What part of the total care consumed by type 2 diabetes patients is directly related to diabetes? Implications for disease management programs

<p><strong>Background</strong>: 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.</p><p><strong>Research design and methods:</strong> 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.</p><p><strong>Results:</strong> On average 4.3 different disciplines of healthcare providers were involved in the care for diabetes patients. 96% 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.</p><p><strong>Conclusion:</strong> 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.</p

Associations between proximity to livestock farms, primary health care visits and self-reported symptoms

BACKGROUND: Living in a neighbourhood with a high density of livestock farms has been associated with adverse respiratory health effects, but less is known about healthcare utilisation. This study aimed at investigating the associations between livestock exposure and primary health care visits and self-reported symptoms. In addition, we examined the potentially confounding effect of distance from home to general practice. METHODS: Contact data between 2006 and 2009 were obtained from electronic medical records of 54,777 persons registered within 16 general practices in an area with a high density of livestock farms in the Netherlands. Data on self-reported symptoms were used from a cross-sectional sample of 531 patients in 2010. Livestock presence in a 500 m radius from home was computed using Geographic Information System data. RESULTS: In general, livestock exposure was associated with fewer contacts and self-reported symptoms for respiratory and other conditions. The number of poultry within 500 m was positively associated with the number of contacts. A longer distance to general practice was associated with fewer contacts, but did not confound associations. CONCLUSIONS: People living close to livestock farms less often see their general practitioner and report symptoms

Trends in sexually transmitted infections in the Netherlands, combining surveillance data from general practices and sexually transmitted infection centers

<p>Abstract</p> <p>Background</p> <p>Sexually transmitted infections (STI) care in the Netherlands is primarily provided by general practitioners (GPs) and specialized STI centers. STI surveillance is based on data from STI centers, which show increasing numbers of clients. Data from a GP morbidity surveillance network were used to investigate the distribution in the provision of STI care and the usefulness of GP data in surveillance.</p> <p>Methods</p> <p>Data on STI-related episodes and STI diagnoses based on ICPC codes and, for chlamydia, prescriptions, were obtained from GP electronic medical records (EMRs) of the GP network and compared to data from STI centers from 2002 to 2007. Incidence rates were estimated for the total population in the Netherlands.</p> <p>Results</p> <p>The incidence of STI-consultations and -diagnoses increased substantially in recent years, both at GPs and STI centers. The increase in consultations was larger than the increase in diagnoses; Chlamydia incidence rose especially at STI centers. GPs were responsible for 70% of STI-related episodes and 80-85% of STI diagnoses. STI centers attract relatively younger and more often male STI-patients than GPs. Symptomatic STIs like <it>Herpes genitalis </it>and genital warts were more frequently diagnosed at GPs and chlamydia, gonorrhea and syphilis at STI centers.</p> <p>Conclusions</p> <p>GPs fulfill an important role in STI care, complementary to STI centers. Case definitions of STI could be improved, particularly by including laboratory results in EMRs. The contribution of primary care is often overlooked in STI health care. Including estimates from GP EMRs can improve the surveillance of STIs.</p

Minor surgery in general practice and effects on referrals to hospital care: Observational study

<p>Abstract</p> <p>Background</p> <p>Strengthening primary care is the focus of many countries, as national healthcare systems with a strong primary care sector tend to have lower healthcare costs. However, it is unknown to what extent general practitioners (GPs) that perform more services generate fewer hospital referrals. The objective of this study was to examine the association between the number of surgical interventions and hospital referrals.</p> <p>Methods</p> <p>Data were derived from electronic medical records of 48 practices that participated in the Netherlands Information Network of General Practice (LINH) in 2006-2007. For each care-episode of benign neoplasm skin/nevus, sebaceous cyst or laceration/cut it was determined whether the patient was referred to a medical specialist and/or minor surgery was performed. Multilevel multinomial regression analyses were used to determine the relation between minor surgery and hospital referrals on the level of the GP-practice.</p> <p>Results</p> <p>Referral rates differed between diagnoses, with 1.0% of referrals for a laceration/cut, 8.2% for a sebaceous cyst and 10.2% for benign neoplasm skin/nevus. The GP practices performed minor surgery for a laceration/cut in 8.9% (SD:14.6) of the care-episodes, for a benign neoplasm skin/nevus in 27.4% (SD:14.4) of cases and for a sebaceous cyst in 26.4% (SD:13.8). GP practices that performed more minor surgery interventions had a lower referral rate for patients with a laceration/cut (-0.38; 95%CI:-0.60- -0.11) and those with a sebaceous cyst (-0.42; 95%CI:-0.63- -0.16), but not for people with benign neoplasm skin/nevus (-0.26; 95%CI:-0.51-0.03). However, the absolute difference in referral rate appeared to be relevant only for sebaceous cysts.</p> <p>Conclusions</p> <p>The effects of minor surgery vary between diagnoses. Minor surgery in general practice appears to be a substitute for specialist medical care only in relation to sebaceous cysts. Measures to stimulate minor surgery for sebaceous cysts may induce substitution.</p

