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1.  From concept to content: assessing the implementation fidelity of a chronic care model for frail, older people who live at home 
Background
Implementation fidelity, the degree to which a care program is implemented as intended, can influence program impact. Since results of trials that aim to implement comprehensive care programs for frail, older people have been conflicting, assessing implementation fidelity alongside these trials is essential to differentiate between flaws inherent to the program and implementation issues. This study demonstrates how a theory-based assessment of fidelity can increase insight in the implementation process of a complex intervention in primary elderly care.
Methods
The Geriatric Care Model was implemented among 35 primary care practices in the Netherlands. During home visits, practice nurses conducted a comprehensive geriatric assessment and wrote a tailored care plan. Multidisciplinary team consultations were organized with the aim to enhance the coordination between professionals caring for a single patient with complex needs. To assess fidelity, we identified 5 key intervention components and formulated corresponding research questions using Carroll’s framework for fidelity. Adherence (coverage, frequency, duration, content) was assessed per intervention component during and at the end of the intervention period. Two moderating factors (participant responsiveness and facilitation strategies) were assessed at the end of the intervention.
Results
Adherence to the geriatric assessments and care plans was high, but decreased over time. Adherence to multidisciplinary consultations was initially poor, but increased over time. We found that individual differences in adherence between practice nurses and primary care physicians were moderate, while differences in participant responsiveness (satisfaction, involvement) were more distinct. Nurses deviated from protocol due to contextual factors and personal work routines.
Conclusions
Adherence to the Geriatric Care Model was high for most of the essential intervention components. Study limitations include the limited number of assessed moderating factors. We argue that a longitudinal investigation of adherence per intervention component is essential for a complete understanding of the implementation process, but that such investigations may be complicated by practical and methodological challenges.
Trial registration
The Netherlands National Trial Register (NTR). Trial number: 2160.
doi:10.1186/s12913-014-0662-6
PMCID: PMC4312437  PMID: 25608876
Implementation fidelity; Comprehensive care model; Elderly care; Primary care; Chronic care model; Complex intervention
2.  The Ariadne principles: how to handle multimorbidity in primary care consultations 
BMC Medicine  2014;12(1):223.
Multimorbidity is a health issue mostly dealt with in primary care practice. As a result of their generalist and patient-centered approach, long-lasting relationships with patients, and responsibility for continuity and coordination of care, family physicians are particularly well placed to manage patients with multimorbidity. However, conflicts arising from the application of multiple disease oriented guidelines and the burden of diseases and treatments often make consultations challenging. To provide orientation in decision making in multimorbidity during primary care consultations, we developed guiding principles and named them after the Greek mythological figure Ariadne. For this purpose, we convened a two-day expert workshop accompanied by an international symposium in October 2012 in Frankfurt, Germany. Against the background of the current state of knowledge presented and discussed at the symposium, 19 experts from North America, Europe, and Australia identified the key issues of concern in the management of multimorbidity in primary care in panel and small group sessions and agreed upon making use of formal and informal consensus methods. The proposed preliminary principles were refined during a multistage feedback process and discussed using a case example. The sharing of realistic treatment goals by physicians and patients is at the core of the Ariadne principles. These result from i) a thorough interaction assessment of the patient’s conditions, treatments, constitution, and context; ii) the prioritization of health problems that take into account the patient’s preferences – his or her most and least desired outcomes; and iii) individualized management realizes the best options of care in diagnostics, treatment, and prevention to achieve the goals. Goal attainment is followed-up in accordance with a re-assessment in planned visits. The occurrence of new or changed conditions, such as an increase in severity, or a changed context may trigger the (re-)start of the process. Further work is needed on the implementation of the formulated principles, but they were recognized and appreciated as important by family physicians and primary care researchers.
Please see related article: http://www.biomedcentral.com/1741-7015/12/222.
