148 research outputs found
Primary prevention of cardiovascular diseases: a cost study in family practices
Background: Considering the scarcity of health care resources and the high costs associated with cardiovascular diseases, we investigated the spending on cardiovascular primary preventive activities and the prescribing behaviour of primary preventive cardiovascular medication (PPCM) in Dutch family practices (FPs). Methods. A mixed methods design was used, which consisted of a questionnaire (n = 80 FPs), video recordings of hypertension- or cholesterol-related general practitioner visits (n = 56), and the database of Netherlands Information Network of General Practic
Increased incidence of kidney diseases in general practice after a nationwide albuminuria self-test program
<p>Abstract</p> <p>Background</p> <p>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.</p> <p>Methods</p> <p>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.</p> <p>Results</p> <p>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)).</p> <p>Conclusions</p> <p>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.</p
Inter-practice variation in diagnosing hypertension and diabetes mellitus: a cross-sectional study in general practice
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 mellitu
Vitamin G: effects of green space on health, well-being, and social safety
BACKGROUND: Looking out on and being in the green elements of the landscape around us seem to affect health, well-being and feelings of social safety. This article discusses the design of a research program on the effects of green space in the living environment on health, well-being and social safety. METHODS/DESIGN: The program consists of three projects at three different scales: at a macro scale using data on the Netherlands as a whole, at an intermediate scale looking into the specific effect of green space in the urban environment, and at micro scale investigating the effects of allotment gardens. The projects are observational studies, combining existing data on land use and health interview survey data, and collecting new data through questionnaires and interviews. Multilevel analysis and GIS techniques will be used to analyze the data. DISCUSSION: Previous (experimental) research in environmental psychology has shown that a natural environment has a positive effect on well-being through restoration of stress and attentional fatigue. Descriptive epidemiological research has shown a positive relationship between the amount of green space in the living environment and physical and mental health and longevity. The program has three aims. First, to document the relationship between the amount and type of green space in people's living environment and their health, well-being, and feelings of safety. Second, to investigate the mechanisms behind this relationship. Mechanisms relate to exposure (leading to stress reduction and attention restoration), healthy behavior and social integration, and selection. Third, to translate the results into policy on the crossroads of spatial planning, public health, and safety. Strong points of our program are: we study several interrelated dependent variables, in different ordinary settings (as opposed to experimental or extreme settings), focusing on different target groups, using appropriate multilevel methods
Is the prevalence of psychiatric disorders associated with urbanization?
Objectives In many countries, the total rate of psychiatric disorders tends to be higher in urban areas than in rural areas. The relevance of this phenomenon is that it may help in identifying environmental factors that are important in the pathogenesis of mental disorders. Moreover, urban preponderance suggests that the allocation of funds and services should take urbanization levels into account. Method The Netherlands Mental Health Survey and Incidence Study (NEMESIS) used the Composite International Diagnostic Interview (CIDI) to determine the prevalence of DSM-III-R disorders in a sample of 7,076 people aged 18–64. The sample was representative of the population as a whole. The study population was assigned to five urbanization categories defined at the level of municipalities. The association between urbanization and 12-month prevalence rates of psychiatric disorders was studied using logistic regression taking several confounders into account. Results The prevalence of psychiatric disorders gradually increased over five levels of urbanization. This pattern remained after adjustment for a range of confounders. Comorbidity rates also increased with level of urbanization. Conclusion This study confirms that psychiatric disorders are more common and more complex in more urbanized areas. This should be reflected in service allocation and may help in identifying environmental factors of importance for the aetiology of mental disorders. j Key words population survey – psychiatric epidemiology – mental disorders – urbanizatio
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
Determinants of the range of drugs prescribed in general practice: a cross-sectional analysis
Background: Current health policies assume that prescribing is more efficient and rational when
general practitioners (GPs) work with a formulary or restricted drugs lists and thus with a limited
range of drugs. Therefore we studied determinants of the range of drugs prescribed by general
practitioners, distinguishing general GP-characteristics, characteristics of the practice setting,
characteristics of the patient population and information sources used by GPs.
Methods: Secondary analysis was carried out on data from the Second Dutch Survey in General
Practice. Data were available for 138 GPs working in 93 practices.
ATC-coded prescription data from electronic medical records, census data and data from GP/
practice questionnaires were analyzed with multilevel techniques.
Results: The average GP writes prescriptions for 233 different drugs, i.e. 30% of the available drugs
on the market within one year. There is considerable variation between ATC main groups and
subgroups and between GPs. GPs with larger patient lists, GPs with higher prescribing volumes and
GPs who frequently receive representatives from the pharmaceutical industry have a broader range
when controlled for other variables.
