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1.  The effectiveness of interventions using electronic reminders to improve adherence to chronic medication: a systematic review of the literature 
Many patients experience difficulties in adhering to long-term treatment. Although patients' reasons for not being adherent are diverse, one of the most commonly reported barriers is forgetfulness. Reminding patients to take their medication may provide a solution. Electronic reminders (automatically sent reminders without personal contact between the healthcare provider and patient) are now increasingly being used in the effort to improve adherence.
To examine the effectiveness of interventions using electronic reminders in improving patients' adherence to chronic medication.
A comprehensive literature search was conducted in PubMed, Embase, PsycINFO, CINAHL and Cochrane Central Register of Controlled Trials. Electronic searches were supplemented by manual searching of reference lists and reviews. Two reviewers independently screened all citations. Full text was obtained from selected citations and screened for final inclusion. The methodological quality of studies was assessed.
Thirteen studies met the inclusion criteria. Four studies evaluated short message service (SMS) reminders, seven audiovisual reminders from electronic reminder devices (ERD), and two pager messages. Best evidence synthesis revealed evidence for the effectiveness of electronic reminders, provided by eight (four high, four low quality) studies showing significant effects on patients' adherence, seven of which measured short-term effects (follow-up period <6 months). Improved adherence was found in all but one study using SMS reminders, four studies using ERD and one pager intervention. In addition, one high quality study using an ERD found subgroup effects.
This review provides evidence for the short-term effectiveness of electronic reminders, especially SMS reminders. However, long-term effects remain unclear.
PMCID: PMC3422829  PMID: 22534082
Chronic medication; electronic reminders; interventions; medication adherence; systematic review
2.  Effectiveness of Start to Run, a 6-week training program for novice runners, on increasing health-enhancing physical activity: a controlled study 
BMC Public Health  2013;13:697.
The use of the organized sports sector as a setting for health-promotion is a relatively new strategy. In the past few years, different countries have been investing resources in the organized sports sector for promoting health-enhancing physical activity. In the Netherlands, National Sports Federations were funded to develop and implement “easily accessible” sporting programs, aimed at the least active population groups. Start to Run, a 6-week training program for novice runners, developed by the Dutch Athletics Organization, is one of these programs. In this study, the effects of Start to Run on health-enhancing physical activity were investigated.
Physical activity levels of Start to Run participants were assessed by means of the Short QUestionnaire to ASsess Health-enhancing physical activity (SQUASH) at baseline, immediately after completing the program and six months after baseline. A control group, matched for age and sex, was assessed at baseline and after six months. Compliance with the Dutch physical activity guidelines was the primary outcome measure. Secondary outcome measures were the total time spent in physical activity and the time spent in each physical activity intensity category and domain. Changes in physical activity within groups were tested with paired t-tests and McNemar tests. Changes between groups were examined with multiple linear and logistic regression analyses.
In the Start to Run group, the percentage of people who met the Dutch Norm for Health-enhancing Physical Activity, Fit-norm and Combi-norm increased significantly, both in the short- and longer-term. In the control group, no significant changes in physical activity were observed. When comparing results between groups, significantly more Start to Run participants compared with control group participants were meeting the Fit-norm and Combi-norm after six months. The differences in physical activity between groups in favor of the Start to Run group could be explained by an increase in the time spent in vigorous-intensity activities and sports activities.
Start to Run positively influences levels of health-enhancing physical activity of participants, both in the short- and longer-term. Based on these results, the use of the organized sports sector as a setting to promote health-enhancing physical activity seems promising.
PMCID: PMC3735486  PMID: 23898920
Sports setting; Sporting organizations; Running; Health-enhancing physical activity; Controlled study; Follow-up
3.  Do patient and practice characteristics confound age-group differences in preferences for general practice care? A quantitative study 
BMC Family Practice  2013;14:90.
Previous research showed inconsistent results regarding the relationship between the age of patients and preference statements regarding GP care. This study investigates whether elderly patients have different preference scores and ranking orders concerning 58 preference statements for GP care than younger patients. Moreover, this study examines whether patient characteristics and practice location may confound the relationship between age and the categorisation of a preference score as very important.
Data of the Consumer Quality Index GP Care were used, which were collected in 32 general practices in the Netherlands. The rank order and preference score were calculated for 58 preference statements for four age groups (0–30, 31–50, 51–74, 75 years and older). Using chi-square tests and logistic regression analyses, it was investigated whether a significant relationship between age and preference score was confounded by patient characteristics and practice location.
Elderly patients did not have a significant different ranking order for the preference statements than the other three age groups (r = 0.0193; p = 0.41). However, in 53% of the statements significant differences were found in preference score between the four age groups. Elderly patients categorized significantly less preference statements as ‘very important’. In most cases, the significant relationships were not confounded by gender, education, perceived health, the number of GP contacts and location of the GP practice.