Electronic supplementary material
The online version of this article (doi:10.1186/s12916-014-0223-1) contains supplementary material, which is available to authorized users.
doi:10.1186/s12916-014-0223-1
PMCID: PMC4259090  PMID: 25484244
Comorbidity; Decision making; General practice; Goal-oriented care; Multimorbidity; Patient-centered care; Patient care planning; Patient preference; Primary care
3.  Opti-Med: the effectiveness of optimised clinical medication reviews in older people with ‘geriatric giants’ in general practice; study protocol of a cluster randomised controlled trial 
BMC Geriatrics  2014;14(1):116.
Background
Inappropriate drug use has been identified as one of the most important problems affecting the quality of care in older people. Inappropriate drug use may increase the risk of the occurrence of ‘geriatric giants’ such as immobility, instability, incontinence and cognitive impairment. There are indications that clinical medication reviews (CMR) can reduce inappropriate drug use. However, CMRs have not yet been implemented at a large scale in primary care. An innovative medication review program in primary care will be developed which tackles the most important obstacles for a large scale implementation of CMRs. The aim of this study is to assess whether this CMR program is (cost-) effective compared with usual general practice care for older patients with geriatric symptoms with regard to quality of life and geriatric symptoms.
Methods
A cluster randomised controlled trial will be performed in 20 Dutch general practices including 500 patients. Patients of 65 years and older are eligible if they newly present with pre-specified geriatric symptoms in general practice and chronic use of at least one prescribed drug. GP practices will be stratified by practice size and randomly allocated to control (n = 10) or intervention group (n = 10). The intervention consists of CMRs which will be facilitated and prepared by an expert team consisting of a GP and a pharmacist. Primary outcome measures are patient’s quality of life and the presence of self-reported geriatric symptoms during a follow-up period of 6 months. Secondary outcomes are costs of healthcare utilisation, feasibility, number of drug related problems, medication adherence and satisfaction with medication.
Discussion
This study is expected to add evidence on the (cost-) effectiveness of an optimally facilitated, prepared and structured CMR in comparison with usual care in older patients who present a geriatric symptom to their GP. The strength of this study is that it will be conducted in daily clinical practice. This improves the possibilities to implement the CMRs in the primary care setting on a large scale.
Trial registration
Netherlands Trial register: NTR4264
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2318-14-116) contains supplementary material, which is available to authorized users.
doi:10.1186/1471-2318-14-116
PMCID: PMC4240827  PMID: 25407349
Clinical medication review; Geriatric giants; Cluster randomised controlled trial
4.  Primary care treatment guidelines for skin infections in Europe: congruence with antimicrobial resistance found in commensal Staphylococcus aureus in the community 
BMC Family Practice  2014;15(1):175.
Background
Over 90% of antibiotics for human use in Europe are prescribed in primary care. We assessed the congruence between primary care treatment guidelines for skin infections and commensal Staphylococcus aureus (S. aureus) antimicrobial resistance levels in community-dwelling persons.
Methods
The prevalence of antimicrobial resistance in S. aureus was analysed by taking nose swabs from healthy primary care patients in nine European countries (total N = 32,032). Primary care treatment guidelines for bacterial skin infections were interpreted with respect to these antimicrobial resistance patterns. First- and second-choice recommendations were assessed and considered congruent if resistance to the antibiotic did not exceed 20%.
Results
We included primary care treatment guidelines for impetigo, cellulitis, folliculitis and furuncle. Treatment recommendations in all countries were consistent: most of the first-choice recommendations were beta-lactams, both for children and adults. Antimicrobial resistance levels were low, except for penicillin (on average 73% resistance). Considerable variation in antimicrobial resistance levels was found between countries, with Sweden displaying the lowest levels and Spain the highest. In some countries resistance to penicillin and azithromycin was significantly higher in children (4-17 years) compared with adults.
Conclusions
Most of the first- and second-choice recommendations in the treatment guidelines for skin infections were congruent with commensal S. aureus antimicrobial resistance patterns in the community, except for two recommendations for penicillin. Given the variation in antimicrobial resistance levels between countries, age groups and health care settings, national data regarding antimicrobial resistance in the community should be taken into account when updating or developing primary care treatment guidelines.
