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1.  Increased risk for chronic comorbid disorders in patients with inflammatory arthritis: a population based study 
BMC Family Practice  2013;14:199.
Background
Studies determining the development of a wide variety of different comorbid disorders in inflammatory arthritis (IA) patients are scarce, however, this knowledge could be helpful in optimising preventive care in IA patients. The aim of this study is to establish the risk that new chronic comorbid disorders in newly diagnosed patients with IA in a primary care setting are developed.
Methods
This is a nested-case–control study from 2001–2010 using data from electronic medical patient records in general practice. In total, 3,354 patients with newly diagnosed IA were selected. Each patient was matched with two control patients of the same age and sex in the same general practice. The development of 121 chronic comorbid disorders of index and control patients was compared using Cox regression.
Results
After a median follow-up period of 2.8 years, 56% of the IA-patients had developed at least one chronic comorbid disorder after the onset of IA, compared to 46% of the control patients (p < 0.05). The most frequent developed comorbid disorders after the onset of IA were of cardiovascular (23%), and musculoskeletal (17%) origin. The highest hazard ratios (HRs) were found for anaemia (HR 2.0 [95% CI: 1.4-2.7]) osteoporosis (HR 1.9 [1.4-2.4]), and COPD (HR 1.8 [1.4-2.3]).
Conclusion
Patients with IA developed more chronic comorbid disorders after the onset of IA than one might expect based on age and sex. Since comorbidity has a large impact on the disease course, quality of life, and possibly on treatment itself, prevention of comorbidity should be one of the main targets in the treatment of IA patients.
doi:10.1186/1471-2296-14-199
PMCID: PMC3909051  PMID: 24364915
Inflammatory arthritis; Comorbidity; General practice; Disease onset; Chronic disease
3.  Measuring continuity of care: psychometric properties of the Nijmegen Continuity Questionnaire 
The British Journal of General Practice  2012;62(600):e949-e957.
Background
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.
Aim
To further examine the validity, discriminative ability, and reliability of the NCQ.
Design
A prospective psychometric instrument validation study in primary and secondary care in the Netherlands.
Method
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.
Results
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).
Conclusion
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.
doi:10.3399/bjgp12X652364
PMCID: PMC3381279  PMID: 22782001
continuity of patient care; factor analysis, statistical; healthcare surveys; questionnaires; reproducibility of results
4.  The validity of the diagnosis of inflammatory arthritis in a large population-based primary care database 
BMC Family Practice  2013;14:79.
Background
Large population-based databases based on electronic medical records (EMRs) of patients in primary care are a useful data source to investigate morbidity and health care utilization. Diagnoses recorded in EMRs are doctor-defined, but their validity can be disputed. In this study we investigated the validity of the diagnosis inflammatory arthritis (IA), a group of chronic rheumatic diseases, including rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis, in primary care based EMRs.
Methods
In five general practices, participating in the Netherlands Information Network of General Practice (LINH), EMRs of 219 patients with a diagnostic code of IA were systematically reviewed on characteristics which are not routinely extracted for the LINH database. The diagnosis IA was confirmed when we found, based on a correspondence with a medical specialist, the following diagnoses in the free text fields of the EMR: oligoarthritis, polyarthritis, rheumatoid arthritis and/or spondyloarthropathy. These results were used to determine the validity of the diagnosis IA in EMRs and to develop an algorithm to improve diagnostic validity.
Results
From the 219 patients diagnosed as IA in the database, the diagnosis IA was confirmed in 155 patients (70.8%). The algorithm, which resulted in a group of patients with as many as possible confirmed IA-diagnosed patients without excluding too many patients from our dataset, was when patients fulfilled at least one of the following three criteria: 1) a repeat prescription for a disease-modifying antirheumatic drug (DMARD) and/or biological agent, 2) ≥ four contacts or one episode with a diagnostic code for IA, combined with at least two IA-related prescriptions (excluding DMARDs/biological agents), and 3) age at diagnosis ≥ 61 years. After applying this algorithm, the percentage of correctly diagnosed IA patients increased from 71% to 78% reducing the size of our study population by 36%.
Conclusions
Based on additional diagnostic information, the diagnosis IA from EMRs of patients in primary care is sufficiently valid when using the proposed algorithm. After applying the algorithm, the percentage of correctly diagnosed IA patients increased from 71% to 78%.
doi:10.1186/1471-2296-14-79
PMCID: PMC3682903  PMID: 24128086
Validity; Inflammatory arthritis; General practice; EMRs
5.  Type II diabetes patients in primary care: profiles of healthcare utilization obtained from observational data 
Background
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.