The preferences of elderly patients for GP care concern the same items as younger patients. However, their preferences are less strong, which cannot be ascribed to gender, education, perceived health, the number of GP contacts and practice location.
PMCID: PMC3699367  PMID: 23800156
Preferences; Elderly; GP care
4.  Impact of remuneration on guideline adherence: Empirical evidence in general practice 
Background and objective. Changes in the Dutch GP remuneration system provided the opportunity to study the effects of changes in financial incentives on the quality of care. Separate remuneration systems for publicly insured patients (capitation) and privately insured patients (fee-for-service) were replaced by a combined system of capitation and fee-for-service for all in 2006. The effects of these changes on the quality of care in terms of guideline adherence were investigated. Design and setting. A longitudinal study from 2002 to 2009 using data from patient electronic medical records in general practice. A multilevel (patient and practice) approach was applied to study the effect of changes in the remuneration system on guideline adherence. Subjects. 21 421 to 39 828 patients from 32 to 52 general practices (dynamic panel of GPs). Main outcome measures. Sixteen guideline adherence indicators on prescriptions and referrals for acute and chronic conditions. Results. Guideline adherence increased between 2002 and 2008 by 7% for (formerly) publicly insured patients and 10% for (formerly) privately insured patients. In general, no significant differences in the trends for guideline adherence were found between privately and publicly insured patients, indicating the absence of an effect of the remuneration system on guideline adherence. Adherence to guidelines involving more time investment in terms of follow-up contacts was affected by changes in the remuneration system. For publicly insured patients, GPs showed a higher trend for guideline adherence for guidelines involving more time investment in terms of follow-up contacts compared with privately insured patients. Conclusion. The change in the remuneration system had a limited impact on guideline adherence.
PMCID: PMC3587301  PMID: 23330604
General practice; guideline adherence; quality of care; remuneration system; The Netherlands
5.  Factors associated with the number of consultations per dietetic treatment: an observational study 
Greater understanding of the variance in the number of consultations per dietetic treatment will increase the transparency of dietetic healthcare. Substantial inter-practitioner variation may suggest a potential to increase efficiency and improve quality. It is not known whether inter-practitioner variation also exists in the field of dietetics. Therefore, the aims of this study are to examine inter-practitioner variation in the number of consultations per treatment and the case-mix factors that explain this variation.
For this observational study, data were used from the National Information Service for Allied Health Care (LiPZ). LiPZ is a Dutch registration network of allied health care professionals, including dietitians working in primary healthcare. Data were used from 6,496 patients who underwent dietetic treatment between 2006 and 2009, treated by 27 dietitians working in solo practices located throughout the Netherlands. Data collection was based on the long-term computerized registration of healthcare-related information on patients, reimbursement, treatment and health problems, using a regular software program for reimbursement. Poisson multilevel regression analyses were used to model the number of consultations and to account for the clustered structure of the data.
After adjusting for case-mix, seven percent of the total variation in consultation sessions was due to dietitians. The mean number of consultations per treatment was 4.9 and ranged from 2.3–10.1 between dietitians. Demographic characteristics, patients’ initiative and patients’ health problems explained 28% of the inter-practitioner variation. Certain groups of patients used significantly more dietetic healthcare compared to others, i.e. older patients, females, the native Dutch, patients with a history of dietetic healthcare, patients who started the treatment on their own initiative, patients with multiple diagnoses, overweight, or binge eating disorder.
Considerable variation in number of consultations per dietetic treatment is due to dietitians. Some of this inter-practitioner variation was reduced after adjusting for case-mix. Further research is necessary to study the relation between inter-practitioner variation and the effectiveness and quality of dietetic treatment.
PMCID: PMC3502485  PMID: 22978546
6.  Results after one year introduction of disease oriented payments in the Netherlands 
The purpose of our study was to show the first results after introduction of disease oriented payments for diabetes mellitus type II in the Netherlands.
In 2010 disease oriented payment for diabetes mellitus type II was introduced nationwide in the Netherlands. In disease oriented payment, care for disease groups is organised by a care group that organises both general and more specialised care, and that negotiate a lumpsum for each patient with the health insurer. The care groups can either provide care themselves or sub-contract other providers. Included services within the care program are based on national health care standards. Aim of disease oriented payments is to improve care for chronically ill, by stimulating multidisciplinary collaboration between health care providers.
Selection of patients, health care utilization, organisation of care and self management needs were analysed with the aid data from written structured questionnaires from the National Panel of people with Chronic Illness or Disability (n=275) and data from electronic medical records of general practitioners (n=1144). Diabetes patients with and without disease oriented payment were compared.
