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1.  Multimorbidity of chronic diseases and health care utilization in general practice 
BMC Family Practice  2014;15:61.
Multimorbidity is common among ageing populations and it affects the demand for health services. The objective of this study was to examine the relationship between multimorbidity (i.e. the number of diseases and specific combinations of diseases) and the use of general practice services in the Dutch population of 55 years and older.
Data on diagnosed chronic diseases, contacts (including face-to-face consultations, phone contacts, and home visits), drug prescription rates, and referral rates to specialised care were derived from the Netherlands Information Network of General Practice (LINH), limited to patients whose data were available from 2006 to 2008 (N = 32,583). Multimorbidity was defined as having two or more out of 28 chronic diseases. Multilevel analyses adjusted for age, gender, and clustering of patients in general practices were used to assess the association between multimorbidity and service utilization in 2008.
Patients diagnosed with multiple chronic diseases had on average 18.3 contacts (95% CI 16.8 19.9) per year. This was significantly higher than patients with one chronic disease (11.7 contacts (10.8 12.6)) or without any (6.1 contacts (5.6 6.6)). A higher number of chronic diseases was associated with more contacts, more prescriptions, and more referrals to specialized care. However, the number of contacts per disease decreased with an increasing number of diseases; patients with a single disease had between 9 to 17 contacts a year and patients with five or more diseases had 5 or 6 contacts per disease per year. Contact rates for specific combinations of diseases were lower than what would be expected on the basis of contact rates of the separate diseases.
Multimorbidity is associated with increased health care utilization in general practice, yet the increase declines per additional disease. Still, with the expected rise in multimorbidity in the coming decades more extensive health resources are required.
PMCID: PMC4021063  PMID: 24708798
Multimorbidity; Chronic disease; Epidemiology; Health care utilisation
2.  Continuity in different care modes and its relationship to quality of life: a randomised controlled trial in patients with COPD 
The British Journal of General Practice  2012;62(599):e422-e428.
New care modes in primary care may affect patients’ experienced continuity of care.
To analyse whether experienced continuity for patients with chronic obstructive pulmonary disease (COPD) changes after different care modes are introduced, and to analyse the relationship between continuity of care and patients’ quality of life.
Design and setting
Randomised controlled trial with 2-year follow-up in general practice in the Netherlands.
A total of 180 patients with COPD were randomly assigned to three different care modes: self-management, regular monitoring by a practice nurse, and care provided by the GP at the patient's own initiative (usual care). Experienced continuity of care as personal continuity (proportion of visits with patient's own GP) and team continuity (continuity by the primary healthcare team) was measured using a self-administered patient questionnaire. Quality of life was measured using the Chronic Respiratory Questionnaire.
Of the final sample (n = 148), those patients receiving usual care experienced the highest personal continuity, although the chance of not contacting any care provider was also highest in this group (29% versus 2% receiving self-management, and 5% receiving regular monitoring). There were no differences in experienced team continuity in the three care modes. No relationship was found between continuity and changes in quality of life.
Although personal continuity decreases when new care modes are introduced, no evidence that this affects patients’ experienced team continuity or patients’ quality of life was found. Patients still experienced smooth, ongoing care, and considered care to be connected. Overall, no evidence was found indicating that the introduction of new care modes in primary care for patients with COPD should be discouraged.
PMCID: PMC3361122  PMID: 22687235
continuity of patient care; general practice; pulmonary disease, chronic obstructive; quality of life
3.  Cardiometabolic prevention consultation in the Netherlands: screening uptake and detection of cardiometabolic risk factors and diseases – a pilot study 
BMC Family Practice  2013;14:29.
Until now, cardiometabolic risk assessment in Dutch primary health care was directed at case-finding, and structured, programmatic prevention is lacking. Therefore, the Prevention Consultation cardiometabolic risk (PC CMR), a stepwise approach to identify and manage patients with cardiometabolic risk factors, was developed. The aim of this study was 1) to evaluate uptake rates of the two steps of the PC CMR, 2) to assess the rates of newly diagnosed hypertension, hypercholesterolemia, diabetes mellitus and chronic kidney disease and 3) to explore reasons for non-participation.
Sixteen general practices throughout the Netherlands were recruited to implement the PC CMR during 6 months. In eight practices eligible patients aged between 45 and 70 years without a cardiometabolic disease were actively invited by a personal letter (‘active approach’) and in eight other practices eligible patients were informed about the PC CMR only by posters and leaflets in the practice (‘passive approach’). Participating patients completed an online risk estimation (first step). Patients estimated as having a high risk according to the online risk estimation were advised to visit their general practice to complete the risk profile with blood pressure measurements and blood tests for cholesterol and glucose and to receive recommendations about risk lowering interventions (second step).
