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1.  Effectiveness of physician-targeted interventions to improve antibiotic use for respiratory tract infections 
The British Journal of General Practice  2012;62(605):e801-e807.
Background
Antibiotic use and concomitant resistance are increasing. Literature reviews do not unambiguously indicate which interventions are most effective in improving antibiotic prescribing practice.
Aim
To assess the effectiveness of physician-targeted interventions aiming to improve antibiotic prescribing for respiratory tract infections (RTIs) in primary care, and to identify intervention features mostly contributing to intervention success.
Design and setting
Analysis of a set of physician-targeted interventions in primary care.
Method
A literature search (1990–2009) for studies describing the effectiveness of interventions aiming to optimise antibiotic prescription for RTIs by primary care physicians. Intervention features were extracted and effectiveness sizes were calculated. Association between intervention features and intervention success was analysed in multivariate regression analysis.
Results
This study included 58 studies, describing 87 interventions of which 60% significantly improved antibiotic prescribing; interventions aiming to decrease overall antibiotic prescription were more frequently effective than interventions aiming to increase first choice prescription. On average, antibiotic prescription was reduced by 11.6%, and first choice prescription increased by 9.6%. Multiple interventions containing at least ‘educational material for the physician’ were most often effective. No significant added value was found for interventions containing patient-directed elements. Communication skills training and near-patient testing sorted the largest intervention effects.
Conclusion
This review emphasises the importance of physician education in optimising antibiotic use. Further research should focus on how to provide physicians with the relevant knowledge and tools, and when to supplement education with additional intervention elements. Feasibility should be included in this process.
doi:10.3399/bjgp12X659268
PMCID: PMC3505412  PMID: 23211259
antibiotics; primary health care; education; respiratory tract infection
2.  Evaluation of a web-based intervention to reduce antibiotic prescribing for LRTI in six European countries: quantitative process analysis of the GRACE/INTRO randomised controlled trial 
Background
To reduce the spread of antibiotic resistance, there is a pressing need for worldwide implementation of effective interventions to promote more prudent prescribing of antibiotics for acute LRTI. This study is a process analysis of the GRACE/INTRO trial of a multifactorial intervention that reduced antibiotic prescribing for acute LRTI in six European countries. The aim was to understand how the interventions were implemented and to examine effects of the interventions on general practitioners’ (GPs’) and patients’ attitudes.
Methods
GPs were cluster randomised to one of three intervention groups or a control group. The intervention groups received web-based training in either use of the C-reactive protein (CRP) test, communication skills and use of a patient booklet, or training in both. GP attitudes were measured before and after the intervention using constructs from the Theory of Planned Behaviour and a Website Satisfaction Questionnaire. Effects of the interventions on patients were assessed by a post-intervention questionnaire assessing patient enablement, satisfaction with the consultation, and beliefs about the risks and need for antibiotics.
Results
GPs in all countries and intervention groups had very positive perceptions of the intervention and the web-based training, and felt that taking part had helped them to reduce prescribing. All GPs perceived reducing prescribing as more important and less risky following the intervention, and GPs in the communication groups reported increased confidence to reduce prescribing. Patients in the communication groups who received the booklet reported the highest levels of enablement and satisfaction and had greater awareness that antibiotics could be unnecessary and harmful.
Conclusions
Our findings suggest that the interventions should be broadly acceptable to both GPs and patients, as well as feasible to roll out more widely across Europe. There are also some indications that they could help to engender changes in GP and patient attitudes that will be helpful in the longer-term, such as increased awareness of the potential disadvantages of antibiotics and increased confidence to manage LRTI without them. Given the positive effects of the booklet on patient beliefs and attitudes, it seems logical to extend the use of the patient booklet to all patients.
doi:10.1186/1748-5908-8-134
PMCID: PMC3922910  PMID: 24238118
Prescribing; Antibiotics; Resistance; Questionnaires
3.  Prescription of antiviral drugs during the 2009 influenza pandemic: an observational study using electronic medical files of general practitioners in the Netherlands 
Background
After the clinical impact of the A(H1N1) pdm09 virus was considered to be mild, treatment with antiviral drugs was recommended only to patients who were at risk for severe disease or who had a complicated course of influenza. We investigated to what extent antiviral prescriptions in primary care practices were in accordance with the recommendations, what proportion of patients diagnosed with influenza had been prescribed antiviral drugs, and to what extent prescriptions related to the stated indications for antiviral treatment.
Methods
We used data from routine electronic medical records of practices participating in the Netherlands Information Network of General Practice LINH in the period August - December 2009. We considered patient and practice characteristics, clinical diagnoses and drug prescriptions of all patients who contacted their general practitioner in the given period and who had been prescribed antiviral medication (n = 351) or were diagnosed with influenza (n = 3293).