Results and conclusions
Our first results show no evidence of selection of patients within disease oriented payments. And hardly any differences in the care between diabetes patients with and without disease oriented payments. Diabetes patients within disease oriented payments tended to go less often to a dietician after the introduction of disease oriented payments. It seems that patients within disease oriented payments receive part of their care from less specialist health care providers. Also, care to diabetes patients within disease oriented payment was only to a limited degree provided according to a programmatic approach.
PMCID: PMC3617746
disease oriented payments; chronically ill; diabetes mellitus type II; the Netherlands
7.  Minor surgery in general practice and effects on referrals to hospital care: Observational study 
Strengthening primary care is the focus of many countries, as national healthcare systems with a strong primary care sector tend to have lower healthcare costs. However, it is unknown to what extent general practitioners (GPs) that perform more services generate fewer hospital referrals. The objective of this study was to examine the association between the number of surgical interventions and hospital referrals.
Data were derived from electronic medical records of 48 practices that participated in the Netherlands Information Network of General Practice (LINH) in 2006-2007. For each care-episode of benign neoplasm skin/nevus, sebaceous cyst or laceration/cut it was determined whether the patient was referred to a medical specialist and/or minor surgery was performed. Multilevel multinomial regression analyses were used to determine the relation between minor surgery and hospital referrals on the level of the GP-practice.
Referral rates differed between diagnoses, with 1.0% of referrals for a laceration/cut, 8.2% for a sebaceous cyst and 10.2% for benign neoplasm skin/nevus. The GP practices performed minor surgery for a laceration/cut in 8.9% (SD:14.6) of the care-episodes, for a benign neoplasm skin/nevus in 27.4% (SD:14.4) of cases and for a sebaceous cyst in 26.4% (SD:13.8). GP practices that performed more minor surgery interventions had a lower referral rate for patients with a laceration/cut (-0.38; 95%CI:-0.60- -0.11) and those with a sebaceous cyst (-0.42; 95%CI:-0.63- -0.16), but not for people with benign neoplasm skin/nevus (-0.26; 95%CI:-0.51-0.03). However, the absolute difference in referral rate appeared to be relevant only for sebaceous cysts.
The effects of minor surgery vary between diagnoses. Minor surgery in general practice appears to be a substitute for specialist medical care only in relation to sebaceous cysts. Measures to stimulate minor surgery for sebaceous cysts may induce substitution.
PMCID: PMC3024924  PMID: 21205305
8.  Labour intensity of guidelines may have a greater effect on adherence than GPs' workload 
BMC Family Practice  2009;10:74.
Physicians' heavy workload is often thought to jeopardise the quality of care and to be a barrier to improving quality. The relationship between these has, however, rarely been investigated. In this study quality of care is defined as care 'in accordance with professional guidelines'. In this study we investigated whether GPs with a higher workload adhere less to guidelines than those with a lower workload and whether guideline recommendations that require a greater time investment are less adhered to than those that can save time.
Data were used from the Second Dutch National survey of General Practice (DNSGP-2). This nationwide study was carried out between April 2000 and January 2002.
A multilevel logistic-regression analysis was conducted of 170,677 decisions made by GPs, referring to 41 Guideline Adherence Indicators (GAIs), which were derived from 32 different guidelines. Data were used from 130 GPs, working in 83 practices with 98,577 patients. GP-characteristics as well as guideline characteristics were used as independent variables. Measures include workload (number of contacts), hours spent on continuing medical education, satisfaction with available time, practice characteristics and patient characteristics. Outcome measure is an indicator score, which is 1 when a decision is in accordance with professional guidelines or 0 when the decision deviates from guidelines.
On average, 66% of the decisions GPs made were in accordance with guidelines. No relationship was found between the objective workload of GPs and their adherence to guidelines. Subjective workload (measured on a five point scale) was negatively related to guideline adherence (OR = 0.95). After controlling for all other variables, the variation between GPs in adherence to guideline recommendations showed a range of less than 10%.
84% of the variation in guideline adherence was located at the GAI-level. Which means that the differences in adherence levels between guidelines are much larger than differences between GPs. Guideline recommendations that require an extra time investment during the same consultation are significantly less adhered to: (OR = 0.46), while those that can save time have much higher adherence levels: OR = 1.55). Recommendations that reduce the likelihood of a follow-up consultation for the same problem are also more often adhered to compared to those that have no influence on this (OR = 3.13).
No significant relationship was found between the objective workload of GPs and adherence to guidelines. However, guideline recommendations that require an extra time investment are significantly less well adhered to while those that can save time are significantly more often adhered to.
PMCID: PMC2791751  PMID: 19943953
9.  Does burnout among doctors affect their involvement in patients' mental health problems? A study of videotaped consultations 
BMC Family Practice  2009;10:60.