Methods
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.
Results
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.
Conclusions
Healthcare utilisation of diabetes patients is heterogeneous. This challenges the development of distinguishable DMPs.
doi:10.1186/1472-6963-13-7
PMCID: PMC3570342  PMID: 23289605
Type II diabetes mellitus; Healthcare utilisation profiles; Primary care; Latent Class Analyses
6.  Non-participation in population-based disease prevention programs in general practice 
BMC Public Health  2012;12:856.
Background
The number of people with a chronic disease will strongly increase in the next decades. Therefore, prevention of disease becomes increasingly important. The aim of this systematic review was to identify factors that negatively influence participation in population-based disease prevention programs in General Practice and to establish whether the program type is related to non-participation levels.
Methods
We conducted a systematic review in Pubmed, EMBASE, CINAHL and PsycINFO, covering 2000 through July 6th 2012, to identify publications including information about characteristics of non-participants or reasons for non-participation in population-based disease prevention programs in General Practice.
Results
A total of 24 original studies met our criteria, seven of which focused on vaccination, eleven on screening aimed at early detection of disease, and six on screening aimed at identifying high risk of a disease, targeting a variety of diseases and conditions. Lack of personal relevance of the program, younger age, higher social deprivation and former non-participation were related to actual non-participation. No differences were found in non-participation levels or factors related to non-participation between the three program types. The large variation in non-participation levels within the program types may be partly due to differences in recruitment strategies, with more active, personalized strategies resulting in higher participation levels compared to an invitation letter.
Conclusions
There is still much to be gained by tailoring strategies to improve participation in those who are less likely to do so, namely younger individuals, those living in a deprived area and former non-participants. Participation may increase by applying more active recruitment strategies.
doi:10.1186/1471-2458-12-856
PMCID: PMC3490995  PMID: 23046688
General practice; Prevention; Vaccination; Screening; Non-participation
7.  Cardiovascular disease prevalence in patients with inflammatory arthritis, diabetes mellitus and osteoarthritis: a cross-sectional study in primary care 
Background
There is accumulating evidence for an increased cardiovascular burden in inflammatory arthritis, but the true magnitude of this cardiovascular burden is still debated. We sought to determine the prevalence rate of non-fatal cardiovascular disease (CVD) in inflammatory arthritis, diabetes mellitus and osteoarthritis (non-systemic inflammatory comparator) compared to controls, in primary care.
Methods
Data on CVD morbidity (ICPC codes K75 (myocardial infarction), K89 (transient ischemic attack), and/or K90 (stroke/cerebrovascular accident)) from patients with inflammatory arthritis (n = 1,518), diabetes mellitus (n = 11,959), osteoarthritis (n = 4,040) and controls (n = 158,439) were used from the Netherlands Information Network of General Practice (LINH), a large nationally representative primary care based cohort. Data were analyzed using multi-level logistic regression analyses and corrected for age, gender, hypercholesterolemia and hypertension.
Results
CVD prevalence rates were significantly higher in inflammatory arthritis, diabetes mellitus and osteoarthritis compared with controls. These results attenuated - especially in diabetes mellitus - but remained statistically significant after adjustment for age, gender, hypertension and hypercholesterolemia for inflammatory arthritis (OR = 1.5 (1.2-1.9)) and diabetes mellitus (OR = 1.3 (1.2-1.4)). The association between osteoarthritis and CVD reversed after adjustment (OR = 0.8 (0.7-1.0)).
Conclusions
These results confirm an increased prevalence rate of CVD in inflammatory arthritis to levels resembling diabetes mellitus. By contrast, lack of excess CVD in osteoarthritis further suggests that the systemic inflammatory load is critical to the CVD burden in inflammatory arthritis.
doi:10.1186/1471-2474-13-150
PMCID: PMC3493278  PMID: 22906083
8.  Excess of health care use in general practice and of comorbid chronic conditions in cancer patients compared to controls 
BMC Family Practice  2012;13:60.
Background
The number of cancer patients and the number of patients surviving initial treatments is expected to rise. Traditionally, follow-up monitoring takes place in secondary care. The contribution of general practice is less visible and not clearly defined.
This study aimed to compare healthcare use in general practice of patients with cancer during the follow-up phase compared with patients without cancer. We also examined the influence of comorbid conditions on healthcare utilisation by these patients in general practice.
