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1.  Primary health care: what role for occupational health? 
PMCID: PMC3505386  PMID: 23211235
2.  Qualitative study about the ways teachers react to feedback from resident evaluations 
BMC Medical Education  2013;13:98.
Currently, one of the main interventions that are widely expected to contribute to teachers’ professional development is confronting teachers with feedback from resident evaluations of their teaching performance. Receiving feedback, however, is a double edged sword. Teachers see themselves confronted with information about themselves and are, at the same time, expected to be role models in the way they respond to feedback. Knowledge about the teachers’ responses could be not only of benefit for their professional development, but also for supporting their role modeling. Therefore, research about professional development should include the way teachers respond to feedback.
We designed a qualitative study with semi-structured individual conversations about feedback reports, gained from resident evaluations. Two researchers carried out a systematic analysis using qualitative research software. The analysis focused on what happened in the conversations and structured the data in three main themes: conversation process, acceptance and coping strategies.
The result section describes the conversation patterns and atmosphere. Teachers accepted their results calmly, stating that, although they recognised some points of interest, they could not meet with every standard. Most used coping strategies were explaining the results from their personal beliefs about good teaching and attributing poor results to external factors and good results to themselves. However, some teachers admitted that they had poor results because of the fact that they were not “sharp enough” in their resident group, implying that they did not do their best.
Our study not only confirms that the effects of feedback depend first and foremost on the recipient but also enlightens the meaning and role of acceptance and being a role model. We think that the results justify the conclusion that teachers who are responsible for the day release programmes in the three departments tend to respond to the evaluation results just like human beings do and, at the time of the conversation, are initially not aware of the fact that they are role models in the way they respond to feedback.
PMCID: PMC3751067  PMID: 23866849
Teachers; Professional development; Feedback; Role modeling
3.  GPs' considerations in multimorbidity management: a qualitative study 
The British Journal of General Practice  2012;62(600):e503-e510.
Scientific evidence on how to manage multimorbidity is limited, but GPs have extensive practical experience with multimorbidity management.
To explore GPs’ considerations and main objectives in the management of multimorbidity and to explore factors influencing their management of multimorbidity.
Design and setting
Focus group study of Dutch GPs; with heterogeneity in characteristics such as sex, age and urbanisation.
The moderator used an interview guide in conducting the interviews. Two researchers performed the analysis as an iterative process, based on verbatim transcripts and by applying the technique of constant comparative analysis. Data collection proceeded until saturation was reached.
Five focus groups were conducted with 25 participating GPs. The main themes concerning multimorbidity management were individualisation, applying an integrated approach, medical considerations placed in perspective, and sharing decision making and responsibility. A personal patient–doctor relationship was considered a major factor positively influencing the management of multimorbidity. Mental-health problems and interacting conditions were regarded as major barriers in this respect and participants experienced several practical problems. The concept of patient-centredness overarches the participants’ main objectives.
GPs’ main objective in multimorbidity management is applying a patient-centred approach. This approach is welcomed since it counteracts some potential pitfalls of multimorbidity. Further research should include a similar design in a different setting and should aim at developing best practice in multimorbidity management.
PMCID: PMC3381276  PMID: 22781998
comorbidity; focus groups; multimorbidity; patient-centredness; primary care; qualitative research
4.  Measuring continuity of care: psychometric properties of the Nijmegen Continuity Questionnaire 
The British Journal of General Practice  2012;62(600):e949-e957.
Recently, the Nijmegen Continuity Questionnaire (NCQ) was developed. It aims to measure continuity of care from the patient perspective across primary and secondary care settings. Initial pilot testing proved promising.
To further examine the validity, discriminative ability, and reliability of the NCQ.
A prospective psychometric instrument validation study in primary and secondary care in the Netherlands.
The NCQ was administered to patients with a chronic disease recruited from general practice (n = 145) and hospital outpatient departments (n = 123) (response rate 76%). A principal component analysis was performed to confirm three subscales that had been found previously. Construct validity was tested by correlating the NCQ score to scores of other scales measuring quality of care, continuity, trust, and satisfaction. Discriminative ability was tested by investigating differences in continuity subscores of different subgroups. Test–retest reliability was analysed in 172 patients.