General practitioners' (GPs') feelings of burnout or dissatisfaction may affect their patient care negatively, but it is unknown if these negative feelings also affect their mental health care. GPs' available time, together with specific communication tools, are important conditions for providing mental health care. We investigated if GPs who feel burnt out or dissatisfied with the time available for their patients, are less inclined to encourage their patients to disclose their distress, and have shorter consultations, in order to gain time and energy. This may result in less psychological evaluations of patients' complaints.
We used 1890 videotaped consultations from a nationally representative sample of 126 Dutch GPs to analyse GPs' communication and the duration of their consultations. Burnout was subdivided into emotional exhaustion, depersonalisation and reduced accomplishment. Multilevel regression analyses were used to investigate which subgroups of GPs differed significantly.
GPs with feelings of exhaustion or dissatisfaction with the available time have longer consultations compared to GPs without these feelings. Exhausted GPs, and GPs with feelings of depersonalisation, talk more about psychological or social topics in their consultations. GPs with feelings of reduced accomplishment are an exception: they communicate less affectively, are less patient-centred and have less eye contact with their patients compared to GPs without reduced accomplishment.
We found no relationship between GPs' feelings of burnout or dissatisfaction with the available time and their psychological evaluations of patients' problems.
GPs' feelings of burnout or dissatisfaction with the time available for their patients do not obstruct their diagnosis and awareness of patients' psychological problems. On the contrary, GPs with high levels of exhaustion or depersonalisation, and GPs who are dissatisfied with the available time, sometimes provide more opportunities to discuss mental health problems. This increases the chance that appropriate care will be found for patients with mental health problems. On the other hand, these GPs are themselves more likely to retire, or risk burnout, because of their dissatisfaction. Therefore these GPs may benefit from training or personal coaching to decrease the chance that the process of burnout will get out of hand.
PMCID: PMC2754435  PMID: 19706200
10.  Do list size and remuneration affect GPs' decisions about how they provide consultations? 
Doctors' professional behaviour is influenced by the way they are paid. When GPs are paid per item, i.e., on a fee-for-service basis (FFS), there is a clear relationship between workload and income: more work means more money. In the case of capitation based payment, workload is not directly linked to income since the fees per patient are fixed. In this study list size was considered as an indicator for workload and we investigated how list size and remuneration affect GP decisions about how they provide consultations. The main objectives of this study were to investigate a) how list size is related to consultation length, waiting time to get an appointment, and the likelihood that GPs conduct home visits and b) to what extent the relationships between list size and these three variables are affected by remuneration.
List size was used because this is an important determinant of objective workload. List size was corrected for number of older patients and patients who lived in deprived areas. We focussed on three dependent variables that we expected to be related to remuneration and list size: consultation length; waiting time to get an appointment; and home visits. Data were derived from the second Dutch National Survey of General Practice (DNSGP-2), carried out between 2000 and 2002. The data were collected using electronic medical records, videotaped consultations and postal surveys. Multilevel regression analyses were performed to assess the hypothesized relationships.
Our results indicate that list size is negatively related to consultation length, especially among GPs with relatively large lists. A correlation between list size and waiting time to get an appointment, and a correlation between list size and the likelihood of a home visit were only found for GPs with small practices. These correlations are modified by the proportion of patients for whom GPs receive capitation fees. Waiting times to get an appointment tend to become shorter with increasing patient lists when there is a larger capitation percentage. The likelihood that GPs will conduct home visit rises with increasing patient lists when the capitation percentage is small.
Remuneration appears to affect GPs' decisions about how they provide consultations, especially among GPs with relatively small patient lists. This role is, however, small compared to other factors such as patient characteristics.
PMCID: PMC2654894  PMID: 19245685
11.  Do decision support systems influence variation in prescription? 
Translating scientific evidence into daily practice is problematic. All kinds of intervention strategies, using educational and/or directive strategies, aimed at modifying behavior, have evolved, but have been found only partially successful. In this article the focus is on (computerized) decision support systems (DSSs). DSSs intervene in physicians' daily routine, as opposed to interventions that aim at influencing knowledge in order to change behavior. We examined whether general practitioners (GPs) are prescribing in accordance with the advice given by the DSS and whether there is less variation in prescription when the DSS is used.
Data were used from the Second Dutch National Survey of General Practice (DNSGP2), collected in 2001. A total of 82 diagnoses, 749811 contacts, 133 physicians, and 85 practices was included in the analyses. GPs using the DSS daily were compared to GPs who do not use the DSS. Multilevel analyses were used to analyse the data. Two outcome measures were chosen: whether prescription was in accordance with the advice of the DSS or not, and a measure of concentration, the Herfindahl-Hirschman Index (HHI).
GPs who use the DSS daily prescribe more according to the advice given in the DSS than GPs who do not use the DSS. Contradictory to our expectation there was no significant difference between the HHIs for both groups: variation in prescription was comparable.