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-014-0175-8) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-014-0175-8
PMCID: PMC4220054  PMID: 25413920
Antibiotic resistance; Treatment guidelines; Primary care; Skin infections
5.  Knowledge and acceptability of Chlamydia trachomatis screening among pregnant women and their partners; a cross-sectional study 
BMC Public Health  2014;14:704.
Background
Chlamydia trachomatis infections in pregnancy can cause maternal disease, adverse pregnancy outcomes and neonatal disease, which is why chlamydia screening during pregnancy has been advocated. The effectiveness of a screening program depends on the knowledge of health care professionals, women and partners and the acceptability for screening of the target population. We assessed the knowledge of chlamydia infection among pregnant women and their partners in the Netherlands, their attitudes towards testing, and their experiences of being offered a chlamydia test. In addition, we evaluated the association between participants’ background characteristics and knowledge of chlamydia.
Methods
Pregnant women aged ≤ 30 years and their partners (regardless of their age) attending one of the participating primary midwifery care practices in the Netherlands were invited to participate. All participants completed a questionnaire, pregnant women provided a vaginal swab and partners provided a urine sample to test for C. trachomatis.
Results
In total, 383 pregnant women and 282 partners participated in the study of whom 1.9% women and 2.6% partners tested chlamydia positive. Participants had high levels of awareness (92.8%) of chlamydial infection. They were knowledgeable about the risk of chlamydia infection; median knowledge score was 9.0 out of 12.0. Lower knowledge scores were found among partners (p-value <0.001), younger aged (p-value 0.02), non-western origin (p-value <0.001), low educational level (p-value <0.001), and no history of sexually transmitted infections (p-value <0.001). In total, 78% of respondents indicated that when pregnant women are tested for chlamydia, their partners should also be tested; 54% believed that all women should routinely be tested. Pregnant women more often indicated than partners that testing partners for chlamydial infection was not necessary (p-value <0.001). The majority of pregnant women (56.2%) and partners (59.2%) felt satisfied by being offered the test during antenatal care.
Conclusion
Pregnant women and their partners were knowledgeable about chlamydial infection, found testing, both pregnant women and their partners, for chlamydia acceptable and not stigmatizing.
doi:10.1186/1471-2458-14-704
PMCID: PMC4105044  PMID: 25011479
Chlamydia trachomatis; Prenatal care; Health knowledge; Attitudes; Experiences; Pregnancy
6.  Design of the INTEGRATE study: effectiveness and cost-effectiveness of a cardiometabolic risk assessment and treatment program integrated in primary care 
BMC Family Practice  2014;15:90.
Background
The increasing prevalence of cardiometabolic disease (CMD) in combination with an ageing population is a major public health problem. Early detection and management of individuals at risk for CMD is required to prevent future health problems with associated costs. General practice is the optimal health care setting to accomplish this goal. Prevention programs for identification and treatment of patients with an increased risk for CMD in primary care have been proven feasible. However, the effectiveness and cost-effectiveness have yet to be demonstrated. The ‘Personalized Prevention Approach for CardioMetabolic Risk’ (PPA CMR) is such a prevention program. The objective of the INTEGRATE study is to investigate the effectiveness and cost-effectiveness of PPA CMR, as well as to establish determinants for participation and compliance.
Methods
The INTEGRATE study is designed as a stepped-wedge randomized controlled trial with a waiting list control group. In approximately 40 general practices, all enlisted patients without CMD aged 45–70 years, are invited to participate in PPA CMR. After an online risk estimation, patients with a score above risk threshold are invited to the GP for additional measurements, detailed risk profiling and tailored treatment of risk factors through medication and/or lifestyle counseling. At baseline and after twelve months of follow-up lifestyle, health and work status of all participants are established with online questionnaires. Additionally after twelve months, we will determine health care utilization, costs of PPA CMR and compliance. Primary endpoints are the number of newly detected patients with CMD and changes in individual risk factors between the intervention and waiting list control group. Medical data will be extracted from the GPs’ electronic medical records. In order to assess factors related to participation, we will send questionnaires to non-participants and assess characteristics of participating practices. For all participants, additional demographic characteristics will be available through Statistics Netherlands.
