Do practice characteristics explain differences in morbidity estimates between electronic health record based general practice registration networks?

Background

General practice based registration networks (GPRNs) provide information on population health derived from electronic health records (EHR). Morbidity estimates from different GPRNs reveal considerable, unexplained differences. Previous research showed that population characteristics could not explain this variation. In this study we investigate the influence of practice characteristics on the variation in incidence and prevalence figures between general practices and between GPRNs.

Methods

We analyzed the influence of eight practice characteristics, such as type of practice, percentage female general practitioners, and employment of a practice nurse, on the variation in morbidity estimates of twelve diseases between six Dutch GPRNs. We used multilevel logistic regression analysis and expressed the variation between practices and GPRNs in median odds ratios (MOR). Furthermore, we analyzed the influence of type of EHR software package and province within one large national GPRN.

Results

Hardly any practice characteristic showed an effect on morbidity estimates. Adjusting for the practice characteristics did also not alter the variation between practices or between GPRNs, as MORs remained stable. The EHR software package ‘Medicom’ and the province ‘Groningen’ showed significant effects on the prevalence figures of several diseases, but this hardly diminished the variation between practices.

Conclusion

Practice characteristics do not explain the differences in morbidity estimates between GPRNs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-014-0176-7) contains supplementary material, which is available to authorized users.

Multimorbidity of chronic diseases and health care utilization in general practice

Background

Multimorbidity is common among ageing populations and it affects the demand for health services. The objective of this study was to examine the relationship between multimorbidity (i.e. the number of diseases and specific combinations of diseases) and the use of general practice services in the Dutch population of 55 years and older.

Methods

Data on diagnosed chronic diseases, contacts (including face-to-face consultations, phone contacts, and home visits), drug prescription rates, and referral rates to specialised care were derived from the Netherlands Information Network of General Practice (LINH), limited to patients whose data were available from 2006 to 2008 (N = 32,583). Multimorbidity was defined as having two or more out of 28 chronic diseases. Multilevel analyses adjusted for age, gender, and clustering of patients in general practices were used to assess the association between multimorbidity and service utilization in 2008.

Results

Patients diagnosed with multiple chronic diseases had on average 18.3 contacts (95% CI 16.8 19.9) per year. This was significantly higher than patients with one chronic disease (11.7 contacts (10.8 12.6)) or without any (6.1 contacts (5.6 6.6)). A higher number of chronic diseases was associated with more contacts, more prescriptions, and more referrals to specialized care. However, the number of contacts per disease decreased with an increasing number of diseases; patients with a single disease had between 9 to 17 contacts a year and patients with five or more diseases had 5 or 6 contacts per disease per year. Contact rates for specific combinations of diseases were lower than what would be expected on the basis of contact rates of the separate diseases.

Conclusion

Multimorbidity is associated with increased health care utilization in general practice, yet the increase declines per additional disease. Still, with the expected rise in multimorbidity in the coming decades more extensive health resources are required.

Experienced continuity of care in patients at risk for depression in primary care

BACKGROUND

Existing studies about continuity of care focus on patients with a severe mental illness.

OBJECTIVES

Explore the level of experienced continuity of care of patients at risk for depression in primary care, and compare these to those of patients with heart failure.

METHODS

Explorative study comparing patients at risk for depression with chronic heart failure patients. Continuity of care was measured using a patient questionnaire and defined as ( 1 ) number of care providers contacted (personal continuity); ( 2 ) collaboration between care providers in general practice (team continuity) (six items, score 1-5); and ( 3 ) collaboration between GPs and care providers outside general practice (cross-boundary continuity) (four items, score 1-5).

RESULTS

Most patients at risk for depression contacted several care providers throughout the care spectrum in the past year. They experienced high team continuity and low cross-boundary continuity. In their general practice, they contacted more different care providers for their illness than heart failure patients did (P < 0.01). Patients at risk for depression experienced a slightly better collaboration between these care providers in their practice: a mean score of 4.3 per item compared to 4.0 for heart failure patients (P = 0.03). The perceived cross-boundary continuity, however, was reversed: a mean score of 3.5 per item for patients at risk for depression, compared to 4.0 for heart failure patients (P = 0.01).

CONCLUSION

The explorative comparison between patients at risk for depression and heart failure patients shows small differences in experienced continuity of care. This should be analysed further in a more robust study.

General practitioners' perceptions of their role in cancer follow-up care: a qualitative study in the Netherlands

BACKGROUND

In the last few decades there has been a considerable increase in the number of cancer survivors. Health policy makers would like to see cancer follow-up care moved from secondary to primary care.

