and Amalthea Project, cost of prescribing in primary care, and cost of referrals to other agencies, over four months.

Results

The Amalthea group showed significantly greater improvements in anxiety (average difference between groups after adjustment for baseline −1.9, 95% confidence interval −3.0 to −0.7), other emotional feelings (average adjusted difference −0.5, −0.8 to −0.2), ability to carry out everyday activities (−0.5, −0.8 to −0.2), feelings about general health (−0.4, −0.7 to −0.1), and quality of life (−0.5, −0.9 to −0.1). No difference was detected in depression or perceived social support. The mean cost was significantly greater in the Amalthea arm than the general practitioner care arm (£153 v £133, P=0.025).

Conclusion

Referral to the Amalthea Project and subsequent contact with the voluntary sector results in clinically important benefits compared with usual general practitioner care in managing psychosocial problems, but at a higher cost.

Background

To determine gender differences in health and health care utilisation within and between various ethnic groups in the Netherlands.

Methods

Data from the second Dutch National Survey of General Practice (2000–2002) were used. A total of 7,789 persons from the indigenous population and 1,512 persons from the four largest migrant groups in the Netherlands – Morocco, Netherlands Antilles, Turkey and Surinam – aged 18 years and older were interviewed. Self-reported health outcomes studied were general health status and the presence of acute (past 14 days) and chronic conditions (past 12 months). And self-reported utilisation of the following health care services was analysed: having contacted a general practitioner (past 2 months), a medical specialist, physiotherapist or ambulatory mental health service (past 12 months), hospitalisation (past 12 months) and use of medication (past 14 days). Gender differences in these outcomes were examined within and between the ethnic groups, using logistic regression analyses.

Results

In general, women showed poorer health than men; the largest differences were found for the Turkish respondents, followed by Moroccans, and Surinamese. Furthermore, women from Morocco and the Netherlands Antilles more often contacted a general practitioner than men from these countries. Women from Turkey were more hospitalised than Turkish men. Women from Morocco more often contacted ambulatory mental health care than men from this country, and women with an indigenous background more often used over the counter medication than men with an indigenous background.

Conclusion

In general the self-reported health of women is worse compared to that of men, although the size of the gender differences may vary according to the particular health outcome and among the ethnic groups. This information might be helpful to develop policy to improve the health status of specific groups according to gender and ethnicity. In addition, in some ethnic groups, and for some types of health care services, the use by women is higher compared to that by men. More research is needed to explain these differences.

About one-third of the general practices in the Oxfordshire Health District have access to beds in community hospitals as well as district general hospitals. Hospital Activity Analysis data were used to calculate the average number of hospital beds occupied daily by patients registered with each general practice in the district. Practices with and without access to community hospitals were compared to determine whether such access was associated with a reduction in the use of beds in general medical, geriatric, and other specialties, and an increase in overall utilisation rates. The rate of use of general medical and geriatric beds in district general hospitals by practice populations with access to community hospitals was about half that of populations without such access. Utilisation rates overall, combining the use of beds in both district general hospitals and community hospitals, were a little higher in populations with access to both community hospitals and district general hospitals than in those with access to district general hospitals only.

Background

Comorbidity has been shown to intensify health care utilization and to increase medical care costs for patients with diabetes. However, most studies have been focused on one health care service, mainly hospital care, or limited their analyses to one additional comorbid disease, or the data were based on self-reported questionnaires instead of health care registration data. The purpose of this study is to estimate the effects a broad spectrum of of comorbidities on the type and volume of medical health care utilization of patients with diabetes.

Methods

By linking general practice and hospital based registrations in the Netherlands, data on comorbidity and health care utilization of patients with diabetes (n = 7,499) were obtained. Comorbidity was defined as diabetes-related comorbiiabetes-related comorbidity. Multilevel regression analyses were applied to estimate the effects of comorbidity on health care utilization.

Results

Our results show that both diabetes-related and non diabetes-related comorbidity increase the use of medical care substantially in patients with diabetes. Having both diabeterelated and non diabetes-related comorbidity incrases the demand for health care even more. Differences in health care utilization patterns were observed between the comorbidities.

