250 research outputs found
Critiquing based on computer-stored medical records
The purpose of this study was the creation of a model for critiquing based on
data obtained from computer-stored medical records. The underlying
assumption is that data obtained from automated medical records can be used
to generate a medically relevant critique. To validate our ideas, we developed
a system, HyperCritic, that critiques the decision making of general practitioners
(GPs) caring for patients with hypertensio
Analysis of the practice guidelines of the Dutch College of General Practitioners with respect to the use of blood tests
OBJECTIVE: To determine the consistency among the practice guidelines of
the Dutch College of General Practitioners with respect to the use of
blood tests. METHODS: The authors evaluated 64 practice guidelines of the
Dutch College of General Practitioners. For each guideline, they analyzed
each sentence that contained a reference to a blood test to determine the
clinical situation in which the test should be performed (the indication)
and to determine the tests that should be performed in that situation (the
recommended test). An incomplete recommendation refers to a guideline that
mentioned a blood test but did not identify the indication for that test.
An inconsistency refers to the situation in which one guideline
recommended a certain test for a given indication whereas another
guideline mentioned the same indication but did not recommend the same
test. RESULTS: Twenty-seven practice guidelines mentioned blood tests. Of
these, three explicitly recommended not to request blood tests. Five
guidelines contained incomplete recommendations, and the authors
encountered two inconsistencies among the guidelines. Twenty-three
guidelines mentioned blood tests and allowed the authors to identify
indications and recommended tests. CONCLUSION: The identification of
indications and recommended tests allows evaluation of consistency among
practice guidelines. Although some incomplete recommendations and
inconsistencies were discovered, the majority of the guidelines provide
clear and unambiguous recommendations for blood-test ordering in primary
care
Development and validation of a clinical prediction rule for acute appendicitis in children in primary care
BACKGROUND: Recognising acute appendicitis in children presenting with acute abdominal pain in primary care is challenging. General practitioners (GPs) may benefit from a clinical prediction rule.OBJECTIVES: To develop and validate a clinical prediction rule for acute appendicitis in children presenting with acute abdominal pain in primary care.METHODS: In a historical cohort study data was retrieved from GP electronic health records included in the Integrated Primary Care Information database. We assigned children aged 4-18 years presenting with acute abdominal pain (≤ 7 days) to development (2010-2012) and validation (2013-2016) cohorts, using acute appendicitis within six weeks as the outcome. Multiple logistic regression was used to develop a prediction model based on predictors with > 50% data availability derived from existing rules for secondary care. We performed internal and external temporal validation and derived a point score to stratify risk of appendicitis into three groups, i.e. low-risk, medium-risk and high-risk.RESULTS: The development and validation cohorts included 2,041 and 3,650 children, of whom 95 (4.6%) and 195 (5.3%) had acute appendicitis. The model included male sex, pain duration (<24, 24-48, > 48 h), nausea/vomiting, elevated temperature (≥ 37.3 °C), abnormal bowel sounds, right lower quadrant tenderness, and peritoneal irritation. Internal and temporal validation showed good discrimination (C-statistics: 0.93 and 0.90, respectively) and excellent calibration. In the three groups, the risks of acute appendicitis were 0.5%, 7.5%, and 41%.CONCLUSION: Combined with further testing in the medium-risk group, the prediction rule could improve clinical decision making and outcomes.</p
Cough due to ace inhibitors: A case control study using automated general practice data
Objectives: To determine the risk of coughing as an adverse reaction to ACE inhibitors under everyday circumstances in a large population, and to study whether this adverse effect was duration or dose dependent. Design: A population-based case-control study. Setting: Ten general practices of 14 Dutch general practitioners (GP), in which all consultations, morbidity and medical interventions, including drugs prescribed, were registered over the 18 month period from 1st September, 1992 to 1st March, 1994. Subjects: 1458 patients with incident coughing and up to four controls per case were obtained (total 4182 controls), matched for GP. All cases and controls were 20 years or older and had no record of respiratory infection, influenza, tuberculosis, asthma, chronic