METHOD

Between 2008 and 2010, a qualitative study among primary health care professionals was performed to get more insight into the way they care for cancer survivors. Analysed was whether a coordinating role in cancer survivorship care would fit in with the practical logic underlying the way the general practitioners work.

RESULTS

In their everyday work, general practitioners are used to provide care in a reactive way. Based on this habitus, they classify their patients into 'not special' and 'special' ones. Since general practitioners label cancer survivors as 'not special,' they expect these patients to take the initiative to ask for help and present their complaints in a clear and complete way. Their habitus as a gatekeeper implies that they are reticent about referring patients to other primary health care professionals. In regard to 'not special' patients, such as cancer survivors, general practitioners appear to build on the patients' own strengths.

CONCLUSION

The emphasis on a wait-and-see attitude in contemporary Dutch general practice, as well as the general practitioners' role as a gatekeeper are at odds with the proactive and holistic approach inherent to a coordinating role in cancer follow-up. Therefore, we assume that it will be difficult for general practitioners to shape a pivotal role in this care.

Cardiometabolic prevention consultation in the Netherlands: screening uptake and detection of cardiometabolic risk factors and diseases--a pilot study

BACKGROUND

Until now, cardiometabolic risk assessment in Dutch primary health care was directed at case-finding, and structured, programmatic prevention is lacking. Therefore, the Prevention Consultation cardiometabolic risk (PC CMR), a stepwise approach to identify and manage patients with cardiometabolic risk factors, was developed. The aim of this study was 1) to evaluate uptake rates of the two steps of the PC CMR, 2) to assess the rates of newly diagnosed hypertension, hypercholesterolemia, diabetes mellitus and chronic kidney disease and 3) to explore reasons for non-participation.

METHODS

Sixteen general practices throughout the Netherlands were recruited to implement the PC CMR during 6 months. In eight practices eligible patients aged between 45 and 70 years without a cardiometabolic disease were actively invited by a personal letter ('active approach') and in eight other practices eligible patients were informed about the PC CMR only by posters and leaflets in the practice ('passive approach'). Participating patients completed an online risk estimation (first step). Patients estimated as having a high risk according to the online risk estimation were advised to visit their general practice to complete the risk profile with blood pressure measurements and blood tests for cholesterol and glucose and to receive recommendations about risk lowering interventions (second step).

RESULTS

The online risk estimation was completed by 521 (33%) and 96 (1%) of patients in the practices with an active and passive approach, respectively. Of these patients 392 (64%) were estimated to have a high risk and were referred to the practice; 142 of 392 (36%) consulted the GP. A total of 31 (22%) newly diagnosed patients were identified. Hypertension, hypercholesterolemia, diabetes and chronic kidney disease were diagnosed in 13%, 11%, 1% and 0%, respectively. Privacy risks were the most frequently mentioned reason not to participate.

CONCLUSIONS

One third of the patients responded to an active invitation to complete an online risk estimation. A passive invitation resulted in only a small number of participating patients. Two third of the participants of the online risk estimation had a high risk, but only one third of them attended the GP office. One in five visiting patients had a diagnosed cardiometabolic risk factor or disease.

Mental health care as delivered by Dutch general practitioners between 2004 and 2008

OBJECTIVE

In the field of mental health care, a major role for general practice is advocated. However, not much is known about the treatment and referral of mental health problems in general practice. This study aims at the volume and nature of treatment of mental health problems in general practice; the degree to which treatment varies according to patients' gender, age, and social economic status; and trends in treatment and referral between 2004 and 2008.

DESIGN/SETTING

Descriptive study with trends in time in general practice in the Netherlands.

SUBJECTS

350,000 patients enlisted in general practice, whose data from the Netherlands Information Network of General Practice were routinely collected from 1 January 2004 to 31 December 2008.

MAIN OUTCOME MEASURES

For all episodes of mental health problems recorded by the GP, the proportion of patients receiving prolonged attention, medication, and referral during each year have been calculated.

RESULTS

More than 75% of patients with a recorded mental health problem received some kind of treatment, most often medication. In 15-20% of cases medication was accompanied by prolonged attention; 9-13% of these patients were referred (given referrals), the majority to specialized mental health care. Age is the most important variable associated with treatment received. During the period 2004-2008, treatment with medication declined slightly and referrals increased slightly.

CONCLUSION

Treatment for psychological disorders is mostly delivered in general practice. Although in recent years restraint has been advocated in prescribing medication and collaboration between primary and secondary care has been recommended, these recommendations are only partially reflected in the treatment provided.

For which health problems do cancer survivors visit their General Practitioner?