Principal factor analysis confirmed the previously found three continuity subscales — personal continuity, care provider knows me; personal continuity, care provider shows commitment; and team/cross-boundary continuity. Construct validity was demonstrated through expected correlations with other variables and discriminative ability through expected differences in continuity subscores of different subgroups. Test–retest reliability was high (the intraclass correlation coefficient varied between 0.71 and 0.82).
This study provides evidence for the validity, discriminative ability, and reliability of the NCQ. The NCQ can be of value to identify problems in continuity of care.
PMCID: PMC3381279  PMID: 22782001
continuity of patient care; factor analysis, statistical; healthcare surveys; questionnaires; reproducibility of results
5.  Context factors in general practitioner - patient encounters and their impact on assessing communication skills - an exploratory study 
BMC Family Practice  2013;14:65.
Assessment of medical communication performance usually focuses on rating generically applicable, well-defined communication skills. However, in daily practice, communication is determined by (specific) context factors, such as acquaintance with the patient, or the presented problem. Merely valuing the presence of generic skills may not do justice to the doctor’s proficiency.
Our aim was to perform an exploratory study on how assessment of general practitioner (GP) communication performance changes if context factors are explicitly taken into account.
We used a mixed method design to explore how ratings would change. A random sample of 40 everyday GP consultations was used to see if previously identified context factors could be observed again. The sample was rated twice using a widely used assessment instrument (the MAAS-Global), first in the standard way and secondly after context factors were explicitly taken into account, by using a context-specific rating protocol to assess communication performance in the workplace. In between first and second rating, the presence of context factors was established. Item score differences were calculated using paired sample t-tests.
In 38 out of 40 consultations, context factors prompted application of the context-specific rating protocol. Mean overall score on the 7-point MAAS-Global scale increased from 2.98 in standard to 3.66 in the context-specific rating (p < 0.00); the effect size for the total mean score was 0.84. In earlier research the minimum standard score for adequate communication was set at 3.17.
Applying the protocol, the mean overall score rose above the level set in an earlier study for the MAAS-Global scores to represent ‘adequate GP communication behaviour’. Our findings indicate that incorporating context factors in communication assessment thus makes a meaningful difference and shows that context factors should be considered as ‘signal’ instead of ‘noise’ in GP communication assessment. Explicating context factors leads to a more deliberate and transparent rating of GP communication performance.
PMCID: PMC3688246  PMID: 23697479
Communication and Interviewing skills; Continuing Medical Education; Graduate Medical Education; Assessment of Learner Performance
6.  Prescribing ANtiDepressants Appropriately (PANDA): a cluster randomized controlled trial in primary care 
BMC Family Practice  2013;14:6.
Inappropriate use of antidepressants (AD), defined as either continuation in the absence of a proper indication or continuation despite the lack of therapeutic efficacy, applies to approximately half of all long term AD users.
We have designed a cluster randomized controlled clinical trial to assess the (cost-) effectiveness of an antidepressant cessation advice in the absence of a proper indication for maintenance treatment with antidepressants in primary care.
We will select all patients using antidepressants for over 9 months from 45 general practices. Patients will be diagnosed using the Composite International Diagnostic Interview (CIDI) version 3.0, extended with questions about the psychiatric history and previous treatment strategies. General practices will be randomized to either the intervention or the control group. In case of overtreatment, defined as the absence of a proper indication according to current guidelines, a cessation advice is given to the general practitioner. In the control groups no specific information is given. The primary outcome measure will be the proportion of patients that successfully discontinue their antidepressants at one-year follow-up. Secondary outcomes are dimensional measures of psychopathology and costs.
This study protocol provides a detailed overview of the design of the trial. Study results will be of importance for refining current guidelines. If the intervention is effective it can be used in managed care programs.