Results
Of all antiviral prescriptions, 69% were in accordance with the recommendations. Only 5% of patients diagnosed with influenza were prescribed antiviral drugs. This percentage increased to 12% among influenza patients belonging to the designated high risk groups. On the other hand, 2.5% of influenza patients not at high risk of complications received antiviral treatment. In addition to the established high risk factors, the total number of drug prescriptions for a patient in this year was a determinant of antiviral prescriptions. Information on time since onset of symptoms and the clinical presentation of patients was not available.
Conclusions
General practitioners in the Netherlands have been restrictive in prescribing antiviral drugs during the influenza pandemic, even when patients met the criteria for antiviral treatment.
doi:10.1186/2050-6511-14-55
PMCID: PMC3854647  PMID: 24143932
Drug prescriptions; General practice; Influenza; Human; Antivirals; Pandemics; Practice guidelines as topic
4.  Measuring safety culture in Dutch primary care: psychometric characteristics of the SCOPE-PC questionnaire 
Background
Patient safety has been a priority in primary healthcare in the last years. The prevailing culture is seen as an important condition for patient safety in practice and several tools to measure patient safety culture have therefore been developed. Although Dutch primary care consists of different professions, such as general practice, dental care, dietetics, physiotherapy and midwifery, a safety culture questionnaire was only available for general practices. The purpose of this study was to modify and validate this existing questionnaire to a generic questionnaire for all professions in Dutch primary care.
Methods
A validated Dutch questionnaire for general practices was modified to make it usable for all Dutch primary care professions. Subsequently, this questionnaire was administered to a random sample of 2400 practices from eleven primary care professions. The instrument’s factor structure, reliability and validity were examined using confirmatory and explorative factor analyses.
Results
921 questionnaires were returned. Of these, 615 were eligible for factor analysis. The resulting SCOPE-PC questionnaire consisted of seven dimensions: ‘open communication and learning from errors’, ‘handover and teamwork’, ‘adequate procedures and working conditions’, ‘patient safety management’, ‘support and fellowship’, ‘intention to report events’ and ‘organisational learning’ with a total of 41 items. All dimensions had good reliability with Cronbach’s alphas ranging from 0.70 – 0.90, and the questionnaire had a good construct validity.
Conclusions
The SCOPE-PC questionnaire has sound psychometric characteristics for use by the different professions in Dutch primary care to gain insight in their safety culture.
doi:10.1186/1472-6963-13-354
PMCID: PMC3851468  PMID: 24044750
Primary care; Patient safety; Safety culture; Questionnaire; Psychometric characteristics
5.  Cluster randomized, controlled trial on patient safety improvement in general practice: a study protocol 
BMC Family Practice  2013;14:127.
Background
An open, constructive safety culture is key in healthcare since it is seen as a main condition for patient safety. Studies have examined culture improvement strategies in hospitals. In primary care, however, not much is known about effective strategies to improve the safety culture yet. The purpose of this study is to examine the effect of two patient safety culture interventions: a patient safety culture questionnaire solely, the SCOPE, or the SCOPE questionnaire combined with a patient safety workshop. The purpose of this paper is to describe the rationale and design of this trial.
Methods/design
The SCOPE Intervention Study is a cluster randomized, three-armed controlled trial, that will be conducted in 30 general practices in the Netherlands. Ten practices in the first intervention arm will complete the SCOPE questionnaire and are expected to draw and implement their own improvement initiatives based on a computerised feedback report. In the second intervention arm, staff of the ten practices also will be asked to complete the SCOPE questionnaire and in addition will be given a complementary workshop. This workshop is theoretical and interactive, educating staff and facilitating discussion, leading to a practice specific action plan for patient safety improvement. The results of the SCOPE questionnaire are incorporated in the workshop. The ten practices in the control arm continue care as usual. Baseline and follow-up measurements will be conducted with an implementation period of one year. The primary outcome will include the number of incidents reported and secondary several quality and safety indicators and the patient safety culture. Moreover, interviews will be conducted at follow-up to evaluate the implementation process of the intervention.
Discussion
Results of this study will give insight in the effect of administering a culture questionnaire or the questionnaire with a complementary workshop. This knowledge will aid implementation of patient safety tools and future research. Attention has been given to the strengths and limitations of the study.