Primary health care use of cancer patients is increased, even years after active treatment. Insight into the reasons for this could help in developing and improving guidelines and planning of health care, which is important given the expected increase in cancer survivors. Using data from the Netherlands Information Network of Primary Care, we selected 1256 adult breast cancer, 503 prostate cancer and 487 colorectal cancer patients diagnosed between 2001 and 2006. We compared diseases and complaints for which they contacted their General Practitioner (GP) 2-5 years after diagnosis to age and sex matched non-cancer controls from the same practice. Cancer patients consulted their GP more often than controls for acute symptoms such as abdominal pain and fatigue (18% more in breast cancer, 26% more in prostate cancer) and infections, such as cystitis or respiratory infections (45% in breast cancer and 17% in colorectal cancer). Consultations for chronic diseases and psychosocial problems were slightly increased: breast cancer patients had more contacts related to diabetes (55%), sleep disturbance (60%) and depression (64%), prostate cancer patients had more contacts related to hypertension (53) and chronic obstructive pulmonary disease (COPD, 34%). Adverse drug effects were almost twice as often observed in prostate and colorectal cancer patients than in controls. Fear of cancer recurrence was noted as the reason for consulting the GP in only 20 patients. Concluding, increased primary health care use in cancer survivors is mostly related to common infections and acute symptoms, which may be due to direct effects of cancer treatment or increased health concerns.

Measurement properties of questionnaires measuring continuity of care: a systematic review

BACKGROUND

Continuity of care is widely acknowledged as a core value in family medicine. In this systematic review, we aimed to identify the instruments measuring continuity of care and to assess the quality of their measurement properties.

METHODS

We did a systematic review using the PubMed, Embase and PsycINFO databases, with an extensive search strategy including 'continuity of care', 'coordination of care', 'integration of care', 'patient centered care', 'case management' and its linguistic variations. We searched from 1995 to October 2011 and included articles describing the development and/or evaluation of the measurement properties of instruments measuring one or more dimensions of continuity of care (1) care from the same provider who knows and follows the patient (personal continuity), (2) communication and cooperation between care providers in one care setting (team continuity), and (3) communication and cooperation between care providers in different care settings (cross-boundary continuity). We assessed the methodological quality of the measurement properties of each instrument using the COSMIN checklist.

RESULTS

We included 24 articles describing the development and/or evaluation of 21 instruments. Ten instruments measured all three dimensions of continuity of care. Instruments were developed for different groups of patients or providers. For most instruments, three or four of the six measurement properties were assessed (mostly internal consistency, content validity, structural validity and construct validity). Six instruments scored positive on the quality of at least three of six measurement properties.

CONCLUSIONS

Most included instruments have problems with either the number or quality of its assessed measurement properties or the ability to measure all three dimensions of continuity of care. Based on the results of this review, we recommend the use of one of the four most promising instruments, depending on the target population Diabetes Continuity of Care Questionnaire, Alberta Continuity of Services Scale-Mental Health, Heart Continuity of Care Questionnaire, and Nijmegen Continuity Questionnaire.

Continuity in different care modes and its relationship to quality of life: a randomised controlled trial in patients with COPD

BACKGROUND

New care modes in primary care may affect patients' experienced continuity of care.

AIM

To analyse whether experienced continuity for patients with chronic obstructive pulmonary disease (COPD) changes after different care modes are introduced, and to analyse the relationship between continuity of care and patients' quality of life.

DESIGN AND SETTING

Randomised controlled trial with 2-year follow-up in general practice in the Netherlands.

METHOD

A total of 180 patients with COPD were randomly assigned to three different care modes: self-management, regular monitoring by a practice nurse, and care provided by the GP at the patient's own initiative (usual care). Experienced continuity of care as personal continuity (proportion of visits with patient's own GP) and team continuity (continuity by the primary healthcare team) was measured using a self-administered patient questionnaire. Quality of life was measured using the Chronic Respiratory Questionnaire.

RESULTS

Of the final sample (n = 148), those patients receiving usual care experienced the highest personal continuity, although the chance of not contacting any care provider was also highest in this group (29% versus 2% receiving self-management, and 5% receiving regular monitoring). There were no differences in experienced team continuity in the three care modes. No relationship was found between continuity and changes in quality of life.

CONCLUSION

Although personal continuity decreases when new care modes are introduced, no evidence that this affects patients' experienced team continuity or patients' quality of life was found. Patients still experienced smooth, ongoing care, and considered care to be connected. Overall, no evidence was found indicating that the introduction of new care modes in primary care for patients with COPD should be discouraged.