Trial registration
PMCID: PMC3544619  PMID: 23297810
Depression; Anxiety; Composite International Diagnostic Interview (CIDI); Randomized controlled trial; General practice; Depressive disorder; Anxiety disorders
7.  Reforming primary care: innovation or destruction? 
PMCID: PMC3252531  PMID: 22520679
8.  Prevalence and incidence density rates of chronic comorbidity in type 2 diabetes patients: an exploratory cohort study 
BMC Medicine  2012;10:128.
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.
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.
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.
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.
PMCID: PMC3523042  PMID: 23106808
type 2 diabetes; comorbidity; primary care; prevalence; incidence
9.  PELICAN: A quality of life instrument for childhood asthma: Study Protocol of two Randomized Controlled Trials in Primary and Specialized Care in the Netherlands 
BMC Pediatrics  2012;12:137.
Asthma is one of the major chronic health problems in children in the Netherlands. The Pelican is a paediatric asthma-related quality of life instrument for children with asthma from 6–11 years old, which is suitable for clinical practice in primary and specialized care. Based on this instrument, we developed a self-management treatment to improve asthma-related quality of life. The Pelican intervention will be investigated in different health care settings. Results of intervention studies are often extrapolated to other health care settings than originally investigated. Because of differences in organization, disease severity, patient characteristics and care provision between health care settings, extrapolating research results could lead to unnecessary health costs without the desired health care achievements. Therefore, interventions have to be investigated in different health care settings when possible. This study is an example of an intervention study in different health care settings. In this article, we will present the study protocol of the Pelican study in primary and specialized care.
This study consists of two randomized controlled trials to assess the effectiveness of the Pelican intervention in primary and specialized care. The trial in primary care is a multilevel design with 170 children with asthma in 16 general practices. All children in one general practices are allocated to the same treatment group. The trial in specialized care is a multicentre trial with 100 children with asthma. Children in one outpatient clinic are randomly allocated to the intervention or usual care group. In both trials, children will visit the care provider four times during a follow-up of nine months. This study is registered and ethically approved.
This article describes the study protocol of the Pelican study in different health care settings. If the Pelican intervention proves to be effective and efficient, implementation in primary and specialized care for paediatric asthma in the Netherlands will be recommended.
Trial registration
This study is registered by (NCT01109745)
PMCID: PMC3512535  PMID: 22935133
Asthma; Quality of life; Children; Primary care; Specialized care; Self-management; Randomized controlled trial (RCT)
10.  Do unexplained symptoms predict anxiety or depression? Ten-year data from a practice-based research network 
The British Journal of General Practice  2011;61(587):e316-e325.
Unexplained symptoms are associated with depression and anxiety. This association is largely based on cross-sectional research of symptoms experienced by patients but not of symptoms presented to the GP.
To investigate whether unexplained symptoms as presented to the GP predict mental disorders.
Design and setting
Cross-sectional and longitudinal analysis of data from a practice-based research network of GPs, the Transition Project, in the Netherlands.
All data about contacts between patients (n = 16 000) and GPs (n = 10) from 1997 to 2008 were used. The relation between unexplained symptoms episodes and depression and anxiety was calculated and compared with the relation between somatic symptoms episodes and depression and anxiety. The predictive value of unexplained symptoms episodes for depression and anxiety was determined.
All somatoform symptom episodes and most somatic symptom episodes are significantly associated with depression and anxiety. Presenting two or more symptoms episodes gives a five-fold increase of the risk of anxiety or depression. The positive predictive value of all symptom episodes for anxiety and depression was very limited. There was little difference between somatoform and somatic symptom episodes with respect to the prediction of anxiety or depression.
Somatoform symptom episodes have a statistically significant relation with anxiety and depression. The same was true for somatic symptom episodes. Despite the significant odds ratios, the predictive value of symptom episodes for anxiety and depression is low. Consequently, screening for these mental health problems in patients presenting unexplained symptom episodes is not justified in primary care.
PMCID: PMC3103694  PMID: 21801510
anxiety; depression; mental health; primary care; somatisation; symptoms, unexplained
11.  Identifying context factors explaining physician's low performance in communication assessment: an explorative study in general practice 
BMC Family Practice  2011;12:138.