Discussion
The INTEGRATE study will provide insight into the effectiveness and cost-effectiveness of PPA CMR as well as determinants for participation and compliance, which represents essential information to guide further large-scale implementation of primary prevention programs for CMD.
Trial registration number
NTR4277, The Netherlands National Trial Register, 26-11-2013.
doi:10.1186/1471-2296-15-90
PMCID: PMC4022539  PMID: 24884779
Cardiometabolic disease; Prevention; (Primary) screening; Non-participation; Primary care; Family practice; Effectiveness; Economic evaluation; RCT
7.  Living with diabetes: a group-based self-management support programme for T2DM patients in the early phases of illness and their partners, study protocol of a randomised controlled trial 
Background
The present article presents the protocol for a randomised controlled trial to test the effectiveness of a group-based self-management support programme for recently diagnosed type 2 diabetes mellitus (T2DM) patients (one to three years post-diagnosis) and their partners. The course aims to support T2DM patients and their partners in successfully integrating diabetes care into their daily lives and hereby enhance self-management and diabetes-specific health-related quality of life. The content of the course is based on the Common-Sense Model of Self-Regulation (CSM). Furthermore, principles from the Social Cognitive Theory (SCT) and social support theories are integrated.
Methods/Design
We aim to recruit 160 recently diagnosed T2DM patients and their partners from general practices in six different regions in the Netherlands. Patients need to be diagnosed with T2DM for one to three years and have to experience some degree of diabetes-related difficulties, as measured with a three-item screener. Participating patients and their partners are randomly allocated to the intervention or control condition. Participants in the intervention condition receive three monthly group sessions and a booster session three months later. Participants in the control condition receive a single information meeting. Data will be collected at baseline (T0), directly after the programme (T1) and six months post-programme (T2), including: self-management, diabetes-specific health-related quality of life, illness perceptions, attitudes, social support and empowerment. A three-level multilevel model will be used to compare change-scores between the conditions (intervention/control) on each outcome.
Discussion
Our study will be the first to determine whether a group-based support programme based on the CSM is effective in enhancing self-management and diabetes-specific health-related quality of life in recently diagnosed T2DM patients. The important role of patients’ partners in effective diabetes care is also acknowledged in the study.
Trial registration
Netherlands National Trial Register (NTR) NTR3302.
doi:10.1186/1472-6963-14-144
PMCID: PMC3977690  PMID: 24690511
Diabetes; Randomised controlled trial; Illness perceptions; Partner support; Self-management; Health-related quality of life
8.  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
10.  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
11.  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
12.  Observational study to assess pregnant women’s knowledge and behaviour to prevent toxoplasmosis, listeriosis and cytomegalovirus 
Background
Toxoplasmosis, listeriosis and cytomegalovirus (CMV) can negatively affect pregnancy outcomes, but can be prevented by simple precautions of pregnant women. Literature suggests that pregnant women are not always adequately informed by their care provider about preventable infectious diseases and most pregnant women have a low level of knowledge regarding these topics. There is not much information about the actual risk behaviour of pregnant women. The purpose of this study was to assess knowledge and risk behaviour related to toxoplasmosis, listeriosis and CMV infection prevention in pregnant women.
Methods
A cross-sectional survey among pregnant women from twenty midwifery practices across the Netherlands that participated in the DELIVER study, between October 2010 and December 2010. The questionnaire items covered respondents’ knowledge of preventive practices in general, risk behaviour, and sources of received information.
Results
Of the 1,097 respondents (response 66.0%), 75.3% had heard, read or seen information about toxoplasmosis, 61.7% about listeriosis and 12.5% about CMV. The majority reported having heard about these infections from their care providers or read about these in printed media or on the Internet. Respondents showed limited knowledge about preventive practices for toxoplasmosis, listeriosis or CMV infection. Regarding toxoplasmosis, risk behaviour was more prevalent among respondents who had a high level of education, had the Dutch nationality, did not take folic acid during their first trimester, and had ever worked in a children day-care setting. Regarding listeriosis, risk behaviour was more prevalent among respondents who where in their third trimester. Regarding CMV infections, risk behaviour was less prevalent among respondents who were in their third trimester of pregnancy.