Methods
We compared health care use of N=8,703 cancer patients with an age and gender-matched control group of patients without cancer from the same practice. Data originate from the Netherlands Information Network of General Practice (LINH), a representative network consisting of 92 general practices with 350,000 enlisted patients. Health care utilisation was assessed using data on contacts with general practice, prescription and referral rates recorded between 1/1/2001 and 31/12/2007. The existence of additional comorbid chronic conditions (ICPC coded) was taken into account.
Results
Compared to matched controls, cancer patients had more contacts with their GP-practice (19.5 vs. 11.9, p<.01), more consultations with the GP (3.5 vs. 2.7, p<.01), more home visits (1.6 vs. 0.4, p<.01) and they got more medicines prescribed (18.7 vs. 11.6, p<.01) during the follow-up phase. Cancer patients more often had a chronic condition than their matched controls (52% vs. 44%, p<.01). Having a chronic condition increased health care use for both patients with and without cancer. Cancer patients with a comorbid condition had the highest health care use.
Conclusion
We found that cancer patients in the follow-up phase consulted general practice more often and suffered more often from comorbid chronic conditions, compared to patients without cancer. It is expected that the number of cancer patients will rise in the years to come and that primary health care professionals will be more involved in follow-up care. Care for comorbid chronic conditions, communication between specialists and GPs, and coordination of tasks then need special attention.
doi:10.1186/1471-2296-13-60
PMCID: PMC3480891  PMID: 22712888
Neoplasms; Cancer; Primary health care; General practitioner; Follow-up; Comorbidity
9.  What part of the total care consumed by type 2 diabetes patients is directly related to diabetes? Implications for disease management programs 
Background
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.
Results
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.
Conclusion
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
10.  Increased incidence of kidney diseases in general practice after a nationwide albuminuria self-test program 
BMC Family Practice  2011;12:81.
Background
To study the influence of a nationwide albuminuria self-test program on the number of GP contacts for urinary complaints and/or kidney diseases and the number of newly diagnosed patients with kidney diseases by the GP.
Methods
Data were used from the Netherlands Information Network of General Practice (LINH), including a representative sample of general practices with a dynamic population of approximately 300.000 listed patients. Morbidity data were retrieved from electronic medical records, kept in a representative sample of general practices. The incidence of kidney diseases and urinary complaints before and after the albuminuria self-test program was compared with logistic regression analyses.
Results
Data were used from 139 general practices, including 444,220 registered patients. The number of GP consultations for kidney diseases and urinary complaints was increased in the year after the albuminuria self-test program and particularly shortly after the start of the program. Compared with the period before the self-test program, more patients have been diagnosed by the GP with symptoms/complaints of kidney disease and urinary diseases (OR = 1.7 (CI 1.4 - 2.0) and OR = 2.1 (CI 1.9 - 2.3), respectively). The odds on an abnormal urine-test in the period after the self-test program was three times higher than the year before (OR = 3.0 (CI 2.4 - 3.6)). The effect of the self-test program on newly diagnosed patients with an abnormal urine test was modified by both the presence of the risk factors hypertension and diabetes mellitus. For this diagnosis the highest OR was found in patients without both conditions (OR = 4.2 (CI 3.3 - 5.4)).
Conclusions
A nationwide albuminuria self-test program resulted in an increasing number of newly diagnosed kidney complaints and diseases the year after the program. The highest risks were found in patients without risk factors for kidney diseases.
doi:10.1186/1471-2296-12-81
PMCID: PMC3162897  PMID: 21812999
11.  The effectiveness of case management for comorbid diabetes type 2 patients; the CasCo study. Design of a randomized controlled trial 
BMC Family Practice  2011;12:68.
Background
More than half of the patients with type 2 diabetes (T2DM) patients are diagnosed with one or more comorbid disorders. They can participate in several single-disease oriented disease management programs, which may lead to fragmented care because these programs are not well prepared for coordinating care between programs. Comorbid patients are therefore at risk for suboptimal treatment, unsafe care, inefficient use of health care services and unnecessary costs. Case management is a possible model to counteract fragmented care for comorbid patients. It includes evidence-based optimal care, but is tailored to the individual patients' preferences.
The objective of this study is to examine the effectiveness of a case management program, in addition to a diabetes management program, on the quality of care for comorbid T2DM patients.