Trial registration
Netherlands Trial Register: NTR3277.
doi:10.1186/1471-2296-14-127
PMCID: PMC3765789  PMID: 23984840
Patient safety; Safety culture; Questionnaire; Intervention; Trial
7.  Central or local incident reporting? A comparative study in Dutch GP out-of-hours services 
Background
Centralised incident reporting in a Dutch collaboration of nine out-of-hours services yielded very few incident reports. To improve incident reporting and the awareness of primary caregivers about patient safety issues, a local incident-reporting procedure was implemented.
Aim
To compare the number and nature of incident reports collected in a local incident-reporting procedure (intervention) versus the currently used centralised incident-reporting procedure.
Design of study
Quasi experiment.
Setting
Three GPs' out-of-hours services (OHSs) in the centre of the Netherlands participated over 2 years before and 2 years after the intervention.
Method
A local incident-reporting procedure was implemented in OHS1, in which participants were encouraged to report all occurring incidents. A local committee with peers analysed the reported incidents fortnightly in order to initiate improvements if necessary. In OHS2 and OHS3, the current centralised incident-reporting procedure was continued, where incidents were reported to an advisory committee of the board of directors of the OHSs collaboration and were assessed every 2 months. The main outcome measures were the number and nature of incidents reported.
Results
At baseline, participants reported fewer than 10 incidents per year each. In the follow-up period, the number of incidents reported in OHS1 increased 16-fold compared with the controls. The type of incidents reported did not alter. In the local incident-reporting procedure, improvements were implemented in a shorter time frame, but reports in the centralised incident-reporting procedure led to a more systematic addressing of general and recurring safety problems.
Conclusion
It is likely that a local incident-reporting procedure increases the willingness to report and facilitates faster implementation of improvements. In contrast, the central procedure, by collating reports from many settings, seems better at addressing generic and recurring safety issues. The advantages of both approaches should be combined.
doi:10.3399/bjgp11X561168
PMCID: PMC3047311  PMID: 21375902
after-hours care; general practice; medical error; primary care; risk management
8.  Patient safety culture measurement in general practice. Clinimetric properties of 'SCOPE' 
BMC Family Practice  2011;12:117.
Background
A supportive patient safety culture is considered to be an essential condition for improving patient safety. Assessing the current safety culture in general practice may be a first step to target improvements. To that end, we studied internal consistency and construct validity of a safety culture questionnaire for general practice (SCOPE) which was derived from a comparable questionnaire for hospitals (Dutch-HSOPS).
Methods
The survey was conducted among caregivers of Dutch general practice as part of an ongoing quality accreditation process using a 46 item questionnaire. We conducted factor analyses and studied validity by calculating correlations between the subscales and testing the hypothesis that respondents' patient safety grade of their practices correlated with their scores on the questionnaire.
Results
Of 72 practices 294 respondents completed the questionnaire. Eight factors were identified concerning handover and teamwork, support and fellowship, communication openness, feedback and learning from error, intention to report events, adequate procedures and staffing, overall perceptions of patient safety and expectations and actions of managers. Cronbach's alpha of the factors rated between 0.64 and 0.85. The subscales intercorrelated moderately, except for the factor about intention to report events. Respondents who graded patient safety highly scored significantly higher on the questionnaire than those who did not.
Conclusions
The SCOPE questionnaire seems an appropriate instrument to assess patient safety culture in general practice. The clinimetric properties of the SCOPE are promising, but future research should confirm the factor structure and construct of the SCOPE and delineate its responsiveness to changes in safety culture over time.
doi:10.1186/1471-2296-12-117
PMCID: PMC3228702  PMID: 22040087
9.  How do COPD patients respond to exacerbations? 
Background
Although timely treatment of COPD exacerbations seems clinically important, nearly half of these exacerbations remain unreported and subsequently untreated. Recent studies have investigated incidence and impact of failure to seek medical treatment during exacerbations. Yet, little is known about type and timing of other self-management actions in periods of symptom deterioration. The current prospective study aims at determining the relative incidence, timing and determinants of three types of patient responses.
Methods
In a multicentre observational study, 121 patients (age 67 ± 11 years, FEV1pred. 48 ± 19) were followed for 6 weeks by daily diary symptom recording. Three types of action were assessed daily: planning periods of rest, breathing techniques and/or sputum clearing (type-A), increased bronchodilator use (type-B) and contacting a healthcare provider (type-C).
Results
Type-A action was taken in 70.7%, type-B in 62.7% and type C in 17.3% of exacerbations (n = 75). Smokers were less likely to take type-A and B actions. Type-C actions were associated with more severe airflow limitation and increased number of hospital admissions in the last year.