bronchitis, emphysema, congestive heart failure, sinusitis, laryngitis, haemoptysis or respiratory neoplasms during the study period. Results: Cases were 2.1-times more likely than controls to have been exposed to ACE inhibitors (95% CI 1.5-3.1), but after adjustment the odds ratio was 1.4 (95% CI 0.9-2.1). The crude odds ratio for captopril was 1.3 (95% CI 0.7-2.5), for enalapril 2.6 (95% CI 1.6-4.2) and for lisinopril 2.0 (95% CI 0.5-9.3). The adjusted odds ratio for captopril was 0.9 (95% CI 0.4-1.7), for enalapril 1.7 (95% CI 1.03-2.8) and for lisinopril 1.7 (95% CI 0.4-7.9). For patients who had been on ACE inhibitor treatment for no longer than 2 months the odds ratio was 4.8 (95% CI 1.7-13.3). The odds ratio declined to 2.0 (95% CI 1.1-3.8) for those who had taken an ACE inhibitor for 2-6 months, and to 1.6 (95% CI 0.9-2.7) for those on ACE-inhibitors for more than 6 months. Conclusion: The risk of coughing was increased twofold among ACE inhibitor users, but the odds ratios were no longer significant after controlling for several confounding factors. The risk of developing cough due to ACE-inhibitors declines with the duration of treatment, possibly due to depletion of susceptible persons
Beta(2)-adrenergic receptor (ADRB2) gene polymorphisms and risk of COPD exacerbations : the Rotterdam study
The role of the beta(2)-adrenergic receptor (ADRB2) gene in patients with chronic obstructive pulmonary disease (COPD) is unclear. We investigated the association between ADRB2 variants and the risk of exacerbations in COPD patients treated with inhaled beta(2)-agonists. Within the Rotterdam Study, a population-based cohort study, we followed 1053 COPD patients until the first COPD exacerbation or end of follow-up and extracted rs1042713 (16Arg > Gly) and rs1042714 (27Gln > Glu) in ADRB2. Exposure to inhaled beta(2)-agonists was categorized into current, past, or non-use on the index date (date of COPD exacerbation for cases and on the same day of follow-up for controls). COPD exacerbations were defined as acute episodes of worsening symptoms requiring systemic corticosteroids and/or antibiotics (moderate exacerbations), or hospitalization (severe exacerbations). The associations between ADRB2 variants and COPD exacerbations were assessed using Cox proportional hazards models, adjusting for age, sex, use of inhaled corticosteroids, daily dose of beta(2)-agonists, and smoking. In current users of beta(2)-agonists, the risk of COPD exacerbation decreased by 30% (hazard ratio (HR); 0.70, 95% CI: 0.59-0.84) for each copy of the Arg allele of rs1042713 and by 20% (HR; 0.80, 95% CI: 0.69-0.94) for each copy of the Gln allele of rs1042714. Furthermore, current users carrying the Arg16/Gln27 haplotype had a significantly lower risk (HR; 0.70, 95% CI: 0.59-0.85) of COPD exacerbation compared to the Gly16/Glu27 haplotype. In conclusion, we observed that the Arg16/Gln27 haplotype in ADRB2 was associated with a reduced risk of COPD exacerbation in current users of inhaled beta(2)-agonists
Simulating an integrated critiquing system
OBJECTIVE: To investigate factors that determine the feasibility and
effectiveness of a critiquing system for asthma/COPD that will be
integrated with a general practitioner's (GP's) information system.
DESIGN: A simulation study. Four reviewers, playing the role of the
computer, generated critiquing comments and requests for additional
information on six electronic medical records of patients with
asthma/COPD. Three GPs who treated the patients, playing users, assessed
the comments and provided missing information when requested. The GPs were
asked why requested missing information was unavailable. The reviewers
reevaluated their comments after receiving requested missing information.
MEASUREMENTS: Descriptions of the number and nature of critiquing comments
and requests for missing information. Assessment by the GPs of the
critiquing comments in terms of agreement with each comment and judgment
of its relevance, both on a five-point scale. Analysis of causes for the
(un-)availability of requested missing information. Assessment of the
impact of missing information on the generation of critiquing comments.
RESULTS: Four reviewers provided 74 critiquing comments on 87 visits in
six medical records. Most were about prescriptions (n = 28) and the GPs'
workplans (n = 27). The GPs valued comments about diagnostics the most.
The correlation between the GPs' agreement and relevance scores was 0.65.
However, the GPs' agreements with prescription comments (complete
disagreement, 31.3%; disagreement, 20.0%; neutral, 13.8%; agreement,
17.5%; complete agreement, 17.5%) differed from their judgments of these
comments' relevance (completely irrelevant, 9.0%; irrelevant, 24.4%;
neutral, 24.4%; relevant, 32.1%; completely relevant, 10.3%). The GPs were
able to provide answers to 64% of the 90 requests for missing information.