Conclusion
Of the respondents, a substantial part did not have knowledge about preventive practices to avoid listeriosis, toxoplasmosis and CMV infections during pregnancy. Many pregnant women are appropriately avoiding risk behaviour, without knowing what they are avoiding. Advising pregnant women about behaviours and life-style habits to prevent infectious diseases remains important and information about preventive practices need to be complete and adequate. However, it may be less important to give pregnant women specific infectious diseases information. More attention towards CMV is necessary.
doi:10.1186/1471-2393-13-98
PMCID: PMC3644250  PMID: 23627427
Infectious diseases; Toxoplasmosis; Listeriosis; Cytomegalovirus; Prenatal health care providers; Pregnant women; Knowledge; Risk behaviour; Prevention
13.  Do pregnant women contact their general practitioner? A register-based comparison of healthcare utilisation of pregnant and non-pregnant women in general practice 
BMC Family Practice  2013;14:10.
Background
Midwives and obstetricians are the key providers of care during pregnancy and postpartum. Information about the consultations with a general practitioner (GP) during this period is generally lacking.
The aim of this study is to compare consultation rates, diagnoses and GP management of pregnant women with those of non-pregnant women.
Methods
Data were retrieved from the Netherlands Information Network of General Practice (LINH), a nationally representative register. This register holds longitudinal data on consultations, prescriptions and the referrals of all patients listed at 84 practices in the Netherlands in 2007–2009, including 15,123 pregnant women and 102,564 non-pregnant women in the same age-range (15 to 45 years). We compared consultation rates (including all contacts with the practice), diagnoses (ICPC-1 coded), medication prescriptions (coded according to the Anatomical Therapeutic Chemical classification system), and rate and type of referrals from the start of the pregnancy until six weeks postpartum (336 days).
Results
Pregnant women contacted their GP on average 3.6 times, compared to 2.2 times for non-pregnant women. The most frequently recorded diagnoses for pregnant women were ‘pregnancy’ and ‘cystitis/urinary infection’, and ‘cystitis/urinary infection’ and ‘general disease not otherwise specified’ for non-pregnant women. The mean number of prescribed medications was lower in pregnant women (2.1 against 4.4). For pregnant women, the most frequent referral indication concerned obstetric care, for non-pregnant women this concerned physiotherapy.
Conclusions
GP consultation rates in pregnancy and postpartum shows that GPs are important providers of care for pregnant women. Therefore, the involvement of GPs in collaborative care during pregnancy and postpartum should be reinforced.
doi:10.1186/1471-2296-14-10
PMCID: PMC3554585  PMID: 23324253
Primary health care; General practitioner; Pregnancy; Health services research; Prenatal care
14.  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
15.  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
16.  Utility of the first few100 approach during the 2009 influenza A(H1N1) pandemic in the Netherlands 
Background
To guide policy and control measures, decent scientific data are needed for a comprehensive assessment of epidemiological, clinical and virological characteristics of the First Few hundred (FF100) cases. We discuss the feasibility of the FF100 approach during the 2009 pandemic and the added value compared with alternative data sources available.
Methods
The pandemic preparedness plan enabled us to perform a case–control study, assessing patient characteristics and risk factors for experiencing symptomatic influenza A(H1N1)2009 infection and providing insight into transmission. We assessed to what extent timely and novel data were generated compared to other available data sources.
Results
In May-December 2009, a total of 68 cases and 48 controls were included in the study. Underlying non-respiratory diseases were significantly more common among cases compared to controls, while a protective effect was found for frequent hand washing. Seroconversion was found for 7/30 controls (23%), and persisting high titers for 4/30 controls (13%). The labour-intensive study design resulted in slow and restricted recruitment.