Conclusions
Our study shows that most patients are willing to take timely self-management actions during exacerbations. Future research is needed to determine whether the low incidence of contacting a healthcare provider is due to a lack of self-management or healthcare accessibility.
doi:10.1186/1471-2466-11-43
PMCID: PMC3170646  PMID: 21854576
10.  Building an international network for a primary care research program: reflections on challenges and solutions in the set-up and delivery of a prospective observational study of acute cough in 13 European countries 
BMC Family Practice  2011;12:78.
Background
Implementing a primary care clinical research study in several countries can make it possible to recruit sufficient patients in a short period of time that allows important clinical questions to be answered. Large multi-country studies in primary care are unusual and are typically associated with challenges requiring innovative solutions. We conducted a multi-country study and through this paper, we share reflections on the challenges we faced and some of the solutions we developed with a special focus on the study set up, structure and development of Primary Care Networks (PCNs).
Method
GRACE-01 was a multi-European country, investigator-driven prospective observational study implemented by 14 Primary Care Networks (PCNs) within 13 European Countries. General Practitioners (GPs) recruited consecutive patients with an acute cough. GPs completed a case report form (CRF) and the patient completed a daily symptom diary. After study completion, the coordinating team discussed the phases of the study and identified challenges and solutions that they considered might be interesting and helpful to researchers setting up a comparable study.
Results
The main challenges fell within three domains as follows:
i) selecting, setting up and maintaining PCNs;
ii) designing local context-appropriate data collection tools and efficient data management systems; and
iii) gaining commitment and trust from all involved and maintaining enthusiasm.
The main solutions for each domain were:
i) appointing key individuals (National Network Facilitator and Coordinator) with clearly defined tasks, involving PCNs early in the development of study materials and procedures.
ii) rigorous back translations of all study materials and the use of information systems to closely monitor each PCNs progress;
iii) providing strong central leadership with high level commitment to the value of the study, frequent multi-method communication, establishing a coherent ethos, celebrating achievements, incorporating social events and prizes within meetings, and providing a framework for exploitation of local data.
Conclusions
Many challenges associated with multi-country primary care research can be overcome by engendering strong, effective communication, commitment and involvement of all local researchers. The practical solutions identified and the lessons learned in implementing the GRACE-01 study may assist in establishing other international primary care clinical research platforms.
Trial registration
ClinicalTrials.gov Identifier: NCT00353951
doi:10.1186/1471-2296-12-78
PMCID: PMC3176157  PMID: 21794112
11.  Undetected chronic obstructive pulmonary disease and asthma in people over 50 years with persistent cough 
Background
Chronic obstructive pulmonary disease (COPD) and asthma are underdiagnosed in primary care.
Aim
To determine how often COPD or asthma are present in middle-aged and older patients who consult their GP for persistent cough.
Design of study
A cross-sectional study in 353 patients older than 50 years, visiting their GP for persistent cough and not known to have COPD or asthma.
Setting
General practice in the Netherlands.
Method
All participants underwent extensive diagnostic work-up, including symptoms, signs, spirometry, and body plethysmography. All results were studied by an expert panel to diagnose or exclude COPD and/or asthma. The reproducibility of the panel diagnosis was assessed by calculation of Cohen's κ statistic in a sample of 41 participants.
Results
Of the 353 participants, 102 (29%, 95% confidence interval [CI] = 24 to 34%) were diagnosed with COPD. In 14 of these 102 participants, both COPD and asthma were diagnosed (4%, 95% CI = 2 to 7%). Asthma (without COPD) was diagnosed in 23 (7%, 95% CI = 4 to 10%) participants. Mean duration of cough was 93 days (median 40 days). The reproducibility of the expert panel was good (Cohen's κ = 0.90).
Conclusion
In patients aged over 50 years who consult their GP for persistent cough, undetected COPD or asthma is frequently present.
doi:10.3399/bjgp10X514738
PMCID: PMC2894377  PMID: 20594438
asthma; cough; COPD; early diagnosis
12.  How to develop a program to increase influenza vaccine uptake among workers in health care settings? 
Background
Apart from direct protection and reduced productivity loss during epidemics, the main reason to immunize healthcare workers (HCWs) against influenza is to provide indirect protection of frail patients through reduced transmission in healthcare settings. Because the vaccine uptake among HCWs remains far below the health objectives, systematic programs are needed to take full advantage of such vaccination. In an earlier report, we showed a mean 9% increase of vaccine uptake among HCWs in nursing homes that implemented a systematic program compared with control homes, with higher rates in those homes that implemented more program elements. Here, we report in detail the process of the development of the implementation program to enable researchers and practitioners to develop intervention programs tailored to their setting.
Methods
We applied the intervention mapping (IM) method to develop a theory- and evidence-based intervention program to change vaccination behaviour among HCWs in nursing homes.