Communication is a key competence for health care professionals. Analysis of registrar and GP communication performance in daily practice, however, suggests a suboptimal application of communication skills. The influence of context factors could reveal why communication performance levels, on average, do not appear adequate. The context of daily practice may require different skills or specific ways of handling these skills, whereas communication skills are mostly treated as generic. So far no empirical analysis of the context has been made. Our aim was to identify context factors that could be related to GP communication.
A purposive sample of real-life videotaped GP consultations was analyzed (N = 17). As a frame of reference we chose the MAAS-Global, a widely used assessment instrument for medical communication. By inductive reasoning, we analyzed the GP behaviour in the consultation leading to poor item scores on the MAAS-Global. In these cases we looked for the presence of an intervening context factor, and how this might explain the actual GP communication behaviour.
We reached saturation after having viewed 17 consultations. We identified 19 context factors that could potentially explain the deviation from generic recommendations on communication skills. These context factors can be categorized into doctor-related, patient-related, and consultation-related factors.
Several context factors seem to influence doctor-patient communication, requiring the GP to apply communication skills differently from recommendations on communication. From this study we conclude that there is a need to explicitly account for context factors in the assessment of GP (and GP registrar) communication performance. The next step is to validate our findings.
PMCID: PMC3262758  PMID: 22166064
12.  Multidimensional prognostic indices for use in COPD patient care. A systematic review 
Respiratory Research  2011;12(1):151.
A growing number of prognostic indices for chronic obstructive pulmonary disease (COPD) is developed for clinical use. Our aim is to identify, summarize and compare all published prognostic COPD indices, and to discuss their performance, usefulness and implementation in daily practice.
We performed a systematic literature search in both Pubmed and Embase up to September 2010. Selection criteria included primary publications of indices developed for stable COPD patients, that predict future outcome by a multidimensional scoring system, developed for and validated with COPD patients only. Two reviewers independently assessed the index quality using a structured screening form for systematically scoring prognostic studies.
Of 7,028 articles screened, 13 studies comprising 15 indices were included. Only 1 index had been explored for its application in daily practice. We observed 21 different predictors and 7 prognostic outcomes, the latter reflecting mortality, hospitalization and exacerbation. Consistent strong predictors were FEV1 percentage predicted, age and dyspnoea. The quality of the studies underlying the indices varied between fairly poor and good. Statistical methods to assess the predictive abilities of the indices were heterogenic. They generally revealed moderate to good discrimination, when measured. Limitations: We focused on prognostic indices for stable disease only and, inevitably, quality judgment was prone to subjectivity.
We identified 15 prognostic COPD indices. Although the prognostic performance of some of the indices has been validated, they all lack sufficient evidence for implementation. Whether or not the use of prognostic indices improves COPD disease management or patients' health is currently unknown; impact studies are required to establish this.
PMCID: PMC3228786  PMID: 22082049
COPD; index; multidimensional; prognosis
13.  Citation, citation, citation 
PMCID: PMC2913735  PMID: 20822688
14.  Prevalence and consequences of patient safety incidents in general practice in the Netherlands: a retrospective medical record review study 
Patient safety can be at stake in both hospital and general practice settings. While severe patient safety incidents have been described, quantitative studies in large samples of patients in general practice are rare. This study aimed to assess patient safety in general practice, and to show areas where potential improvements could be implemented.
We conducted a retrospective review of patient records in Dutch general practice. A random sample of 1,000 patients from 20 general practices was obtained. The number of patient safety incidents that occurred in a one-year period, their perceived underlying causes, and impact on patients' health were recorded.
We identified 211 patient safety incidents across a period of one year (95% CI: 185 until 241). A variety of types of incidents, perceived causes and consequences were found. A total of 58 patient safety incidents affected patients; seven were associated with hospital admission; none resulted in permanent disability or death.
Although this large audit of medical records in general practices identified many patient safety incidents, only a few had a major impact on patients' health. Improving patient safety in this low-risk environment poses specific challenges, given the high numbers of patients and contacts in general practice.