We studied the use of a DSS for drug prescribing in general practice in the Netherlands. The DSS is based on guidelines developed by the Dutch College of General Practitioners and implemented in the Electronic Medical Systems of the GPs. GPs using the DSS more often prescribe in accordance with the advice given in the DSS compared to GPs not using the DSS. This finding, however, did not mean that variation is lower; variation is the same for GPs using and for GPs not using a DSS. Implications of the study are that DSSs can be used to implement guidelines, but that it should not be expected that variation is limited.
PMCID: PMC2662826  PMID: 19183464
12.  Recently enlisted patients in general practice use more health care resources 
BMC Family Practice  2007;8:64.
The continuity of care is one of the cornerstones of general practice. General practitioners find personal relationships with their patients important as they enable them to provide a higher quality of care. A long-lasting relationship with patients is assumed to be a prior condition for attaining this high quality. We studied the differences in use of care between recently enlisted patients and those patients who have been enlisted for a longer period.
104 general practices in the Netherlands participated the study. We performed a retrospective cohort study in which patients who have been enlisted for less than 1 year (n = 10,102) were matched for age, sex and health insurance with patients who have been enlisted for longer in the same general practice. The two cohorts were compared with regard to the number of contacts with the general practice, diagnoses, rate of prescribing, and the referral rate in a year. These variables were chosen as indicators of differences in the use of care.
In the year following their enlistment, a higher percentage of recently enlisted patients had at least one contact with the practice, received a prescription or was referred. They also had a higher probability of receiving a prescription for an antibiotic. Furthermore, they had a higher mean number of contacts and referrals, but not a higher mean number of prescriptions.
Recently enlisted patients used more health care resources in the first year after their enlistment compared to patients enlisted longer. This could not be explained by differences in health.
PMCID: PMC2235863  PMID: 18047642
13.  Determinants of the range of drugs prescribed in general practice: a cross-sectional analysis 
Current health policies assume that prescribing is more efficient and rational when general practitioners (GPs) work with a formulary or restricted drugs lists and thus with a limited range of drugs. Therefore we studied determinants of the range of drugs prescribed by general practitioners, distinguishing general GP-characteristics, characteristics of the practice setting, characteristics of the patient population and information sources used by GPs.
Secondary analysis was carried out on data from the Second Dutch Survey in General Practice. Data were available for 138 GPs working in 93 practices.
ATC-coded prescription data from electronic medical records, census data and data from GP/practice questionnaires were analyzed with multilevel techniques.
The average GP writes prescriptions for 233 different drugs, i.e. 30% of the available drugs on the market within one year. There is considerable variation between ATC main groups and subgroups and between GPs. GPs with larger patient lists, GPs with higher prescribing volumes and GPs who frequently receive representatives from the pharmaceutical industry have a broader range when controlled for other variables.
The range of drugs prescribed is a useful instrument for analysing GPs' prescribing behaviour. It shows both variation between GPs and between therapeutic groups. Statistically significant relationships found were in line with the hypotheses formulated, like the one concerning the influence of the industry. Further research should be done into the relationship between the range and quality of prescribing and the reasons why some GPs prescribe a greater number of different drugs than others.
PMCID: PMC2045668  PMID: 17711593
14.  Striking variations in consultation rates with general practice reveal family influence 
The reasons why patients decide to consult a general practitioner vary enormously. While there may be individual reasons for this variation, the family context has a significant and unique influence upon the frequency of individuals' visits. The objective of this study was to explore which family factors can explain the differences between strikingly high, and correspondingly low, family consultation rates in families with children aged up to 21.
Data were used from the second Dutch national survey of general practice. This survey extracted from the medical records of 96 practices in the Netherlands, information on all consultations with patients during 2001. We defined, through multilevel analysis, two groups of families. These had respectively, predominantly high, and low, contact frequencies due to a significant family influence upon the frequency of the individual's first contacts. Binomial logistic regression analyses were used to analyse which of the family factors, related to shared circumstances and socialisation conditions, can explain the differences in consultation rates between the two groups of families.
In almost 3% of all families, individual consultation rates decrease significantly due to family influence. In 11% of the families, individual consultation rates significantly increase due to family influence. While taking into account the health status of family members, family factors can explain family consultation rates. These factors include circumstances such as their economic status and number of children, as well as socialisation conditions such as specific health knowledge and family beliefs. The chance of significant low frequencies of contact due to family influences increases significantly with factors such as, paid employment of parents in the health care sector, low expectations of general practitioners' care for minor ailments and a western cultural background.
Family circumstances can easily be identified and will add to the understanding of the health complaints of the individual patient in the consulting room. Family circumstances related to health risks often cannot be changed but they can illuminate the reasons for a visit, and mould strategies for prevention, treatment or recovery. Health beliefs, on the other hand, may be influenced by providing specific knowledge.