Results
After a comprehensive needs assessment, we were able to specify proximal program objectives and selected methods and strategies for inducing behavioural change. By consensus, we decided on planning of three main program components, i.e., an outreach visit to all nursing homes, plenary information meetings, and the appointment of a program coordinator -- preferably a physician -- in each home. Finally, we planned program adoption, implementation, and evaluation.
Conclusion
The IM methodology resulted in a systematic, comprehensive, and transparent procedure of program development. A potentially effective intervention program to change influenza vaccination behaviour among HCWs was developed, and its impact was assessed in a clustered randomised controlled trial.
doi:10.1186/1748-5908-6-47
PMCID: PMC3115899  PMID: 21595877
13.  The antibiotic revolution should be more focused 
doi:10.3399/bjgp09X472557
PMCID: PMC2751913  PMID: 19843417
14.  Detecting exacerbations using the Clinical COPD Questionnaire 
Background
Early treatment of COPD exacerbations has shown to be important. Despite a non-negligible negative impact on health related quality of life, a large proportion of these episodes is not reported (no change in treatment). Little is known whether (low burden) strategies are able to capture these unreported exacerbations.
Methods
The Clinical COPD Questionnaire (CCQ) is a short questionnaire with great evaluative properties in measuring health status. The current explorative study evaluates the discriminative properties of weekly CCQ assessment in detecting exacerbations.
Results
In a multicentre prospective cohort study, 121 patients, age 67.4 ± 10.5 years, FEV1 47.7 ± 18.5% pred were followed for 6 weeks by daily diary card recording and weekly CCQ assessment. Weeks were retrospectively labeled as stable or exacerbation (onset) weeks using the Anthonisen symptom diary-card algorithm. Change in CCQ total scores are significantly higher in exacerbation-onset weeks, 0.35 ± 0.69 compared to -0.04 ± 0.37 in stable weeks (p < 0.001). Performance of the Δ CCQ total score discriminating between stable and exacerbation onset weeks was sufficient (area under the ROC curve 0.75). At a cut off point of 0.2, sensitivity was 62.5 (50.3-73.4), specificity 82.0 (79.3-84.4), and a positive and negative predictive value of 43.5 (35.0-51.0) and 90.8 (87.8-93.5), respectively. Using this cut off point, 22 (out of 38) unreported exacerbations were detected while 39 stable patients would have been false positively 'contacted'.
Conclusions
Weekly CCQ assessment is a promising, low burden method to detect unreported exacerbations. Further research is needed to validate discriminative performance and practical implications of the CCQ in detecting exacerbations in daily care.
doi:10.1186/1477-7525-8-102
PMCID: PMC2949819  PMID: 20846428
15.  Prognosis of primary care patients aged 80 years and older with lower respiratory tract infection 
The British Journal of General Practice  2009;59(561):e110-e115.
Background
Predictors for a complicated course of a lower respiratory tract infection (LRTI) episode among patients aged ≥80 years are unknown.
Aim
To determine prognostic factors for hospital admission or death within 30 days after first onset of LRTI among primary care patients aged ≥80 years.
Design of study
Retrospective cohort study.
Setting
Utrecht General Practitioner Research Network.
Method
Data were obtained using the computerised database of the research network over the years 1997 to 2003. Multivariable logistic regression analysis was applied to estimate the independent association of predictors with 30-day hospitalisation or death.
Results
In all, 860 episodes of LRTI were observed in 509 patients; 13% of patients were hospitalised or died within 30 days. Type of LRTI, diabetes, use of oral glucocorticoids, use of antibiotics in the previous month, and hospitalisation in the previous 12 months were independently associated with the combined outcome. Patients with insulin-dependent diabetes mellitus had a greater risk of 30-day hospitalisation or death compared with patients with non-insulin-dependent diabetes.
Conclusion
Independent of age, serious comorbidity – notably the presence of insulin-dependent diabetes or exacerbation of chronic obstructive pulmonary disease requiring oral glucocorticoids – increases the risk for complications, including hospital admissions, in patients aged ≥80 years with an LRTI.
doi:10.3399/bjgp09X420239
PMCID: PMC2662122  PMID: 19341546
elderly; primary health care; prognosis; respiratory tract, infections
16.  Action Plan to enhance self-management and early detection of exacerbations in COPD patients; a multicenter RCT 
Background
Early detection of exacerbations by COPD patients initiating prompt interventions has shown to be clinically relevant. Until now, research failed to identify the effectiveness of a written individualized Action Plan (AP) to achieve this.