Methods/Design
The study is a randomized controlled trial among patients with T2DM and at least one comorbid chronic disease (N = 230), who already participate in a diabetes management program. Randomization will take place at the level of the patients in general practices. Trained practice nurses (case managers) will apply a case management program in addition to the diabetes management program. The case management intervention is based on the Guided Care model and includes six elements; assessing health care needs, planning care, create access to other care providers and community resources, monitoring, coordinating care and recording of all relevant information. Patients in the control group will continue their participation in the diabetes management program and receive care-as-usual from their general practitioner and other care providers.
Discussion
We expect that the case management program, which includes better structured care based on scientific evidence and adjusted to the patients' needs and priorities, will improve the quality of care coordination from both the patients' and caregivers' perspective and will result in less consumption of health care services.
Trial registration
Netherlands Trial Register (NTR): NTR1847
doi:10.1186/1471-2296-12-68
PMCID: PMC3142502  PMID: 21729265
12.  Impact of dizziness on everyday life in older primary care patients: a cross-sectional study 
Background
Dizziness is a common and often disabling symptom, but diagnosis often remains unclear; especially in older persons where dizziness tends to be multicausal. Research on dizziness-related impairment might provide options for a functional oriented approach, with less focus on finding diagnoses. We therefore studied dizziness-related impairment in older primary care patients and aimed to identify indicators related to this impairment.
Methods
In a cross-sectional study we included 417 consecutive patients of 65 years and older presenting with dizziness to 45 general practitioners in the Netherlands from July 2006 to January 2008. We performed tests, including patient history, and physical and additional examination, previously selected by an international expert panel and based on an earlier systematic review. Our primary outcome was impact of dizziness on everyday life measured with the Dutch validated version of the Dizziness Handicap Inventory (DHI). After a bootstrap procedure (1500x) we investigated predictability of DHI-scores with stepwise backward multiple linear and logistic regressions.
Results
DHI-scores varied from 0 to 88 (maximum score: 100) and 60% of patients experienced moderate or severe impact on everyday life due to dizziness. Indicators for dizziness-related impairment were: onset of dizziness 6 months ago or more (OR 2.8, 95% CI 1.7-4.7), frequency of dizziness at least daily (OR 3.3, 95% CI 2.0-5.4), duration of dizziness episode one minute or less (OR 2.4, 95% CI 1.5-3.9), presence of anxiety and/or depressive disorder (OR 4.4, 95% CI 2.2-8.8), use of sedative drugs (OR 2.3, 95% CI 1.3-3.8) , and impaired functional mobility (OR 2.6, 95% CI 1.7-4.2). For this model with only 6 indicators the AUC was .80 (95% CI .76-.84).
Conclusions
Dizziness-related impairment in older primary care patients is considerable (60%). With six simple indicators it is possible to identify which patients suffer the most from their dizziness without exactly knowing the cause(s) of their dizziness. Influencing these indicators, if possible, may lead to functional improvement and this might be effective in patients with moderate or severe impact of dizziness on their daily lives.
doi:10.1186/1477-7525-9-44
PMCID: PMC3142198  PMID: 21679451
13.  ENT problems in Dutch children: Trends in incidence rates, antibiotic prescribing and referrals 2002–2008 
Background
Ear, nose, and throat (ENT) problems are common in childhood and are important reasons to visit the general practitioner.
Objective
To examine trends in incidence rates, antibiotic prescribing, and referrals of five common ENT problems in children.
Design
Netherlands Information Network of General Practice (LINH), a nationally representative general practice database.
Setting
A total of 50 000 children, aged 0–17 years, registered in Dutch general practice over the period 2002–2008.
Methods
Incidence rates were calculated and trends were analysed using linear regression analysis, with incidence rates per age group, proportion treated with antibiotics, and referrals as dependent variables and year of observation as independent variable.
Results
In general, incidence rates of acute otitis media, serous otitis, sinusitis, tonsillitis, and tonsil hypertrophy remained stable over the period 2002–2008. An increasing trend was observed for serous otitis media in children aged 0–4 years (RR = 1.04, p < 0.001). A decreasing trend was observed for sinusitis in children aged 5–11 and for tonsillitis in children aged 11–17 years (RR 0.99, p < 0.001 and RR 0.94, p < 0.001, respectively). Antibiotics were prescribed in 10–60% of the diagnoses. An increasing trend for antibiotic prescription was found for acute otitis media (beta = 0.07, p < 0.001), mainly on account of amoxicillin. Although antibiotic treatment of tonsillitis remained stable, pheneticillin prescriptions showed a downward trend (beta = −0.10, p < 0.001). First-choice antibiotics were prescribed in >80% of cases.