The online risk estimation was completed by 521 (33%) and 96 (1%) of patients in the practices with an active and passive approach, respectively. Of these patients 392 (64%) were estimated to have a high risk and were referred to the practice; 142 of 392 (36%) consulted the GP. A total of 31 (22%) newly diagnosed patients were identified. Hypertension, hypercholesterolemia, diabetes and chronic kidney disease were diagnosed in 13%, 11%, 1% and 0%, respectively. Privacy risks were the most frequently mentioned reason not to participate.
One third of the patients responded to an active invitation to complete an online risk estimation. A passive invitation resulted in only a small number of participating patients. Two third of the participants of the online risk estimation had a high risk, but only one third of them attended the GP office. One in five visiting patients had a diagnosed cardiometabolic risk factor or disease.
PMCID: PMC3605095  PMID: 23442805
4.  Mental health care as delivered by Dutch general practitioners between 2004 and 2008 
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.
Descriptive study with trends in time in general practice in the Netherlands.
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.
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.
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.
PMCID: PMC3443939  PMID: 22794194
Anxiety; depression; drug therapy; general practice; referral and consultation; therapy
5.  Measurement Properties of Questionnaires Measuring Continuity of Care: A Systematic Review 
PLoS ONE  2012;7(7):e42256.
Continuity of care is widely acknowledged as a core value in family medicine. In this systematic review, we aimed to identify the instruments measuring continuity of care and to assess the quality of their measurement properties.
We did a systematic review using the PubMed, Embase and PsycINFO databases, with an extensive search strategy including ‘continuity of care’, ‘coordination of care’, ‘integration of care’, ‘patient centered care’, ‘case management’ and its linguistic variations. We searched from 1995 to October 2011 and included articles describing the development and/or evaluation of the measurement properties of instruments measuring one or more dimensions of continuity of care (1) care from the same provider who knows and follows the patient (personal continuity), (2) communication and cooperation between care providers in one care setting (team continuity), and (3) communication and cooperation between care providers in different care settings (cross-boundary continuity). We assessed the methodological quality of the measurement properties of each instrument using the COSMIN checklist.
We included 24 articles describing the development and/or evaluation of 21 instruments. Ten instruments measured all three dimensions of continuity of care. Instruments were developed for different groups of patients or providers. For most instruments, three or four of the six measurement properties were assessed (mostly internal consistency, content validity, structural validity and construct validity). Six instruments scored positive on the quality of at least three of six measurement properties.
Most included instruments have problems with either the number or quality of its assessed measurement properties or the ability to measure all three dimensions of continuity of care. Based on the results of this review, we recommend the use of one of the four most promising instruments, depending on the target population Diabetes Continuity of Care Questionnaire, Alberta Continuity of Services Scale-Mental Health, Heart Continuity of Care Questionnaire, and Nijmegen Continuity Questionnaire.
PMCID: PMC3409169  PMID: 22860100
6.  Bridging the gap between public health and primary care in prevention of cardiometabolic diseases; background of and experiences with the Prevention Consultation in The Netherlands 
Family Practice  2012;29(Suppl 1):i126-i131.
Background. There is an increasing need for programmatic prevention of cardiometabolic diseases (cardiovascular disease, type 2 diabetes and chronic kidney disease). Therefore, in the Netherlands, a prevention programme linked to primary care has been developed. This initiative was supported by the national professional organizations of GPs and occupational physicians as well as three large health foundations.
Objectives. To describe and discuss the content, structure of and first experiences with this initiative.
Methods. Description of context, risk assessment tool, guideline, content of the Prevention Consultation and pilot studies.
Results. Preceding surveys revealed a need for proactive disease prevention, linked to primary care. An evidence-based guideline was developed using a validated eight-question screening list. According to the guideline, high-risk participants were advised to attend two consultations at the general practice, for completing the risk assessment and for tailored advice. Three pilot studies revealed that the programme was feasible and that (sufficient) participants with a condition requiring treatment were detected. We learned that with a ‘passive’ recruitment (with only posters and brochures), screening uptake is limited. A more active approach with a personal invitation from the GP is more effective. Both an Internet as written questionnaire should be available and reminders are necessary. The need for a consultation with the GP practice after a high-risk test result should be emphasized. The first consultation can be performed by a practice nurse.
Conclusions. A national systematic screening programme for cardiometabolic diseases linked to primary care is feasible. The cost-effectiveness still has to be established.