Methods/Design
The current multicenter, single-blind RCT with a follow-up period of 6 months, evaluates the hypothesis that individualized AP's reduce exacerbation recovery time. Patients are included from regular respiratory nurse clinics and allocated to either usual care or the AP intervention. The AP provides individualized treatment prescriptions (pharmaceutical and non-pharmaceutical) related to a color coded symptom status (reinforcement at 1 and 4 months). Although usually not possible in self-management trials, we ensured blinding of patients, using a modified informed consent procedure in which patients give consent to postponed information. Exacerbations in both study arms are defined using the Anthonisen symptom diary-card algorithm. The Clinical COPD Questionnaire (CCQ) is assessed every 3-days. CCQ-recovery time of an exacerbation is the primary study outcome. Additionally, healthcare utilization, anxiety, depression, treatment delay, and self-efficacy are assessed at baseline and 6 months. We aim at including 245 COPD patients from 7 hospitals and 5 general practices to capture the a-priori sample size of at least 73 exacerbations per study arm.
Discussion
This RCT identifies if an AP is an effective component of self-management in patients with COPD and clearly differentiates from existing studies in its design, outcome measures and generalizability of the results considering that the study is carried out in multiple sites including general practices.
Trial Registration
NCT00879281
doi:10.1186/1471-2466-9-52
PMCID: PMC2805602  PMID: 20040088
17.  Prediction of complicated lower respiratory tract infections in older patients with diabetes 
Background
Patients with diabetes have an elevated risk of developing complicated lower respiratory tract infections (LRTIs). However, up until now, GPs have not had the tools to assess individual risks.
Aim
To assess the applicability of an existing prediction rule for complicated LRTI among patients with diabetes.
Design of study
Retrospective cohort study.
Setting
The Utrecht GP Research Network.
Method
An existing rule that was used estimates the risk of 30-day hospitalisation or death following an episode of LRTI. Predictors were exacerbation of chronic obstructive pulmonary disease, or pneumonia, increasing age, heart failure, number of hospitalisations in the previous year, use of antibiotics in the previous month, diabetes medication, and prednisone use. Discriminative capacity of the rule was estimated in patients with diabetes. Other potential predictors from the original study were examined, to test for a potentially improved model.
Results
Of 445 episodes of LRTI in patients with diabetes, 68 had an outcome of hospitalisation or death within 30 days of diagnosis of LRTI (15.3%). Results showed good reliability of the model (goodness of fit test P = 0.16) and discriminative properties (area under the receiver operating characteristic curve: 0.79, 95% confidence interval = 0.73 to 0.86). No other predictors could be added. Patients with a lower-risk assignment (score ≤2) had a probability of 5.2%, and those with higher risks (score ≥7) had a probability of 36.6% for the composite endpoint of hospitalisation or death within 30 days of diagnosis of LRTI.
Conclusion
The use of a prediction rule may help GPs to assess the risk of hospitalisation or death in patients with diabetes who have an episode of LRTI.
doi:10.3399/bjgp08X319620
PMCID: PMC2486383  PMID: 18682019
diabetes mellitus; patient admission; prediction, primary health care; respiratory tract, infection
18.  Illness behaviour and antibiotic prescription in patients with respiratory tract symptoms 
Background
Although the vast majority of respiratory tract symptoms are self-limiting, many patients visit their GP for these symptoms and antibiotics are overprescribed.
Aim
To explore determinants of patients visiting GPs for recent cough, sore throat, or earache; for being prescribed antibiotics; and for patients' satisfaction with visiting the GP.
Design of the study
Second Dutch National Survey of General Practice (DNSGP-2) with a health interview and an additional questionnaire.
Setting
A total of 7057 adult patients of 163 GPs in the Netherlands.
Method
Characteristics of patients and GPs as well as morbidity data were derived from the DNSGP-2 and a health interview. Characteristics of the symptoms, GPs' management and patients' satisfaction were measured by an additional written questionnaire. Data were analysed by means of multivariate logistic regression.
Results
About 40% of the responders (n = 1083) reported cough, sore throat, or earache in the 2 weeks preceding the interview and, of them, 250 visited their GP. Of this latter group, 97 patients were prescribed antibiotics. Apart from non-medical reasons, relevant medical factors played an important role in deciding to visit the GP. Smokers and patients with cardiac disease or diabetes mellitus were not especially inclined to see their GP. Smoking behaviour, fever, and views on respiratory tract symptoms and antibiotics of patients and GPs were associated with being prescribed antibiotics. Patients' perception of having been carefully examined was associated with their satisfaction, while receiving antibiotics was not.