Conclusions
This study showed remarkably stable trends in incidence rates, antibiotic prescribing, and referrals of common ENT problems. The low proportion of antibiotic treatment in ENT problems did not show negative consequences.
doi:10.3109/02813432.2011.569140
PMCID: PMC3347949  PMID: 21591837
Antibiotics; children; ear; nose; and throat diseases; general practice; incidence; prescribing; referrals
14.  Profiling Dizziness in Older Primary Care Patients: An Empirical Study 
PLoS ONE  2011;6(1):e16481.
Background
The diagnostic approach to dizzy, older patients is not straightforward as many organ systems can be involved and evidence for diagnostic strategies is lacking. A first differentiation in diagnostic subtypes or profiles may guide the diagnostic process of dizziness and can serve as a classification system in future research. In the literature this has been done, but based on pathophysiological reasoning only.
Objective
To establish a classification of diagnostic profiles of dizziness based on empirical data.
Design
Cross-sectional study.
Participants and Setting
417 consecutive patients of 65 years and older presenting with dizziness to 45 primary care physicians in the Netherlands from July 2006 to January 2008.
Methods
We performed tests, including patient history, and physical and additional examination, previously selected by an international expert panel and based on an earlier systematic review. We used the results of these tests in a principal component analysis for exploration, data-reduction and finally differentiation into diagnostic dizziness profiles.
Results
Demographic data and the results of the tests yielded 221 variables, of which 49 contributed to the classification of dizziness into six diagnostic profiles, that may be named as follows: “frailty”, “psychological”, “cardiovascular”, “presyncope”, “non-specific dizziness” and “ENT”. These explained 32% of the variance.
Conclusions
Empirically identified components classify dizziness into six profiles. This classification takes into account the heterogeneity and multicausality of dizziness and may serve as starting point for research on diagnostic strategies and can be a first step in an evidence based diagnostic approach of dizzy older patients.
doi:10.1371/journal.pone.0016481
PMCID: PMC3031582  PMID: 21304984
15.  Influenza A(H1N1) Oseltamivir Resistant Viruses in the Netherlands During the Winter 2007/2008 
The Open Virology Journal  2011;5:154-162.
Background:
Antiviral susceptibility surveillance in the Netherlands was intensified after the first reports about the emergence of influenza A(H1N1) oseltamivir resistant viruses in Norway in January, 2008.
Methods:
Within the existing influenza surveillance an additional questionnaire study was performed to retrospectively assess possible risk factors and establish clinical outcome of all patients with influenza virus A(H1N1) positive specimens. To discriminate resistant and sensitive viruses, fifty percent inhibitory concentrations for the neuramidase inhibitors oseltamivir and zanamivir were determined in a neuraminidase inhibition assay. Mutations previously associated with resistance to neuramidase inhibitors and M2 blockers (amantadine and rimantadine) were searched for by nucleotide sequencing of neuraminidase and M2 genes respectively.
Results:
Among 171 patients infected with A(H1N1) viruses an overall prevalence of oseltamivir resistance of 27% (95% CI: 20-34%) was found. None of influenza A(H1N1) oseltamivir resistant viruses tested was resistant against amantadine or zanamivir. Patient characteristics, underlying conditions, influenza vaccination, symptoms, complications, and exposure to oseltamivir and other antivirals did not differ significantly between patients infected with resistant and sensitive A(H1N1) viruses.
Conclusion:
In 2007/2008 a large proportion of influenza A(H1N1) viruses resistant to oseltamivir was detected. There were no clinical differences between patients infected with resistant and sensitive A(H1N1) viruses. Continuous monitoring of the antiviral drug sensitivity profile of influenza viruses is justified, preferably using the existing sentinel surveillance, however, complemented with data from the more severe end of the clinical spectrum. In order to act timely on emergencies of public health importance we suggest setting up a surveillance system that can guarantee rapid access to the latter.
doi:10.2174/1874357901105010154
PMCID: PMC3249654  PMID: 22253652
Drug resistance; Viral; Epidemiology; Influenza A virus; H1N1 subtype; Oseltamivir; Signs and symptoms; Surveillance; Netherlands; Virology.
16.  Low hospital admission rates for respiratory diseases in children 
BMC Family Practice  2010;11:76.
Background
Population-based data on hospital admissions for children aged 0-17 years concerning all respiratory diseases are scarce. This study examined hospital admissions in relation to the preceding consultations in general practice in this age group.