Primary care nurses: effects on secondary care referrals for diabetes

Background: Primary care nurses play an important role in diabetes care, and were introduced in GP-practice partly to shift care from hospital to primary care. The aim of this study was to assess whether the referral rate for hospital treatment for diabetes type II (T2DM) patients has changed with the introduction of primary care nurses, and whether these changes were related to the number of diabetes-related contacts in a general practice. Methods: Healthcare utilisation was assessed for a period of 365 days for 301 newly diagnosed and 2124 known T2DM patients in 2004 and 450 and 3226 patients in 2006 from general practices that participated in the Netherlands Information Network of General Practice (LINH). Multilevel logistic and linear regression analyses were used to analyse the effect of the introduction of primary care nurses on referrals to internists, ophthalmologists and cardiologists and diabetes-related contact rate. Separate analyses were conducted for newly diagnosed and known T2DM patients. Results: Referrals to internists for newly diagnosed T2DM patients decreased between 2004 and 2006 (OR:0.44; 95%CI:0.22-0.87) in all practices. For known T2DM patients no overall decrease in referrals to internists was found, but practices with a primary care nurse had a lower trend (OR:0.59). The number of diabetes-related contacts did not differ between practices with and without primary care nurses. Cardiologists’ and ophthalmologists’ referral rate did not change. Conclusions: The introduction of primary care nurses seems to have led to a shift of care from internists to primary care for known diabetes patients, while the diabetes-related contact rate seem to have remained unchanged.

Multimorbidity and comorbidity in the Dutch population - data from general practices

<p>Abstract</p> <p>Background</p> <p>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.</p> <p>Methods</p> <p>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.</p> <p>Results</p> <p>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.</p> <p>Conclusion</p> <p>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.</p

Child and adolescent mental health care in Dutch general practice: time trend analyses

Abstract Background Because most children and adolescents visit their general practitioner (GP) regularly, general practice is a useful setting in which child and adolescent mental health problems can be identified, treated or referred to specialised care. Measures to strengthen Dutch primary mental health care have stimulated cooperation between primary and secondary mental health care and have led to an increase in the provision of social workers and primary care psychologists. These measures may have affected GPs' roles in child and adolescent mental health care. This study aims to investigate the identification and treatment of child and adolescent mental health problems in general practice over a five-year period (2004-2008). Methods Data of patients aged 0-18 years (N ranging from 37716 to 73432) were derived from electronic medical records of 42-82 Dutch general practices. Time trends in the prevalence of recorded mental health problems, prescriptions for psychotropic medication, and referrals to primary and secondary mental health care were analysed. Results In 2008, 6.6% of children and 7.5% of adolescents were recorded as having mental health problems; 15.2% of these children and 29.4% of these adolescents were prescribed psychotropic medication; 18.9% of these children and 22.9% of these adolescents were referred, mainly to secondary mental health care. Between 2004 and 2008, the percentages of children (chi-square: 22.06; p Conclusions Although GPs' identification of mental health problems and referrals to primary mental health care have increased, most referrals are still made to secondary care. To further strengthen primary mental health care, effective short-term interventions for child and adolescent mental health problems that can be applied in general practice need to be developed.</p

Admissions for ambulatory care sensitive conditions: A national observational study in the general and COPD population

Background: Hospital admissions for ambulatory care sensitive conditions (ACSCs) may be prevented by effective ambulatory management and treatment. ACSC admissions is used as indicator for primary care quality and accessibility. However, debate continues to which extent these admissions are truly preventable. The aim of this study was to provide more objective insight into the preventability of ACSC admissions. Methods: Observational study using 2012-15 health insurer claim data of 13 182 602 Dutch insured inhabitants. Logistic multilevel regression analyses were conducted to investigate factors (ambulatory care and characteristics of inhabitants) possibly associated with ACSC admissions. Prior ambulatory care use was examined for patients with an ACSC contributing to the highest number of ACSC admissions: chronic obstructive pulmonary disease (COPD). Results: In 2014, 89.8 hospital admissions for ACSCs per 10 000 insured inhabitants were claimed. Percentage of inhabitants with ACSC admissions varied between general practices from 0.58-0.84%. ASCS admissions were hardly associated with ambulatory care. One month prior to admission, 97% of admitted COPD patients had at least one ambulatory care contact. Conclusions: Variation in ACSC admissions between general practitioners was observed, indicating that certain hospital admissions may be prevented. However, we found no indication that ACSC admissions were preventable, as no link was found with the provision of ambulatory care and ACSC admissions. This may indicate that this indicator is country and health care system specific. Before including ACSC admission as quality indicator of primary care in the Netherlands, more insight into the causes of variation is required