PMCID: PMC3080333  PMID: 21470418
16.  The Beck Depression Inventory (BDI-II) and a single screening question as screening tools for depressive disorder in Dutch advanced cancer patients 
Supportive Care in Cancer  2011;20(2):319-324.
Depression is highly prevalent in advanced cancer patients, but the diagnosis of depressive disorder in patients with advanced cancer is difficult. Screening instruments could facilitate diagnosing depressive disorder in patients with advanced cancer. The aim of this study was to determine the validity of the Beck Depression Inventory (BDI-II) and a single screening question as screening tools for depressive disorder in advanced cancer patients.
Patients with advanced metastatic disease, visiting the outpatient palliative care department, were asked to fill out a self-questionnaire containing the Beck Depression Inventory (BDI-II) and a single screening question “Are you feeling depressed?” The mood section of the PRIME-MD was used as a gold standard.
Sixty-one patients with advanced metastatic disease were eligible to be included in the study. Complete data were obtained from 46 patients. The area under the curve of the receiver operating characteristics analysis of the BDI-II was 0.82. The optimal cut-off point of the BDI-II was 16 with a sensitivity of 90% and a specificity of 69%. The single screening question showed a sensitivity of 50% and a specificity of 94%.
The BDI-II seems an adequate screening tool for a depressive disorder in advanced cancer patients. The sensitivity of a single screening question is poor.
PMCID: PMC3244603  PMID: 21243377
Depression; Advanced cancer; Validation; Screening tool; BDI-II
17.  Trends in COPD prevalence and exacerbation rates in Dutch primary care 
Changes in the burden of chronic obstructive pulmonary disease (COPD) and its exacerbations on primary health care are not well studied.
To identify trends in the prevalence of physician-diagnosed COPD and exacerbation rates by age, sex, and socioeconomic status in a general practice population.
Design of study
Trend analysis of COPD data from a 27-year prospective cohort of a dynamic general practice population.
Data were taken from the Continuous Morbidity Registration Nijmegen.
For the period 1980–2006, COPD and COPD exacerbation data were extracted for patients aged ≥40 years. Data were standardised for the composition of the Continuous Morbidity Registration population in the year 2000. Regression coefficients for trends were estimated by sex, age, and socioeconomic status. Rate ratios were calculated for prevalence differences in different demographic subgroups.
During the study period, the overall COPD prevalence decreased from 72.7 to 54.5 per 1000 patients per year. The exacerbation rate decreased from 44.1 to 31.5 per 100 patients, and the percentage of patients with COPD who had exacerbations declined from 27.6% to 21.0%. The prevalence of COPD increased significantly in women, in particular those aged ≥65 years with low socioeconomic status. Decreases in exacerbation rates and percentages of patients with exacerbations were independent of sex, age, and socioeconomic status.
The decline in COPD prevalence and exacerbation rates suggests a reduction of the burden on Dutch primary care. The increase of the prevalence in women indicates a need to focus on this particular subgroup in COPD management and research.
PMCID: PMC2784530  PMID: 19891824
chronic obstructive pulmonary disease; family practice; prevalence; trends
18.  Getting a grip on guidelines: how to make them more relevant for practice 
The British Journal of General Practice  2009;59(562):e143-e144.
PMCID: PMC2673179  PMID: 19401005
20.  Predictive value and utility of oral steroid testing for treatment of COPD in primary care: the COOPT study 
The oral prednisolone test is widely used to distinguish chronic obstructive pulmonary disease (COPD) patients who might benefit from inhaled steroid treatment. Previous studies used selected patient groups that did not represent the large COPD population in primary care.
The study included smokers and exsmokers with chronic bronchitis or COPD from primary care, who underwent prednisolone testing (30 mg for 14 days) before randomization in a three-year follow-up randomized controlled trial (COOPT Study). Spirometry was performed before and after the test. Responders and nonresponders were classified according to international criteria. Effectiveness of inhaled fluticasone relative to placebo was compared in terms of health status (Chronic Respiratory Disease Questionnaire), exacerbations, and postbronchodilator forced expiratory volume in one second (FEV1), using repeated measurement analysis.