Conclusion
GPs should inform patients with clear elevated risk when to visit their GP in cases of cough, sore throat, or earache. There is still a need for GPs and patients to be better informed about the limited significance of single inflammation signs (for example, fever and green phlegm) as an indication for antibiotics. Careful examination of the patient contributes to patient satisfaction.
PMCID: PMC2099639  PMID: 17727749
antibiotics; general practice; respiratory tract infections; satisfaction; views
19.  Quality of life in smokers: focus on functional limitations rather than on lung function? 
Background
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification of severity of chronic obstructive pulmonary disease (COPD) is based solely on obstruction and does not capture physical functioning. The hypothesis that the Medical Research Council (MRC) dyspnoea scale would correlate better with quality of life than the level of airflow limitation was examined.
Aim
To study the associations between quality of life in smokers and limitations in physical functioning (MRC dyspnoea scale) and, quality of life and airflow limitation (GOLD COPD stages).
Design
Cross-sectional study.
Setting
The city of IJsselstein, a small town in the centre of The Netherlands.
Method
Male smokers aged 40–65 years without a prior diagnosis of COPD and enlisted with a general practice, participated in this study. Quality of life was assessed by means of a generic (SF–36) and a disease-specific, questionnaire (QOLRIQ).
Results
A total of 395 subjects (mean age 55.4 years, pack years 27.1) performed adequate spirometry and completed the questionnaires. Limitations of physical functioning according to the MRC dyspnoea scale were found in 25.1 % (99/395) of the participants and airflow limitation in 40.2% (159/395). The correlations of limitations of physical functioning with all quality-of-life components were stronger than the correlations of all quality-of-life subscales with the severity of airflow limitation.
Conclusion
In middle-aged smokers the correlation of limitations of physical functioning (MRC dyspnoea scale) with quality of life was stronger than the correlation of the severity of airflow limitation with quality of life. Future staging systems of severity of COPD should capture this and not rely on forced expiratory volume in one second (FEV1) alone.
PMCID: PMC2078172  PMID: 17550673
dyspnoea; FEV1; middle-aged; FEV1; quality of life; smokers
20.  Diagnostic labelling as determinant of antibiotic prescribing for acute respiratory tract episodes in general practice 
BMC Family Practice  2007;8:55.
Background
Next to other GP characteristics, diagnostic labelling (the proportion of acute respiratory tract (RT) episodes to be labelled as infections) probably contributes to a higher volume of antibiotic prescriptions for acute RT episodes. However, it is unknown whether there is an independent association between diagnostic labelling and the volume of prescribed antibiotics, or whether diagnostic labelling is associated with the number of presented acute RT episodes and consequently with the number of antibiotics prescribed per patient per year.
Methods
Data were used from the Second Dutch National Survey of General Practice (DNSGP-2) with 163 GPs from 85 Dutch practices, serving a population of 359,625 patients. Data over a 12 month period were analysed by means of multiple linear regression analysis. Main outcome measure was the volume of antibiotic prescriptions for acute RT episodes per 1,000 patients.
Results
The incidence was 236.9 acute RT episodes/1,000 patients. GPs labelled about 70% of acute RT episodes as infections, and antibiotics were prescribed in 41% of all acute RT episodes. A higher incidence of acute RT episodes (beta 0.67), a stronger inclination to label episodes as infections (beta 0.24), a stronger endorsement of the need of antibiotics in case of white spots in the throat (beta 0.11) and being male (beta 0.11) were independent determinants of the prescribed volume of antibiotics for acute RT episodes, whereas diagnostic labelling was not correlated with the incidence of acute RT episodes.
Conclusion
Diagnostic labelling is a relevant factor in GPs' antibiotic prescribing independent from the incidence of acute RT episodes. Therefore, quality assurance programs and postgraduate courses should emphasise to use evidence based prognostic criteria (e.g. chronic respiratory co-morbidity and old age) as an indication to prescribe antibiotics in stead of single inflammation signs or diagnostic labels.
doi:10.1186/1471-2296-8-55
PMCID: PMC2039734  PMID: 17883832
21.  Incidence and determinants of moderate COPD (GOLD II) in male smokers aged 40–65 years: 5-year follow up 
Background
Chronic obstructive pulmonary disease (COPD) is a major health problem with an estimated prevalence of 10–15% among smokers. The incidence of moderate COPD, as defined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD), is largely unknown.
Aim
To determine the cumulative incidence of moderate COPD (forced expiratory volume in 1 second/forced vital capacity ratio [FEV1/FVC] <0.7 and FEV1 <80% predicted) and its association with patient characteristics in a cohort of male smokers.
Design
Prospective cohort study.
Setting
The city of IJsselstein, a small town in the Netherlands.