Methods
Data on children aged 0-17 years with respiratory diseases included in the Second Dutch National Survey of General Practice (DNSGP-2) were linked to all hospital admissions in the Dutch National Medical Registration. Admission rates for respiratory diseases were calculated. Data were analysed using multivariate logistic regression.
Results
Of all 79,272 children within the DNSGP-2, 1.8% were admitted to hospital for any respiratory diagnosis. The highest admission rates per 1000 children were for chronic disease of tonsils and adenoids (12.9); pneumonia and influenza (0.97); and asthma (0.92). Children aged 0-4 years and boys were admitted more frequently. Of children with asthma, 2.3% were admitted for respiratory diseases. For asthma, admission rates varied by urbanisation level: 0.47/1000 children/year in cities with ≤ 30,000 inhabitants, 1.12 for cities with ≥ 50,000 inhabitants, and 1.73 for the three largest cities (p = 0.002). Multivariate logistic regression showed that within two weeks after a GP consultation, younger age (OR 0.81, 95% CI 0.76-0.88) and more severe respiratory diseases (5.55, 95% CI 2.99-8.11) predicted hospital admission.
Conclusions
Children in the general population with respiratory diseases (especially asthma) had very low hospital admission rates. In urban regions children were more frequently admitted due to respiratory morbidity. For effectiveness studies in a primary care setting, hospital admission rates should not be used as quality end-point.
doi:10.1186/1471-2296-11-76
PMCID: PMC2958964  PMID: 20932339
17.  Dizziness reported by elderly patients in family practice: prevalence, incidence, and clinical characteristics 
BMC Family Practice  2010;11:2.
Background
Although dizziness in elderly patients is very common in family practice, most prevalence studies on dizziness are community-based and include a study population that is not representative of family practice. The aim of this study was to investigate the prevalence and incidence of dizziness reported by elderly patients in family practice, to describe their final diagnoses as recorded by the family physician, and to compare the clinical characteristics of dizzy patients with those of non-dizzy patients.
Methods
Data were obtained from the Second Dutch National Survey of General Practice, a prospective registration study which took place over a 12-month period in 2001. We developed a search strategy consisting of 15 truncated search terms (based on Dutch synonyms for dizziness), and identified all patients aged 65 or older who visited their family physician because of dizziness (N = 3,990). We used the mid-time population as denominator to calculate the prevalence and incidence, and for group comparisons we used the Student's t and Chi-square test, and logistic regression analysis.
Results
The one-year prevalence of dizziness in family practice in patients aged 65 or older was 8.3%, it was higher in women than in men, and it increased with age. In patients aged 85 or older the prevalence was similar for men and women. The incidence of dizziness was 47.1 per 1000 person-years. For 39% of the dizzy patients the family physicians did not specify a diagnosis, and recorded a symptom diagnosis as the final diagnosis. Living alone, lower level of education, pre-existing cerebrovascular disease, and pre-existing hypertension were independently associated with dizziness.
Conclusions
Dizziness in family practice patients increases with age. It is more common in women than in men, but this gender difference disappears in the very old. Because a large proportion of dizzy elderly patients in family practice remains undiagnosed, it would be worthwhile to carry out more diagnostic research on dizziness in a family practice setting.
doi:10.1186/1471-2296-11-2
PMCID: PMC2817676  PMID: 20064231
18.  The usefulness of a free self-test for screening albuminuria in the general population: a cross-sectional survey 
BMC Public Health  2009;9:381.
Background
In this study we evaluated the usefulness of a free self-test for screening albuminuria in the general population.
Methods
Dutch adults were invited by the Dutch Kidney Foundation to order a free albuminuria self-test, consisting of three semi quantitative dipstick tests, via the Internet. Results were classified in negative, low-positive and high-positive. In case of a positive test result, the tester was recommended to visit a GP for supplementary examination and/or treatment. Participants of the programme were sent a questionnaire for evaluation by e-mail eight weeks after receiving the self-test.
Results
During the first 30 days of the self-test programme, 996,927 self-tests were ordered. In total, 71,714 participants completed the questionnaire: 79% had a negative test result and 21% had a positive test result (20% low-positive and 1% high-positive). Of the positive testers, 25% visited a GP after testing for albuminuria. Among the 3,983 participants who visited a GP, 193 new diseases were detected: 25 chronic renal failure, 152 hypertension and 31 diabetes mellitus.