Reasons available information had not been recorded were: the GPs had not
recorded the information explicitly; they had assumed it to be common
knowledge; it was available elsewhere in the record. Reasons information
was unavailable were: the decision had been made by another; the GP had
not recorded the information. The reviewers left 74% of the comments
unchanged after receiving requested missing information. CONCLUSION: Human
reviewers can generate comments based on information currently available
in electronic medical records of patients with asthma/COPD. The GPs valued
comments regarding the diagnostic process the most. Although they judged
prescription comments relevant, they often strongly disagreed with them, a
discrepancy that poses a challenge for the presentation of critiquing
comments for the future critiquing system. Requested additional
information that was provided by the GPs led to few changes. Therefore, as
system developers faced with the decision to build an integrated,
non-inquisitive or an inquisitive critiquing system, the authors choose
the former
Compliance of general practitioners with a guideline-based decision support system for ordering blood tests
BACKGROUND: Guidelines are viewed as a mechanism for disseminating a
rapidly increasing body of knowledge. We determined the compliance of
Dutch general practitioners with the recommendations for blood test
ordering as defined in the guidelines of the Dutch College of General
Practitioners. METHODS: We performed an audit of guideline compliance over
a 12-month period (March 1996 through February 1997). In an observational
study, a guideline-based decision support system for blood test ordering,
BloodLink, was integrated with the electronic patient records of 31
general practitioners practicing in 23 practices (16 solo). BloodLink
followed the guidelines of the Dutch College of General Practitioners. We
determined compliance by comparing the recommendations for test ordering
with the test(s) actually ordered. Compliance was expressed as the
percentage of order forms that followed the recommendations for test
ordering. RESULTS: Of 12 668 orders generated, 9091 (71%) used the
decision-support software rather than the paper order forms. Twelve
indications accounted for >80% of the 7346 order forms that selected a
testing indication in BloodLink. The most frequently used indication for
test ordering was "vague complaints" (2209 order forms; 30.1%). Of the
7346 order forms, 39% were compliant. The most frequent type of
noncompliance was the addition of tests. Six of the 12 tests most
frequently added to the order forms were supported by revisions of
guidelines that occurred within 3 years after the intervention period.
CONCLUSIONS: In general practice, noncompliance with guidelines is
predominantly caused by adding tests. We conclude that noncompliance with
a guideline seems to be partly caused by practitioners applying new
medical insight before it is incorporated in a revision of that guideline
Why are structured data different? Relating differences in data representation to the rationale of OpenSDE
OpenSDE is an application that supports clinicians with structured recording of narrative patient data to enable use of data in both clinical practice and research. OpenSDE is based on a rationale and requirements for structured data entry. In this study, we analyse the impact of the rationale and the requirements on data representation using OpenSDE. Three paediatricians transcribed 20 paper patient records using OpenSDE. The transcribed records were compared; the findings that were the same in content but differed in representation (e.g. recorded as free text instead of in a structured manner) were categorized in one of three categories of difference in representation. The transcribed records contained 1764 findings in total. The medical content of 302 of these findings was represented differently by at least one clinician and was thus included in this study. In OpenSDE, clinicians are free to determine the degree of detail at which patient data are described. This flexibility accounts for 87% of the differences in data representation. Thirteen per cent of the differences are due to clinicians interpreting and translating phrases from the source text and transcribing these to (different) concepts in OpenSDE. The differences in data representation largely result from initial design decisions for OpenSDE
Cholgate - a randomized controlled trial comparing the effect of automated and on-demand decision support on the management of cardiovascular disease factors in primary care
Automated and on-demand decision support systems integrated into an
electronic medical record have proven to be an effective implementation
strategy for guidelines. Cholgate is a randomized controlled trial
comparing the effect of automated and on-demand decision support on the
management of cardiovascular disease factors in primary care
Appendicitis in children with acute abdominal pain in primary care:a retrospective cohort study
BACKGROUND: General practitioners (GPs) face a diagnostic challenge when assessing acute abdominal pain in children. However, no information is available on the current diagnostic process or the diagnostic accuracy of history and physical examination in primary care settings. OBJECTIVE: To describe the diagnostic process for acute abdominal pain among children in primary care, focusing on appendicitis, and to assess the diagnostic accuracy of individual clinical features. METHODS: A retrospective cohort study in Dutch primary care, using the Integrated Primary Care Information database. Children aged 4-18 years were included if they had no history of appendicitis and presented with acute abdominal pain during 2010-2016. We evaluated GP management and the diagnostic accuracy of clinical features for appendicitis. Pre- and post-test probabilities were calculated for each clinical feature and compared with the probability of appendicitis after GP assessment. RESULTS: Out of 5691 children, 944 (16.6%) were referred and 291 (5.1%) had appendicitis, of whom 55 (18.9%) were initially misdiagnosed. The pre-test probability (i.e. of appendicitis in evaluated children) varied from 3% (rigidity) to 28% (migratory pain). Concerning post-test probabilities, positive values for rebound pain (32.1%) and guarding (35.8%) and the negative value for right lower quadrant tenderness (0.6%) were superior to overall GP assessment (29.6% and 1.1%, respectively). CONCLUSIONS: GP assessment will miss almost one-fifth of children with appendicitis at their first presentation, and about two-third of GP referrals will be negative. The presence of specific signs can increase or decrease the likelihood of appendicitis, emphasising the importance of a physical examination
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