Method
Smokers aged 40–65 years who were registered with local GPs, participated in a study to identify undetected COPD. Baseline measurements were taken in 1998 of 399 smokers with normal spirometry (n = 292) or mild COPD (FEV1/FVC <0.7 and FEV1 ≥80% predicted, n = 107) and follow-up measurements were conducted in 2003.
Results
After a mean follow-up of 5.2 years, 33 participants developed moderate COPD (GOLD II). This showed an estimated cumulative incidence of 8.3% (95% CI = 5.8 to 11.4) and a mean annual incidence of 1.6%. No participant developed severe airflow obstruction. The risk of developing moderate COPD in smokers with baseline mild COPD (GOLD I) was five times higher than in those with baseline normal spirometry (one in five versus one in 25).
Conclusions
In a cohort of middle-aged male smokers, the estimated cumulative incidence of moderate COPD (GOLD II) over 5 years was relatively high (8.3%). Age, childhood smoking, cough, and one or more GP contacts for lower respiratory tract problems were independently associated with incident moderate COPD.
PMCID: PMC1876630  PMID: 16953996
incidence; middle-age; moderate COPD; patient characteristics; smokers
22.  Prescribing antibiotics for respiratory tract infections by GPs: management and prescriber characteristics 
Background
Due to clinical and non-clinical factors, considerable variation exists in the prescribing of antibiotics for respiratory tract infections (RTIs) by GPs based in the Netherlands.
Aims
To assess, in patients with RTIs in Dutch general practice: the prescribing rates of antibiotics; the relationship between GP characteristics and antibiotic prescribing; and the type of antibiotics prescribed.
Design of study
Descriptive and prognostic.
Setting
Eighty-four GPs in the middle region of the Netherlands.
Method
All patient consultations for RTIs were registered by 84 GPs during 3 weeks in autumn and winter 2001 and 2002. In addition, all GPs completed a questionnaire related to individual and practice characteristics.
Results
The mean proportion of consultations in which GPs prescribed antibiotics was 33% (95% CI = 29 to 35%) of all RTIs. This proportion varied from 21% for patients with upper RTIs or an exacerbation of asthma/COPD, to about 70% when patients had sinusitis-like complaints or pneumonia. Amoxycillin and doxycycline were the most frequently prescribed antibiotics, while 17% of the antibiotics prescribed were macrolides. Multiple linear regression analysis showed that the longer GPs had practised, the more frequently they prescribed antibiotics, especially in combination with relatively little knowledge about RTIs or the less time GPs felt they had available per patient. The final model, with seven factors, explained 29% of the variance of antibiotic prescribing.
Conclusion
The prescribing behaviour of Dutch GPs might be improved with regard to choice of type and indication of antibiotics.
PMCID: PMC1463185  PMID: 15720932
antibiotics; prescribing rates; respiratory tract infections
23.  The PINE study: rationale and design of a randomised comparison of epidural injection of local anaesthetics and steroids versus care-as-usual to prevent postherpetic neuralgia in the elderly [ISRCTN32866390] 
BMC Anesthesiology  2004;4:2.
Background
Postherpetic neuralgia (PHN) is by far the most common complication of herpes zoster (HZ) and one of the most intractable pain disorders. Since PHN is seen most often in the elderly, the number of patients with this disorder is expected to increase in our ageing society. PHN may last for months to years and has a high impact on the quality of life. The results of PHN treatment are rather disappointing. Epidural injection of local anaesthetics and steroids in the acute phase of HZ is a promising therapy for the prevention of PHN. Since randomised trials on the effectiveness of this intervention are lacking, the PINE (Prevention by epidural Injection of postherpetic Neuralgia in the Elderly) study was set up. The PINE study compares the effectiveness and cost-effectiveness of a single epidural injection of local anaesthetics and steroids during the acute phase of HZ with that of care-as-usual (i.e. antivirals and analgesics) in preventing PHN in elderly patients.
Methods / design
The PINE study is an open, multicenter clinical trial in which 550 elderly (age ≥ 50 yr.) patients who consult their general practitioner in the acute phase of HZ (rash < 7 days) are randomised to one of the treatment groups. The primary clinical endpoint is the presence of HZ-related pain one month after the onset of the rash. Secondary endpoints include duration and severity of pain, re-interventions aiming to treat the existing pain, side effects, quality of life, and cost-effectiveness.
Conclusion
The PINE study is aimed to quantify the (cost-) effectiveness of a single epidural injection during the acute phase of HZ on the prevention of PHN.
doi:10.1186/1471-2253-4-2
PMCID: PMC341453  PMID: 15005813

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