Conclusion
Using a free self-test for screening albuminuria in the general population resulted in a large response and a number of newly detected diseases. However, we found a very high percentage of positive testers of which probably a large part is false positive. Furthermore, only a small part of the positive testers visited a GP for additional examination and/or treatment. The efficiency of such a campaign could be increased by embedding the testing in health care to reduce the number of false-positive results and to ensure follow-up and treatment in case of a positive test result.
doi:10.1186/1471-2458-9-381
PMCID: PMC2767353  PMID: 19818129
19.  Upper gastrointestinal symptoms, psychosocial co-morbidity and health care seeking in general practice: population based case control study 
BMC Family Practice  2009;10:63.
Background
The pathophysiology of upper gastrointestinal (GI) symptoms is still poorly understood. Psychological symptoms were found to be more common in patients with functional gastrointestinal complaints, but it is debated whether they are primarily linked to GI symptoms or rather represent motivations for health-care seeking. Purpose of our study was to compare co-morbidity, in particular psychological and social problems, between patients with and without upper GI symptoms. In addition, we investigated whether the prevalence of psychological and social problems is part of a broader pattern of illness related health care use.
Methods
Population based case control study based on the second Dutch National Survey of general practice (conducted in 2001). Cases (adults visiting their primary care physician (PCP) with upper GI symptoms) and controls (individuals not having any of these complaints), matched for gender, age, PCP-practice and ethnicity were compared. Main outcome measures were contact frequency, prevalence of somatic as well as psychosocial diagnoses, prescription rate of (psycho)pharmacological agents, and referral rates. Data were analyzed using odds ratios, the Chi square test as well as multivariable logistic regression analysis.
Results
Data from 13,389 patients with upper GI symptoms and 13,389 control patients were analyzed. Patients with upper GI symptoms visited their PCP twice as frequently as controls (8.6 vs 4.4 times/year). Patients with upper GI symptoms presented not only more psychological and social problems, but also more other health problems to their PCP (odds ratios (ORs) ranging from 1.37 to 3.45). Patients with upper GI symptoms more frequently used drugs of any ATC-class (ORs ranging from 1.39 to 2.90), including psychotropic agents. The observed differences were less pronounced when we adjusted for non-attending control patients. In multivariate regression analysis, contact frequency and not psychological or social co-morbidity was strongest associated with patients suffering from upper GI symptoms.
Conclusion
Patients with upper GI symptoms visit their PCP more frequently for problems of any organ system, including psychosocial problems. The relationship between upper GI symptoms and psychological problems is equivocal and may reflect increased health care demands in general.
doi:10.1186/1471-2296-10-63
PMCID: PMC2749014  PMID: 19740413
20.  Characteristics of children consulting for cough, sore throat, or earache 
Background
GPs are often consulted for respiratory tract symptoms in children.
Aim
To explore characteristics of children, their parents, and their GPs that are correlated with consulting a GP for cough, sore throat, or earache.
Design of study
Second Dutch National Survey of General Practice (DNSGP-2) with a health interview and an additional questionnaire.
Setting
Children aged 0–17 years registered with 122 GPs in Dutch general practice.
Method
Characteristics of patients and their GPs were derived from the DNSGP-2 health interview and a questionnaire, respectively. Characteristics of the illness symptoms and GP consultation were acquired by means of an additional questionnaire. Data were analysed using multivariate logistic regression.
Results
Of all children who completed the questionnaire, 550 reported cough, sore throat, or earache in the 2 weeks preceding the interview with 147 of them consulting their GP. Young children more frequently consulted the GP for respiratory symptoms, as did children with fever, longer duration of symptoms, those reporting their health to be ‘poor to good’, and living in an urban area. When parents were worried, and when a child or their parents were cued by someone else, the GP was also consulted more often. GP-related determinants were not associated with GP consultation by children.
Conclusion
This study emphasises the importance of establishing the reasons behind children with respiratory tract symptoms consulting their GP. When GPs are aware of possible determinants of the decision to consult a GP, more appropriate advice and reassurance can be given regarding these respiratory symptoms, which are generally self-limiting.
doi:10.3399/bjgp08X279751
PMCID: PMC2277110  PMID: 18387228
children; consultation; family practice; respiratory tract infections
21.  Development of a diagnostic protocol for dizziness in elderly patients in general practice: a Delphi procedure 
BMC Family Practice  2009;10:12.
Background
Dizziness in general practice is very common, especially in elderly patients. The empirical evidence for diagnostic tests in the evaluation of dizziness is scarce. Aim of our study was to determine which set of diagnostic tests should be part of a diagnostic protocol for evaluating dizziness in elderly patients in general practice.