PMCID: PMC3296474  PMID: 22399541
Cardiovascular disease; diabetes; hypertension; kidney disease; prevention; primary care; screening; the Netherlands
7.  Co-occurrence of diabetes, myocardial infarction, stroke, and cancer: quantifying age patterns in the Dutch population using health survey data 
The high prevalence of chronic diseases in Western countries implies that the presence of multiple chronic diseases within one person is common. Especially at older ages, when the likelihood of having a chronic disease increases, the co-occurrence of distinct diseases will be encountered more frequently. The aim of this study was to estimate the age-specific prevalence of multimorbidity in the general population. In particular, we investigate to what extent specific pairs of diseases cluster within people and how this deviates from what is to be expected under the assumption of the independent occurrence of diseases (i.e., sheer coincidence).
We used data from a Dutch health survey to estimate the prevalence of pairs of chronic diseases specified by age. Diseases we focused on were diabetes, myocardial infarction, stroke, and cancer. Multinomial P-splines were fitted to the data to model the relation between age and disease status (single versus two diseases). To assess to what extent co-occurrence cannot be explained by independent occurrence, we estimated observed/expected co-occurrence ratios using predictions of the fitted regression models.
Prevalence increased with age for all disease pairs. For all disease pairs, prevalence at most ages was much higher than is to be expected on the basis of coincidence. Observed/expected ratios of disease combinations decreased with age.
Common chronic diseases co-occur in one individual more frequently than is due to chance. In monitoring the occurrence of diseases among the population at large, such multimorbidity is insufficiently taken into account.
PMCID: PMC3175448  PMID: 21884614
multimorbidity; comorbidity; diabetes; cancer; cardiovascular disease; stroke; P-splines
8.  Health problems of people with intellectual disabilities: the impact for general practice 
This study aimed to analyse the health problems and prescriptions of people with intellectual disabilities registered with GPs. Within the Second Dutch National Survey of General Practice evidence was gathered on the differences in health problems between people with intellectual disabilities and control persons (without intellectual disabilities). In a 1:5 matched sample, people with intellectual disabilities paid 1.7 times more visits to GPs. They presented a different morbidity pattern, and received four times as many repeat prescriptions. People with intellectual disabilities increase a GP's workload.
PMCID: PMC2032703  PMID: 17244427
consultations; family practice; intellectual disabilities; morbidity; pharmacotherapy
9.  Carpal tunnel syndrome in general practice (1987 and 2001): incidence and the role of occupational and non-occupational factors 
Most studies on the incidence of the carpal tunnel syndrome and the relation of this disorder with occupation are population-based. In this study we present data from general practice.
To compare incidence rates of carpal tunnel syndrome in 1987 with those in 2001, and to study the relationship between carpal tunnel syndrome and occupation.
Design of study
Analysis of the data of the first and second Dutch National Survey of General Practice, conducted in 1987 and 2001, respectively.
General practices in The Netherlands.
One hundred and three general practices in 1987 with 355 201 listed patients, and 96 practices with 364 998 listed patients in 2001, registered all patients who presented with a new episode of carpal tunnel syndrome. Patient and GP populations were representative for The Netherlands.
The crude incidence rate was 1.3 per 1000 (95% confidence interval [CI] = 1.0 to 1.5) in 1987, and 1.8 per 1000 (95% CI = 1.7 to 2.0) in 2001. In males it was 0.6 (95% CI = 0.5 to 0.7) and 0.9 (95% CI = 0.8 to 1.0) respectively; in females 1.9 (95% CI = 1.7 to 2.1) and 2.8 (95% CI = 2.6 to 3.1). At both study periods, peak incidence rate occurred in the 45–64-year age group: in 2001 this peak reached 4.8 per 1000 (95 CI = 4.1 to 5.4) for females and 1.6 (95 CI = 1.2 to 2.0) for males. Women who performed unskilled and semi-skilled work had 1.5 times greater risk of acquiring carpal tunnel syndrome than women with higher-skilled jobs (P<0.001). In men no relationship of this kind was found.
In 2001 the crude incidence rate of carpal tunnel syndrome was 1.5 times higher than in 1987, but the difference was not statistically significant after subdividing by age and sex. In both years the female:male ratio was 3:1. Incidence rates were related to the job level of women, but not of men.
PMCID: PMC2032698  PMID: 17244422
age distribution; carpal tunnel syndrome; epidemiology; incidence; occupational diseases
10.  Changes in the sociodemographic composition of the lowest socioeconomic group over time, 1987–2001 
BMC Public Health  2007;7:305.
When comparing health differences of groups with equal socioeconomic status (SES) over time, the sociodemographic composition of such a SES group is considered to be constant. However, when the periods are sufficiently spaced in time, sociodemographic changes may have occurred. The aim of this study is to examine in which respects the sociodemographic composition of lowest SES group changed between 1987 and 2001.