Conclusion

Non diabetes-related comorbidity increases the health care demand as much as diabetes-related comorbidity. Current single-disease approach of integrated diabetes care should be extended with additional care modules, which must be generic and include multiple diseases in order to meet the complex health care demands of patients with diabetes in the future.

BACKGROUND/AIMS—International comparisons of clinical practice may help in assessing the magnitude and possible causes of variation in cross national healthcare utilisation. With this aim, the indications for cataract surgery in the United States, Denmark, the province of Manitoba (Canada), and the city of Barcelona (Spain) were compared.
METHODS—In a prospective multicentre study, patients scheduled for first eye cataract surgery and aged 50 years or older were enrolled consecutively. From the United States 766 patients were enrolled; from Denmark 291; from Manitoba 152; and from Barcelona 200. Indication for surgery was measured as preoperative visual status of patients enlisted for cataract surgery. Main variables were preoperative visual acuity in operative eye, the VF-14 score (an index of functional impairment in patients with cataract) and ocular comorbidity.
RESULTS—Mean visual acuity were 0.23 (USA), 0.17 (Denmark), 0.15 (Manitoba), and 0.07 (Barcelona) (p<0.001). When restricting the sample to eyes with normal retina and macula, no significant difference between United States and Denmark was observed (p>0.05). Mean VF-14 scores were 76 (USA), 76 (Denmark), 71 (Manitoba), and 64 (Barcelona) (p<0.001).
CONCLUSION—Similar indications for cataract surgery were found in the United States and Denmark. Significantly more restricted indications were observed in Manitoba and Barcelona. Possible explanations for the results are discussed, including differences in sociodemographic characteristics, access to care, surgeons' willingness to operate, and patient demand.

 Keywords: cataract surgery; North America; Europe

Objectives

To analyse how comorbidity among patients with back pain, depression and osteoarthritis influences healthcare costs per patient. A special focus was made on the distribution of costs for primary healthcare compared with specialist care, hospital care and drugs.

Design

Population-based cross-sectional study.

Setting

The County of Östergötland, Sweden.

Patients

Data on diagnoses and healthcare costs for all 266 354 individuals between 20 and 75 years of age, who were residents of the County of Östergötland, Sweden, in the year 2006, were extracted from the local healthcare register and the national register of drug prescriptions.

Main outcome measures

The effects of comorbidity on healthcare costs were estimated as interactions in regression models that also included age, sex, number of other health conditions and education.

Results

The largest diagnosed group was back pain (11 178 patients) followed by depression (7412 patients) and osteoarthritis (5174 patients). The largest comorbidity subgroup was the combination of back pain and depression (772 patients), followed by the combination of back pain and osteoarthritis (527 patients) and the combination of depression and osteoarthritis (206 patients). For patients having both a depression diagnosis and a back pain diagnosis, there was a significant negative interaction effect on total healthcare costs. The average healthcare costs among patients with depression and back pain was SEK 11 806 lower for a patient with both diagnoses. In this comorbidity group, there were tendencies of a positive interaction for general practitioner visits and negative interactions for all other visits and hospital days. Small or no interactions at all were seen between depression diagnoses and osteoarthritis diagnoses.

Conclusions

A small increase in primary healthcare visits in comorbid back pain and depression patients was accompanied with a substantial reduction in total healthcare costs and in hospital costs. Our results can be of value in analysing the cost effects of comorbidity and how the coordination of primary and secondary care may have an impact on healthcare costs.

Article summary

Article focus

Comorbidity is often associated with high healthcare costs and raises questions that are of interest for the organisation of primary and secondary healthcare, for example, what is the impact on healthcare costs?

Is there an increase in costs because the complexity is high in the management of the different diseases? Or maybe there is a decline in costs due to an efficient handling and therefore a lower numbers of healthcare contacts for single persons with many diseases?

Key messages

The comorbidity influence on healthcare costs tended to be less—not more—than additive and among patients with back pain and depression, significantly less than additive.

Strengths and limitations of this study

The possibility to measure total healthcare utilisation on an individual level both in primary care and hospital care was an advantage in this study.