Two hundred eighty-six patients recruited from 44 primary care practices were randomized. Nine percent to 16% of the COPD population was classified as responder, depending on the international guideline criteria used. On average, responders did not reach the minimum clinically important difference in health status (0.29 points/year, P = 0.05), although a borderline significant effect of inhaled fluticasone was noted. Possible clinically relevant reductions in exacerbation rate (rate ratio 0.67) and FEV1 decline (39 mL/year) occurred in responders, but did not reach statistical significance.
Oral steroid testing identifies a limited proportion of COPD patients, but does not reveal any clinically relevant benefit from inhaled steroid treatment on health status. No significant effects on exacerbation rate and lung function decline occurred.
PMCID: PMC2793071  PMID: 20037682
COPD; primary care; oral steroid testing; prednisolone test
21.  Explanation and relations. How do general practitioners deal with patients with persistent medically unexplained symptoms: a focus group study 
BMC Family Practice  2009;10:68.
Persistent presentation of medically unexplained symptoms (MUS) is troublesome for general practitioners (GPs) and causes pressure on the doctor-patient relationship. As a consequence, GPs face the problem of establishing an ongoing, preferably effective relationship with these patients. This study aims at exploring GPs' perceptions about explaining MUS to patients and about how relationships with these patients evolve over time in daily practice.
A qualitative approach, interviewing a purposive sample of twenty-two Dutch GPs within five focus groups. Data were analyzed according to the principles of constant comparative analysis.
GPs recognise the importance of an adequate explanation of the diagnosis of MUS but often feel incapable of being able to explain it clearly to their patients. GPs therefore indicate that they try to reassure patients in non-specific ways, for example by telling patients that there is no disease, by using metaphors and by normalizing the symptoms. When patients keep returning with MUS, GPs report the importance of maintaining the doctor-patient relationship. GPs describe three different models to do this; mutual alliance characterized by ritual care (e.g. regular physical examination, regular doctor visits) with approval of the patient and the doctor, ambivalent alliance characterized by ritual care without approval of the doctor and non-alliance characterized by cutting off all reasons for encounter in which symptoms are not of somatic origin.
GPs feel difficulties in explaining the symptoms. GPs report that, when patients keep presenting with MUS, they focus on maintaining the doctor-patient relationship by using ritual care. In this care they meticulously balance between maintaining a good doctor-patient relationship and the prevention of unintended consequences of unnecessary interventions.
PMCID: PMC2758831  PMID: 19775481
22.  Barriers in recognising, diagnosing and managing depressive and anxiety disorders as experienced by Family Physicians; a focus group study 
BMC Family Practice  2009;10:52.
The recognition and treatment of depressive- and anxiety disorders is not always in line with current standards. The results of programs to improve the quality of care, are not encouraging. Perhaps these programs do not match with the problems experienced in family practice. This study aims to systematically explore how FPs perceive recognition, diagnosis and management of depressive and anxiety disorders.
focus group discussions with FPs, qualitative analysis of transcriptions using thematic coding.
The FPs considered recognising, diagnosing and managing depressive- and anxiety disorders as an important task. They expressed serious doubts about the validity and usefulness of the DSM IV concept of depressive and anxiety disorders in family practice especially because of the high frequency of swift natural recovery. An important barrier was that many patients have difficulties in accepting the diagnosis and treatment with antidepressant drugs. FPs lacked guidance in the assessment of patients' burden. The FPs experienced they had too little time for patient education and counseling. The under capacity of specialised mental health care and its minimal collaboration with FPs were experienced as problematic. Valuable suggestions for solving the problems encountered were made
Next to serious doubts regarding the diagnostic concept of depressive- and anxiety disorders a number of factors were identified which serve as barriers for suitablemental health care by FPs. These doubts and barriers should be taken into account in future research and in the design of interventions to improve mental health care in family practice.
PMCID: PMC2734533  PMID: 19619278

Results 1-25 (53)