Our data were derived from the first and second Dutch National Survey of General Practice conducted in 1987 and 2001. In 1987 sociodemographic data from all listed patients (N = 334,007) were obtained by filling out a registration form at the practice (response 78.3%, 261,691 persons), in 2001 these data from all listed patients (385,461) were obtained by postal survey (response 76.9%, 296,243 persons). Participants were primarily classified according to their occupation into three SES groups: lowest, middle and highest.
In comparison with 1987, the lowest SES group decreased in relative size from 34.9% to 29.5%. Within this smaller SES group, the relative contribution of persons with a higher education more than doubled for females and doubled for males. This indicates that the relation between educational level and occupation was less firmly anchored in 2001 than in 1987.
The relative proportion of some disadvantaged groups (divorced, unemployed) increased in the lowest SES group, but the size of this effect was smaller than the increase from higher education. Young people (0–24 years) were proportionally less often represented in the lowest SES group.
Non-Western immigrants contributed in 2001 proportionally less to the lowest SES group than in 1987, because of an intergenerational upward mobility of the second generation.
On balance, the changes in the composition did not result in an accumulation of disadvantaged groups in the lowest SES group. On the contrary, the influx of people with higher educational qualifications between 1987 and 2001 could result in better health outcomes and health perspectives of the lowest SES group
PMCID: PMC2169236  PMID: 17961246
11.  Health disparities by occupation, modified by education: a cross-sectional population study 
BMC Public Health  2007;7:196.
Socio-economic disparities in health status are frequently reported in research. By comparison with education and income, occupational status has been less extensively studied in relation to health status or the occurrence of specific chronic diseases. The aim of this study was to investigate health disparities in the working population based on occupational position and how they were modified by education.
Our data were derived from the National Survey of General Practice that comprised 104 practices in the Netherlands. 136,189 working people aged 25–64 participated in the study. Occupational position was assessed by the International Socio-Economic Index of occupational position (ISEI). Health outcomes were self-perceived health status and physician-diagnosed diseases. Odds ratios were estimated using multivariate logistic regression analysis.
The lowest occupational position was observed to be associated with poor health in men (OR = 1.6, 95% CI 1,5 to 1.7) and women (OR = 1.3, 95% CI 1.2 to 1.4). The risk of poor health gradually decreased in relation to higher occupational positions. People with the lowest occupational positions were more likely to suffer from depression, diabetes, ischaemic heart disease, arthritis, muscle pain, neck and back pain and tension headache, in comparison to people with the highest occupational position (OR 1.2 to 1.6). A lower educational level induced an additional risk of poor health and disease. We found that gender modified the effects on poor health when both occupational position and education were combined in the analysis.
A low occupational position was consistently associated working people with poor health and physician-diagnosed morbidity. However a low educational level was not. Occupational position and education had a combined effect on self-perceived health, which supports the recent call to improve the conceptual framework of health disparities.
PMCID: PMC1988822  PMID: 17686141
12.  Prevalence of STI related consultations in general practice: results from the second Dutch National Survey of General Practice 
The role of the GP in the care of sexually transmitted infections (STIs) is unclear.
We studied the prevalence of STI related consultations in Dutch general practice in order to obtain insight into the contribution of the GP in STI control.
Design of study
A descriptive study.
The study took place within the framework of the second Dutch National Survey of General Practice in 2001, a large nationally representative population-based survey.
During 1 year, data of all patient contacts with the participating GPs were recorded in electronic medical records. Contacts for the same health problem were clustered into disease episodes and their diagnosis coded according to the International Classification of Primary Care. All STI and STI related episodes were analysed.
In total, 1 524 470 contacts of 375 899 registered persons in 104 practices were registered during 1 year and 2460 STI related episodes were found. The prevalence rate of STI was 39 per 10 000 persons and of STI/HIV related questions 23 per 10 000. More than half of all STIs were found in highly urbanised areas and STIs were overrepresented in deprived areas. Three quarters of all STIs diagnosed in the Netherlands are made in general practice. An important number of other reproductive health visits in general practice offer opportunities for meaningful STI counselling and tailored prevention.
GPs contribute significantly to STI control, see the majority of patients with STI related symptoms and questions and are an important player in STI care. In particular, GPs in urban areas and inner-city practices should be targeted for accelerated sexual health programmes.
PMCID: PMC1828215  PMID: 16464323
prevalence; primary care; sexually transmitted diseases; sexually transmitted infections
13.  Comorbidity in patients with diabetes mellitus: impact on medical health care utilization 
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.
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.
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.
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.
PMCID: PMC1534031  PMID: 16820048

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