There are broad clinical variations in register data, for instance variations in the definition of diagnoses. An under-reporting of diagnoses in the medical records is common, especially in primary care.

Background

Evidence-based diabetes guidelines generally neglect comorbidity, which may interfere with diabetes management. The prevalence of comorbidity described in patients with type 2 diabetes (T2D) shows a wide range depending on the population selected and the comorbid diseases studied. This exploratory study aimed to establish comorbidity rates in an unselected primary-care population of patients with T2D.

Methods

This was a cohort study of 714 adult patients with newly diagnosed T2D within the study period (1985-2007) in a practice-based research network in the Netherlands. The main outcome measures were prevalence and incidence density rates of chronic comorbid diseases and disease clusters. All chronic disease episodes registered in the practice-based research network were considered as comorbidities. We categorised comorbidity into 'concordant' (that is, shared aetiology, risk factors, and management plans with diabetes) and 'discordant' comorbidity. Prevalence and incidence density were assessed for both categories of comorbidity.

Results

The mean observation period was 17.3 years. At the time of diabetes diagnosis, 84.6% of the patients had one or more chronic comorbid disease of 'any type', 70.6% had one or more discordant comorbid disease, and 48.6% and 27.2% had three or more chronic comorbid diseases of 'any type' or of 'discordant only', respectively. A quarter of those without any comorbid disease at the time of their diabetes diagnosis developed at least one comorbid disease in the first year afterwards. Cardiovascular diseases (considered concordant comorbidity) were the most common, but there were also high rates of musculoskeletal and mental disease. Discordant comorbid diseases outnumbered concordant diseases.

Conclusions

We found high prevalence and incidence density rates for both concordant and discordant comorbidity. The latter may interfere with diabetes management, thus future research and clinical practice should take discordant comorbidity in patients with T2D into account.

Objective

To test whether a disclosure intervention improves subjective health and reduces medical consumption and sick leave in somatising patients in general practice.

Design

Non-blind randomised controlled trial.

Setting

10 general practices in the Netherlands.

Participants

161 patients who frequently attended general practice with somatising symptoms.

Intervention

Patients in the intervention group were visited two to three times and invited to disclose emotionally important events in their life. Control patients received normal care from their general practitioners.

Main outcome measures

Use of medical services (drugs and healthcare visits), subjective health, and sick leave assessed by self completion questionnaires after 6, 12, and 24 months.

Results

Of the 161 patients, 137 completed the trial (85%). Both groups were comparable at baseline. The intervention had no effect on the main outcome measures at any point. Intervention patients made one more visit to health care (95% confidence interval −4 to 6); the use of medicines did not change in both groups (−1 to 1); subjective health improved 3.6 points more in the control group (−11.2 to 4.3); and disclosure patients were on sick leave one more week (−1 to 3). Patients often had a depression or anxiety disorder for which they were not receiving adequate care.

Conclusion

Although the intervention was well received by patients and doctors, disclosure had no effect on the health of somatising patients in general practice.

What is already known on this topicUp to 5% of patients in general practice attend frequently with somatising symptomsEmotional expression techniques have been shown to have favourable effects on subjective health, visits to the doctor, and symptoms in healthy peopleWhat this study addsA disclosure intervention does not improve somatisation in primary careAbout 45% of patients had an anxiety or depressive disorder, which was often unrecognised

Abstract

Background

The treatment of patients with advanced cancer with multiple comorbid illnesses is complex. Although an increasing number of such patients are being referred to hospice, the comorbidity burden of this patient population is largely unknown but has implications for the complexity of care provided by hospices. This study reports the comorbidity burden in a national sample of hospice users with cancer and estimates the effect of higher comorbidity on health care use and site of death.

Methods

Cross-sectional study using Surveillance, Epidemiology and End Results-Medicare data for hospice users who died of cancer in 2002 (N = 27,166). We measured comorbidity burden using the Charlson comorbidity index and used multivariable generalized estimating equations to estimate the association between comorbidity burden and the following outcomes: emergency department and intensive care unit (ICU) admission, hospitalization, hospice disenrollment, and hospital death.