PMCID: PMC1784094  PMID: 17233891
15.  Does the attention General Practitioners pay to their patients' mental health problems add to their workload? A cross sectional national survey 
BMC Family Practice  2006;7:71.
The extra workload induced by patients with mental health problems may sometimes cause GPs to be reluctant to become involved in mental health care. It is known that dealing with patients' mental health problems is more time consuming in specific situations such as in consultations. But it is unclear if GPs who are more often involved in patients' mental health problems, have a higher workload than other GPs. Therefore we investigated the following: Is the attention GPs pay to their patients' mental health problems related to their subjective and objective workload?
Secondary analyses were made using data from the Second Dutch National Survey of General Practice, a cross sectional study conducted in the Netherlands in 2000–2002. A nationally representative selection of 195 GPs from 104 general practices participated in this National Survey. Data from: 1) a GP questionnaire; 2) a detailed log of the GP's time use during a week and; 3) an electronic medical registration system, including all patients' contacts during a year, were used. Multiple regression analyses were conducted with the GP's workload as an outcome measure, and the GP's attention for mental health problems as a predictor. GP, patient, and practice characteristics were included in analyses as potential confounders.
Results show that GPs with a broader perception of their role towards mental health care do not have more working hours or patient contacts than GPs with a more limited perception of their role. Neither are they more exhausted or dissatisfied with the available time. Also the number of patient contacts in which a psychological or social diagnosis is made is not related to the GP's objective or subjective workload.
The GP's attention for a patient's mental health problems is not related to their workload. The GP's extra workload when dealing in a consultation with patients' mental health problems, as is demonstrated in earlier research, is not automatically translated into a higher overall workload. This study does not confirm GPs' complaints that mental health care is one of the components of their job that consumes a lot of their time and energy. Several explanations for these results are discussed.
PMCID: PMC1693554  PMID: 17147799
16.  Changing patterns of home visiting in general practice: an analysis of electronic medical records 
BMC Family Practice  2006;7:58.
In most European countries and North America the number of home visits carried out by GPs has been decreasing sharply. This has been influenced by non-medical factors such as mobility and pressures on time. The objective of this study was to investigate changes in home visiting rates, looking at the level of diagnoses in1987 and in 2001.
We analysed routinely collected data on diagnoses in home visits and surgery consultations from electronic medical records by general practitioners. Data were used from 246,738 contacts among 124,791 patients in 103 practices in 1987, and 77,167 contacts among 58,345 patients in 80 practices in 2001. There were 246 diagnoses used. The main outcome measure was the proportion of home visits per diagnosis in 2001.
Within the period studied, the proportion of home visits decreased strongly. The size of this decrease varied across diagnoses. The relation between the proportion of home visits for a diagnosis in 1987 and the same proportion in 2001 is curvilinear (J-shaped), indicating that the decrease is weaker at the extreme points and stronger in the middle.
By comparison with 1987, the proportion of home visits shows a distinct decline. However, the results show that this decline is not necessarily a problem. The finding that this decline varied mainly between diagnoses for which home visits are not always urgent, shows that medical considerations still play an important role in the decision about whether or not to carry out a home visit.
PMCID: PMC1624836  PMID: 17044914
17.  Effectiveness of a Web-Based Physical Activity Intervention in Patients With Knee and/or Hip Osteoarthritis: Randomized Controlled Trial 
Patients with knee and/or hip osteoarthritis (OA) are less physically active than the general population, while the benefits of physical activity (PA) have been well documented. Based on the behavioral graded activity treatment, we developed a Web-based intervention to improve PA levels in patients with knee and/or hip OA, entitled “Join2move”. The Join2move intervention is a self-paced 9-week PA program in which the patient’s favorite recreational activity is gradually increased in a time-contingent way.
The aim of the study was to investigate whether a fully automated Web-based PA intervention in patients with knee and/or hip OA would result in improved levels of PA, physical function, and self-perceived effect compared with a waiting list control group.
The study design was a two-armed randomized controlled trial which was not blinded. Volunteers were recruited via articles in newspapers and health-related websites. Eligibility criteria for participants were: (1) aged 50-75 years, (2) self-reported knee and/or hip OA, (3) self-reported inactivity (30 minutes of moderate PA, 5 times or less per week), (4) no face-to-face consultation with a health care provider other than general practitioners, for OA in the last 6 months, (5) ability to access the Internet weekly, and (6) no contra-indications to exercise without supervision. Baseline, 3-month, and 12-month follow-up data were collected through online questionnaires. Primary outcomes were PA, physical function, and self-perceived effect. In a subgroup of participants, PA was measured objectively using accelerometers. Secondary outcomes were pain, fatigue, anxiety, depression, symptoms, quality of life, self-efficacy, pain coping, and locus of control.