Conclusions
The findings of our case–control study gave new insights in transmission risks and possible interventions for improved control. Nevertheless, the FF100 approach lacked timeliness and power due to limited recruitment. For future pandemics we suggest pooling data from several countries, to enable collecting sufficient data in a relatively short period.
doi:10.1186/2047-2994-1-30
PMCID: PMC3511807  PMID: 22995284
17.  Multimorbidity and comorbidity in the Dutch population – data from general practices 
BMC Public Health  2012;12:715.
Background
Multimorbidity is increasingly recognized as a major public health challenge of modern societies. However, knowledge about the size of the population suffering from multimorbidity and the type of multimorbidity is scarce. The objective of this study was to present an overview of the prevalence of multimorbidity and comorbidity of chronic diseases in the Dutch population and to explore disease clustering and common comorbidities.
Methods
We used 7 years data (2002–2008) of a large Dutch representative network of general practices (212,902 patients). Multimorbidity was defined as having two or more out of 29 chronic diseases. The prevalence of multimorbidity was calculated for the total population and by sex and age group. For 10 prevalent diseases among patients of 55 years and older (N = 52,014) logistic regressions analyses were used to study disease clustering and descriptive analyses to explore common comorbid diseases.
Results
Multimorbidity of chronic diseases was found among 13% of the Dutch population and in 37% of those older than 55 years. Among patients over 55 years with a specific chronic disease more than two-thirds also had one or more other chronic diseases. Most disease pairs occurred more frequently than would be expected if diseases had been independent. Comorbidity was not limited to specific combinations of diseases; about 70% of those with a disease had one or more extra chronic diseases recorded which were not included in the top five of most common diseases.
Conclusion
Multimorbidity is common at all ages though increasing with age, with over two-thirds of those with chronic diseases and aged 55 years and older being recorded with multimorbidity. Comorbidity encompassed many different combinations of chronic diseases. Given the ageing population, multimorbidity and its consequences should be taken into account in the organization of care in order to avoid fragmented care, in medical research and healthcare policy.
doi:10.1186/1471-2458-12-715
PMCID: PMC3490727  PMID: 22935268
Multimorbidity; Comorbidity; Chronic disease; Epidemiology; Prevalence
18.  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
19.  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
20.  The appropriateness of prescribing antibiotics in the community in Europe: study design 
BMC Infectious Diseases  2011;11:293.
Background
Over 90% of all antibiotics in Europe are prescribed in primary care. It is important that antibiotics are prescribed that are likely to be effective; however, information about antibiotic resistance in the community is incomplete. The aim of our study is to investigate the appropriateness of antibiotic prescribing in primary care in Europe by collecting and combining patterns of antibiotic resistance patterns and antibiotic prescription patterns in primary care. We will also evaluate the appropriateness of national antibiotic prescription guidelines in relation to resistance patterns.
Methods/Design
Antibiotic resistance will be studied in an opportunistic sample from the community in nine European countries. Resistance data will be collected by taking a nose swab of persons (N = 4,000 per country) visiting a primary care practice for a non-infectious disease. Staphylococcus aureus and Streptococcus pneumoniae will be isolated and tested for resistance to a range of antibiotics in one central laboratory. Data on antibiotic prescriptions over the past 5 years will be extracted from the electronic medical records of General Practitioners (GPs). The results of the study will include the prevalence and resistance data of the two species and 5 years of antibiotic prescription data in nine European countries.
The odds of receiving an effective antibiotic in each country will be calculated as a measure for the appropriateness of prescribing. Multilevel analysis will be used to assess the appropriateness of prescribing. Relevant treatment guidelines of the nine participating countries will be evaluated using a standardized instrument and related to the resistance patterns in that country.
Discussion
This study will provide valuable and unique data concerning resistance patterns and prescription behaviour in primary care in nine European countries. It will provide evidence-based recommendations for antibiotic treatment guidelines that take resistance patterns into account which will be useful for both clinicians and policy makers. By improving antibiotic use we can move towards controlling the resistance problem globally.
doi:10.1186/1471-2334-11-293
PMCID: PMC3220649  PMID: 22032233
21.  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
22.  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
23.  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
24.  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
25.  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

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