Results

Patients with cancer who used hospice had an average Charlson comorbidity index value of 1.24, including 18.8% who suffered from comorbid dementia. In analyses adjusted for patient demographics, site of primary cancer, and number of days with hospice, higher comorbidity burden was associated with higher likelihood of emergency department admission (odds ratio [OR] = 1.69, 95% confidence interval [CI] 1.52, 1.87), ICU admission (OR = 3.28, 95% CI 2.45, 4.38), inpatient hospitalization (OR = 2.14, 95% CI 1.90, 2.42), hospice disenrollment (OR = 1.41, 95% CI 1.29, 1.56) and hospital death (OR = 2.51, 95% CI 2.08, 3.02).

Conclusion

These findings underscore the complexity of the hospice patient population and highlight a potential need to risk adjust the per diem hospice reimbursement rates to account for increased resource requirements for hospices serving patients with higher comorbidity burden.

Background

Although multimorbidity has important implications for patient care in general practice, limited research has examined chronic illness and health service utilisation among problem drug users. This study aimed to determine chronic illness prevalence and health service utilisation among problem drug users attending primary care for methadone treatment, to compare these rates with matched 'controls' and to develop and pilot test a valid study instrument.

Methods

A cross-sectional study of patients attending three large urban general practices in Dublin, Ireland for methadone treatment was conducted, and this sample was compared with a control group matched by practice, age, gender and General Medical Services (GMS) status.

Results

Data were collected on 114 patients. Fifty-seven patients were on methadone treatment, of whom 52(91%) had at least one chronic illness (other then substance use) and 39(68%) were prescribed at least one regular medication. Frequent utilisation of primary care services and secondary care services in the previous six months was observed among patients on methadone treatment and controls, although the former had significantly higher chronic illness prevalence and primary care contact rates. The study instrument facilitated data collection that was feasible and with minimal inter-observer variation.

Conclusion

Multimorbidity is common among problem drug users attending general practice for methadone treatment. Primary care may therefore have an important role in primary and secondary prevention of chronic illnesses among this population. This study offers a feasible study instrument for further work on this issue. (238 words)

Background

Community‐care networks are a partnership between the local police force, housing corporations, general social services, specialised home care and mental healthcare services. The networks were set up to improve the healthcare for patients with (chronic) psychiatric problems through local cooperation between different agencies operating in underprivileged areas.

Objective

To evaluate the effects of community‐care networks on psychiatric emergency contacts, hospitalisation and involuntary admission.

Design

An ecological intervention design was used, comparing neighbourhoods with and without a community‐care network. Mean numbers and standardised ratios of psychiatric emergency contacts, hospitalisation rates and involuntary admissions were assessed over a 10‐year period, covering the early stages and the years in which community‐care networks were fully operational.

Setting

Underprivileged neighbourhoods in the city of Rotterdam, The Netherlands.

Patients

Inhabitants aged 20–64 years living in these neighbourhoods.

Results

Standardised ratios for contact with psychiatric emergency services were higher in the neighbourhoods where community‐care networks were set up (standardised ratios = 137, 95% CI 121 to 145 in the network neighbourhoods vs standardised ratios = 107, 95% CI 96 to 119 in the control neighbourhoods). Number of admissions and standardised ratios for involuntary admissions were lower in the community‐care network neighbourhoods than in the control neighbourhoods (standardised ratios = 123, 95% CI 95 to 157 vs standardised ratios = 152, 95% CI 120 to 191).

Conclusions

Community‐care networks have a significant impact on the use of mental healthcare services. These networks may be an important tool in the prevention of involuntary admissions.

Background and objective

Indicators to measure the quality of healthcare are increasingly used by healthcare professionals and policy makers. In the context of increasing antimicrobial resistance, this study aimed to develop valid drug‐specific quality indicators for outpatient antibiotic use in Europe, derived from European Surveillance of Antimicrobial Consumption (ESAC) data.