Of the 581 interested respondents, 199 eligible participants were randomly assigned to the intervention (n=100) or waiting list control group (n=99). Response rates of questionnaires were 84.4% (168/199) after 3 months and 75.4% (150/199) after 12 months. In this study, 94.0% (94/100) of participants actually started the program, and 46.0% (46/100) reached the adherence threshold of 6 out of 9 modules completed. At 3 months, participants in the intervention group reported a significantly improved physical function status (difference=6.5 points, 95% CI 1.8-11.2) and a positive self-perceived effect (OR 10.7, 95% CI 4.3-26.4) compared with the control group. No effect was found for self-reported PA. After 12 months, the intervention group showed higher levels of subjective (difference=21.2 points, 95% CI 3.6-38.9) and objective PA (difference=24 minutes, 95% CI 0.5-46.8) compared with the control group. After 12 months, no effect was found for physical function (difference=5 points, 95% CI −1.0 to 11.0) and self-perceived effect (OR 1.2, 95% CI 0.6-2.4). For several secondary endpoints, the intervention group demonstrated improvements in favor of the intervention group.
Join2move resulted in changes in the desired direction for several primary and secondary outcomes. Given the benefits and its self-help format, Join2move could be a component in the effort to enhance PA in sedentary patients with knee and/or hip OA.
Trial Registration
The Netherlands National Trial Register: NTR2483; (Archived by WebCite at
PMCID: PMC3841352  PMID: 24269911
physical activity; osteoarthritis; Web-based intervention; randomized controlled trial
18.  Type II diabetes patients in primary care: profiles of healthcare utilization obtained from observational data 
The high burden of diabetes for healthcare costs and their impact on quality of life and management of the disease have triggered the design and introduction of disease management programmes (DMPs) in many countries. The extent to which diabetes patients vary with regard to their healthcare utilisation and costs is largely unknown and could impact on the design of DMPs. The objectives of this study are to develop profiles based on both the diabetes-related healthcare utilisation and total healthcare utilisation in primary care, to investigate which patient and disease characteristics determine ‘membership’ of each profile, and to investigate the association between these profiles.
Data were used from electronic medical records of 6721 known type II diabetes patients listed in 48 Dutch general practices. Latent Class Analyses were conducted to identify profiles of healthcare and regression analyses were used to analyse the characteristics of the profiles.
For both diabetes-related healthcare utilisation and total healthcare utilisation three profiles could be distinguished: for the diabetes-related healthcare utilisation these were characterised as ‘high utilisation and frequent home visits’ (n=393), ‘low utilisation, GP only’ (n=3231) and ‘high utilisation, GP and nurse’ (n=3097). Profiles differed with respect to the patients’ age and type of medication; the oldest patients using insulin were dominant in the ‘high utilisation, GP and nurse’ profile. High total healthcare utilisation was not associated with high diabetes-related healthcare utilisation.
Healthcare utilisation of diabetes patients is heterogeneous. This challenges the development of distinguishable DMPs.
PMCID: PMC3570342  PMID: 23289605
Type II diabetes mellitus; Healthcare utilisation profiles; Primary care; Latent Class Analyses
19.  What part of the total care consumed by type 2 diabetes patients is directly related to diabetes? Implications for disease management programs 
Disease management programs (DMP) aim at improving coordination and quality of care and reducing healthcare costs for specific chronic diseases. This paper investigates to what extent total healthcare utilization of type 2 diabetes patients is actually related to diabetes and its implications for diabetes management programs.
Research design and methods
Healthcare utilization for diabetes patients was analyzed using 2008 self-reported data (n=316) and data from electronic medical records (EMR) (n=9023), and divided whether or not care was described in the Dutch type 2 diabetes multidisciplinary healthcare standard.
On average 4.3 different disciplines of healthcare providers were involved in the care for diabetes patients. Ninety-six percent contacted a GP-practice and 63% an ophthalmologist, 24% an internist, 32% a physiotherapist and 23% a dietician. Diabetes patients had on average 9.3 contacts with GP-practice of which 53% were included in the healthcare standard. Only a limited part of total healthcare utilization of diabetes patients was included in the healthcare standard and therefore theoretically included in DMPs.
Organizing the care for diabetics in a DMP might harm the coordination and quality of all healthcare for diabetics. DMPs should be integrated in the overall organization of care.