Conclusion: The range of drugs prescribed is a useful instrument for analysing GPs' prescribing
behaviour. It shows both variation between GPs and between therapeutic groups. Statistically
significant relationships found were in line with the hypotheses formulated, like the one concerning
the influence of the industry. Further research should be done into the relationship between the
range and quality of prescribing and the reasons why some GPs prescribe a greater number of
different drugs than others.
Do list size and remuneration affect GPs' decisions about how they provide consultations?
Background: Doctors' professional behaviour is influenced by the way they are paid. When GPs are paid per
item, i.e., on a fee-for-service basis (FFS), there is a clear relationship between workload and income: more work
means more money. In the case of capitation based payment, workload is not directly linked to income since the
fees per patient are fixed. In this study list size was considered as an indicator for workload and we investigated
how list size and remuneration affect GP decisions about how they provide consultations. The main objectives of
this study were to investigate a) how list size is related to consultation length, waiting time to get an appointment,
and the likelihood that GPs conduct home visits and b) to what extent the relationships between list size and
these three variables are affected by remuneration.
Methods: List size was used because this is an important determinant of objective workload. List size was
corrected for number of older patients and patients who lived in deprived areas. We focussed on three
dependent variables that we expected to be related to remuneration and list size: consultation length; waiting
time to get an appointment; and home visits. Data were derived from the second Dutch National Survey of
General Practice (DNSGP-2), carried out between 2000 and 2002. The data were collected using electronic
medical records, videotaped consultations and postal surveys. Multilevel regression analyses were performed to
assess the hypothesized relationships.
Results: Our results indicate that list size is negatively related to consultation length, especially among GPs with
relatively large lists. A correlation between list size and waiting time to get an appointment, and a correlation
between list size and the likelihood of a home visit were only found for GPs with small practices. These
correlations are modified by the proportion of patients for whom GPs receive capitation fees. Waiting times to
get an appointment tend to become shorter with increasing patient lists when there is a larger capitation
percentage. The likelihood that GPs will conduct home visit rises with increasing patient lists when the capitation
percentage is small.
Conclusion: Remuneration appears to affect GPs' decisions about how they provide consultations, especially
among GPs with relatively small patient lists. This role is, however, small compared to other factors such as
patient characteristics.
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.
Increased permeability-oedema and atelectasis in pulmonary dysfunction after trauma and surgery: a prospective cohort study
<p>Abstract</p> <p>Background</p> <p>Trauma and surgery may be complicated by pulmonary dysfunction, acute lung injury (ALI) and acute respiratory distress syndrome (ARDS), but the mechanisms are incompletely understood.</p> <p>Methods</p> <p>We evaluated lung capillary protein permeability non-invasively with help of the <sup>67</sup>Ga-transferrin pulmonary leak index (PLI) technique and extravascular lung water (EVLW) by the transpulmonary thermal-dye dilution technique in consecutive, mechanically ventilated patients in the intensive care unit within 24 h of direct, blunt thoracic trauma (n = 5, 2 with ARDS), and within 12 h of indirect trauma by transhiatal oesophagectomy (n = 8), abdominal surgery for cancer (n = 6) and bone surgery (n = 4). We studied transfusion history, haemodynamics, oxygenation and mechanics of the lungs. The lung injury score (LIS, 0–4) was calculated. Plain radiography was also done to judge densities and atelectasis.</p> <p>Results</p> <p>The PLI and EVLW were elevated above normal in 61 and 30% of patients, respectively, and the PLI directly related to the number of red cell concentrates given (r<sub>s </sub>= 0.69, P < 0.001), without group differences. Oxygenation, lung mechanics, radiographic densities and thus the LIS (1.0 [0.25–3.5]) did not relate to PLI and EVLW. However, groups differed in oxygenation and airway pressures and impaired oxygenation related to the number of radiographic quadrants with densities (r<sub>s </sub>= 0.55, P = 0.007). Thoracic trauma patients had a worse oxygenation requiring higher airway pressures and thus higher LIS than the other patient groups, unrelated to PLI and EVLW but attributable to a higher cardiac output and thereby venous admixture. Finally, patients with radiographic signs of atelectasis had more impaired oxygenation and more densities than those without.</p> <p>Conclusion</p> <p>The oxygenation defect and radiographic densities in mechanically ventilated patients with pulmonary dysfunction and ALI/ARDS after trauma and surgery are likely caused by atelectasis rather than by increased permeability-oedema related to red cell transfusion.</p
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