Methods

27 experts (15 countries), in a European Science Foundation workshop, built on the expertise within the European Drug Utilisation Research Group, the General Practice Respiratory Infections Network, the ESCMID Study Group on Primary Care Topics, the Belgian Antibiotic Policy Coordination Committee, the World Health Organization, ESAC, and other experts. A set of proposed indicators was developed using 1997–2003 ESAC data. Participants scored the relevance of each indicator to reducing antimicrobial resistance, patient health benefit, cost effectiveness and public health policy makers (scale: 1 (completely disagree) to 9 (completely agree)). The scores were processed according to the UCLA‐RAND appropriateness method. Indicators were judged relevant if the median score was not in the 1–6 interval and if there was consensus (number of scores within the 1–3 interval was fewer than one third of the panel). From the relevant indicators providing overlapping information, the one with the highest scores was selected for the final set of quality indicators—values were updated with 2004 ESAC data.

Results

22 participants (12 countries) completed scoring of a set of 22 proposed indicators. Nine were rated as relevant antibiotic prescribing indicators on all four dimensions; five were rated as relevant if only relevance to reducing antimicrobial resistance and public health policy makers was taken into account. A final set of 12 indicators was selected.

Conclusion

12 of the proposed ESAC‐based quality indicators for outpatient antibiotic use in Europe have face validity and are potentially applicable. These indicators could be used to better describe antibiotic use in ambulatory care and assess the quality of national antibiotic prescribing patterns in Europe.

Background

Practice guidelines rarely consider comorbid illness, and resulting overuse of health services may increase costs without conferring benefit.

Objective

To individualize a framework for inferring when patients with comorbid illness are not likely to benefit from colorectal cancer screening guidelines.

Methods

We modified the “payoff time” framework (the minimum time until a guideline’s cumulative benefits exceed its cumulative harms) to increase its applicability to a wide range of primary care patients. We show how it may inform colorectal (CR) cancer screening decisions for 3 typical patients in general practice for whom CR screening would be recommended by current guidelines: (1) 60-year-old man with diabetes, congestive heart failure, lung disease, stroke, and substantial frailty; (2) 60-year-old woman with diabetes and obesity, without other comorbidity or frailty; and (3) 50-year-old woman with inflammatory bowel disease.

Results

For patient 1, the payoff time for CR screening (minimum time until benefits exceed harms) is 7.3 years, and for patient 2, the payoff time for CR screening is 5.4 years. Evidence is insufficient to estimate the payoff time for patient 3. Because patient 1’s estimated life expectancy is 3.7 years (less than his payoff time), he is unlikely to benefit from CR screening. Because patient 2’s estimated life expectancy exceeds 10 years (greater than her payoff time), she may benefit from CR screening. Because evidence is insufficient to estimate the payoff time for patient 3, the payoff time framework does not inform decision making.

Conclusion

The payoff time framework may identify patients for whom particular clinical guidelines are unlikely to confer benefit, and has the potential to decrease unnecessary health care.

Background

Primary care physicians are caring for increasing numbers of persons with comorbid chronic illness. Longitudinal information on health outcomes associated with specific chronic conditions may be particularly relevant in caring for these populations. Our objective was to assess the effect of certain comorbid conditions on physical well being over time in a population of persons with chronic medical conditions; and to compare these effects to that of hypertension alone.

Methods

We conducted a secondary analysis of 4-year longitudinal data from the Medical Outcomes Study. A heterogeneous population of 1574 patients with either hypertension alone (referent) or one or more of the following conditions: diabetes, coronary artery disease, congestive heart failure, respiratory illness, musculoskeletal conditions and/or depression were recruited from primary and specialty (endocrinology, cardiology or mental health) practices within HMO and fee-for-service settings in three U.S. cities. We measured categorical change (worse vs. same/better) in the SF-36® Health Survey physical component summary score (PCS) over 4 years. We used logistic regression analysis to determine significant differences in longitudinal change in PCS between patients with hypertension alone and those with other comorbid conditions and linear regression analysis to assess the contribution of the explanatory variables.

Results

Specific diagnoses of CHF, diabetes and/or chronic respiratory disease; or 4 or more chronic conditions, were predictive of a clinically significant decline in PCS.

Conclusions

Clinical recognition of these specific chronic conditions or 4 or more of a list of chronic conditions may provide an opportunity for proactive clinical decision making to maximize physical functioning in these populations.