PMCID: PMC3280920  PMID: 22359520
diabetes; disease management program; healthcare standards
20.  Improving medication adherence in diabetes type 2 patients through Real Time Medication Monitoring: a Randomised Controlled Trial to evaluate the effect of monitoring patients' medication use combined with short message service (SMS) reminders 
Innovative approaches are needed to support patients' adherence to drug therapy. The Real Time Medication Monitoring (RTMM) system offers real time monitoring of patients' medication use combined with short message service (SMS) reminders if patients forget to take their medication. This combination of monitoring and tailored reminders provides opportunities to improve adherence. This article describes the design of an intervention study aimed at evaluating the effect of RTMM on adherence to oral antidiabetics.
Randomised Controlled Trial (RCT) with two intervention arms and one control arm involving diabetes type 2 patients with suboptimal levels of adherence to oral antidiabetics (less than 80% based on pharmacy refill data). Patients in the first intervention arm use RTMM including SMS reminders and a personal webpage where they can monitor their medication use. Patients in the second intervention arm use RTMM without SMS reminders or webpage access. Patients in the control arm are not exposed to any intervention. Patients are randomly assigned to one of the three arms. The intervention lasts for six months. Pharmacy refill data of all patients are available from 11 months before, until 11 months after the start of the intervention. Primary outcome measure is adherence to oral antidiabetics calculated from: 1) data collected with RTMM, as a percentage of medication taken as prescribed, and as percentage of medication taken within the correct time interval, 2) refill data, taking the number of days for which oral antidiabetics are dispensed during the study period divided by the total number of days of the study period. Differences in adherence between the intervention groups and control group are studied using refill data. Differences in adherence between the two intervention groups are studied using RTMM data.
The intervention described in this article consists of providing RTMM to patients with suboptimal adherence levels. This system combines real time monitoring of medication use with SMS reminders if medication is forgotten. If RTMM proves to be effective, it can be considered for use in various patient populations to support patients with their medication use and improve their adherence.
Trial registration
Netherlands Trial Register NTR1882
PMCID: PMC3024217  PMID: 21219596
21.  Primary care nurses: effects on secondary care referrals for diabetes 
Primary care nurses play an important role in diabetes care, and were introduced in GP-practice partly to shift care from hospital to primary care. The aim of this study was to assess whether the referral rate for hospital treatment for diabetes type II (T2DM) patients has changed with the introduction of primary care nurses, and whether these changes were related to the number of diabetes-related contacts in a general practice.
Healthcare utilisation was assessed for a period of 365 days for 301 newly diagnosed and 2124 known T2DM patients in 2004 and 450 and 3226 patients in 2006 from general practices that participated in the Netherlands Information Network of General Practice (LINH). Multilevel logistic and linear regression analyses were used to analyse the effect of the introduction of primary care nurses on referrals to internists, ophthalmologists and cardiologists and diabetes-related contact rate. Separate analyses were conducted for newly diagnosed and known T2DM patients.
Referrals to internists for newly diagnosed T2DM patients decreased between 2004 and 2006 (OR:0.44; 95%CI:0.22-0.87) in all practices. For known T2DM patients no overall decrease in referrals to internists was found, but practices with a primary care nurse had a lower trend (OR:0.59). The number of diabetes-related contacts did not differ between practices with and without primary care nurses. Cardiologists' and ophthalmologists' referral rate did not change.
The introduction of primary care nurses seems to have led to a shift of care from internists to primary care for known diabetes patients, while the diabetes-related contact rate seem to have remained unchanged.
PMCID: PMC2924333  PMID: 20691051
22.  Comparing patient characteristics and treatment processes in patients receiving physical therapy in the United States, Israel and the Netherlands: Cross sectional analyses of data from three clinical databases 
Many assume that outcomes from physical therapy research in one country can be generalized to other countries. However, no well designed studies comparing outcomes among countries have been conducted. In this exploratory study, our goal was to compare patient demographics and treatment processes in outpatient physical therapy practice in the United States, Israel and the Netherlands.
Cross-sectional data from three different clinical databases were examined. Data were selected for patients aged 18 years and older and started an episode of outpatient therapy between January 1st 2005 and December 31st 2005. Results are based on data from approximately 63,000 patients from the United States, 100,000 from Israel and 12,000 from the Netherlands.
Age, gender and the body part treated were similar in the three countries. Differences existed in episode duration of the health problem, with more patients with chronic complaints treated in the United States and Israel compared to the Netherlands. In the United States and Israel, physical agents and mechanical modalities were applied more often than in the Netherlands. The mean number of visits per treatment episode, adjusted for age, gender, and episode duration, varied from 8 in Israel to 11 in the United States and the Netherlands.
The current study showed that clinical databases can be used for comparing patient demographic characteristics and for identifying similarities and differences among countries in physical therapy practice. However, terminology used to describe treatment processes and classify patients was different among databases. More standardisation is required to enable more detailed comparisons. Nevertheless the differences found in number of treatment visits per episode imply that one has to be careful to generalize outcomes from physical therapy research from one country to another.
PMCID: PMC2533658  PMID: 18667062

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