Methods
We conducted a Delphi procedure with a panel of 16 national and international experts of all relevant medical specialities in the field of dizziness. A selection of 36 diagnostic tests, based on a systematic review and practice guidelines, was presented to the panel. Each test was described extensively, and data on test characteristics and methodological quality (assessed with the Quality Assessment of Diagnostic Accuracy Studies, QUADAS) were presented. The threshold for in- or exclusion of a diagnostic test was set at an agreement of 70%.
Results
During three rounds 21 diagnostic tests were selected, concerning patient history (4 items), physical examination (11 items), and additional tests (6 items). Five tests were excluded, although they are recommended by existing practice guidelines on dizziness. Two tests were included, although several practice guidelines question their diagnostic value. Two more tests were included that have never been recommended by practice guidelines on dizziness.
Conclusion
In this study we successfully combined empirical evidence with expert opinion for the development of a set of diagnostic tests for evaluating dizziness in elderly patients. This comprehensive set of tests will be evaluated in a cross-sectional diagnostic study.
doi:10.1186/1471-2296-10-12
PMCID: PMC2660288  PMID: 19200395
22.  Inter-practice variation in diagnosing hypertension and diabetes mellitus: a cross-sectional study in general practice 
BMC Family Practice  2009;10:6.
Background
Previous studies of inter-practice variation of the prevalence of hypertension and diabetes mellitus showed wide variations between practices. However, in these studies inter-practice variation was calculated without controlling for clustering of patients within practices and without adjusting for patient and practice characteristics. Therefore, in the present study inter-practice variation of diagnosed hypertension and diabetes mellitus prevalence rates was calculated by 1) using a multi-level design and 2) adjusting for patient and practice characteristics.
Methods
Data were used from the Netherlands Information Network of General Practice (LINH) in 2004. Of all 168.045 registered patients, the presence of hypertension, diabetes mellitus and all available ICPC coded symptoms and diseases related to hypertension and diabetes, were determined. Also, the characteristics of practices were used in the analyses. Multilevel logistic regression analyses were performed.
Results
The 95% prevalence range for the practices for the prevalence of diagnosed hypertension and diabetes mellitus was 66.3 to 181.7 per 1000 patients and 22.2 to 65.8 per 1000 patients, respectively, after adjustment for patient and practice characteristics. The presence of hypertension and diabetes was best predicted by patient characteristics. The most important predictors of hypertension were obesity (OR = 3.5), presence of a lipid disorder (OR = 3.0), and diabetes mellitus (OR = 2.6), whereas the presence of diabetes mellitus was particularly predicted by retinopathy (OR = 8.5), lipid disorders (OR = 2.8) and hypertension (OR = 2.7).
Conclusion
Although not the optimal case-mix could be used in this study, we conclude that even after adjustment for patient (demographic variables and risk factors for hypertension and diabetes mellitus) and practice characteristics (practice size and presence of a practice nurse), there is a wide difference between general practices in the prevalence rates of diagnosed hypertension and diabetes mellitus.
doi:10.1186/1471-2296-10-6
PMCID: PMC2632987  PMID: 19159455
23.  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
24.  Recently enlisted patients in general practice use more health care resources 
BMC Family Practice  2007;8:64.
Background
The continuity of care is one of the cornerstones of general practice. General practitioners find personal relationships with their patients important as they enable them to provide a higher quality of care. A long-lasting relationship with patients is assumed to be a prior condition for attaining this high quality. We studied the differences in use of care between recently enlisted patients and those patients who have been enlisted for a longer period.
Methods
104 general practices in the Netherlands participated the study. We performed a retrospective cohort study in which patients who have been enlisted for less than 1 year (n = 10,102) were matched for age, sex and health insurance with patients who have been enlisted for longer in the same general practice. The two cohorts were compared with regard to the number of contacts with the general practice, diagnoses, rate of prescribing, and the referral rate in a year. These variables were chosen as indicators of differences in the use of care.
Results
In the year following their enlistment, a higher percentage of recently enlisted patients had at least one contact with the practice, received a prescription or was referred. They also had a higher probability of receiving a prescription for an antibiotic. Furthermore, they had a higher mean number of contacts and referrals, but not a higher mean number of prescriptions.
Conclusion
Recently enlisted patients used more health care resources in the first year after their enlistment compared to patients enlisted longer. This could not be explained by differences in health.
doi:10.1186/1471-2296-8-64
PMCID: PMC2235863  PMID: 18047642
25.  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

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