Bridging the gap between public health and primary care in prevention of cardiometabolic diseases; background of and experiences with the Prevention Consultation in The Netherlands

BACKGROUND

There is an increasing need for programmatic prevention of cardiometabolic diseases (cardiovascular disease, type 2 diabetes and chronic kidney disease). Therefore, in the Netherlands, a prevention programme linked to primary care has been developed. This initiative was supported by the national professional organizations of GPs and occupational physicians as well as three large health foundations.

OBJECTIVES

To describe and discuss the content, structure of and first experiences with this initiative.

METHODS

Description of context, risk assessment tool, guideline, content of the Prevention Consultation and pilot studies.

RESULTS

Preceding surveys revealed a need for proactive disease prevention, linked to primary care. An evidence-based guideline was developed using a validated eight-question screening list. According to the guideline, high-risk participants were advised to attend two consultations at the general practice, for completing the risk assessment and for tailored advice. Three pilot studies revealed that the programme was feasible and that (sufficient) participants with a condition requiring treatment were detected. We learned that with a 'passive' recruitment (with only posters and brochures), screening uptake is limited. A more active approach with a personal invitation from the GP is more effective. Both an Internet as written questionnaire should be available and reminders are necessary. The need for a consultation with the GP practice after a high-risk test result should be emphasized. The first consultation can be performed by a practice nurse.

CONCLUSIONS

A national systematic screening programme for cardiometabolic diseases linked to primary care is feasible. The cost-effectiveness still has to be established.

The influence of population characteristics on variation in general practice based morbidity estimations

Background

General practice based registration networks (GPRNs) provide information on morbidity rates in the population. Morbidity rate estimates from different GPRNs, however, reveal considerable, unexplained differences. We studied the range and variation in morbidity estimates, as well as the extent to which the differences in morbidity rates between general practices and networks change if socio-demographic characteristics of the listed patient populations are taken into account.

Methods

The variation in incidence and prevalence rates of thirteen diseases among six Dutch GPRNs and the influence of age, gender, socio economic status (SES), urbanization level, and ethnicity are analyzed using multilevel logistic regression analysis. Results are expressed in median odds ratios (MOR).

Results

We observed large differences in morbidity rate estimates both on the level of general practices as on the level of networks. The differences in SES, urbanization level and ethnicity distribution among the networks' practice populations are substantial. The variation in morbidity rate estimates among networks did not decrease after adjusting for these socio-demographic characteristics.

Conclusion

Socio-demographic characteristics of populations do not explain the differences in morbidity estimations among GPRNs.

Co-occurrence of diabetes, myocardial infarction, stroke, and cancer: quantifying age patterns in the Dutch population using health survey data

Background

The high prevalence of chronic diseases in Western countries implies that the presence of multiple chronic diseases within one person is common. Especially at older ages, when the likelihood of having a chronic disease increases, the co-occurrence of distinct diseases will be encountered more frequently. The aim of this study was to estimate the age-specific prevalence of multimorbidity in the general population. In particular, we investigate to what extent specific pairs of diseases cluster within people and how this deviates from what is to be expected under the assumption of the independent occurrence of diseases (i.e., sheer coincidence).

Methods

We used data from a Dutch health survey to estimate the prevalence of pairs of chronic diseases specified by age. Diseases we focused on were diabetes, myocardial infarction, stroke, and cancer. Multinomial P-splines were fitted to the data to model the relation between age and disease status (single versus two diseases). To assess to what extent co-occurrence cannot be explained by independent occurrence, we estimated observed/expected co-occurrence ratios using predictions of the fitted regression models.

Results

Prevalence increased with age for all disease pairs. For all disease pairs, prevalence at most ages was much higher than is to be expected on the basis of coincidence. Observed/expected ratios of disease combinations decreased with age.

Conclusion

Common chronic diseases co-occur in one individual more frequently than is due to chance. In monitoring the occurrence of diseases among the population at large, such multimorbidity is insufficiently taken into account.

Childhood nonspecific abdominal pain in family practice: incidence, associated factors, and management

PURPOSE

Nonspecific abdominal pain (NSAP) is a common complaint in childhood. In specialist care, childhood NSAP is considered to be a complex and time-consuming problem, and parents are hard to reassure. Little is known about NSAP in family practice, but the impression is that family physicians consider it to be a benign syndrome needing little more than reassurance. This discrepancy calls for a better understanding of NSAP in family practice.

METHODS

Data were obtained from the Second Dutch National Survey of General Practice (2001). Using registration data of 91 family practices, we identified children aged 4 to 17 years with NSAP. We calculated the incidence, and we studied factors associated with childhood NSAP, referrals, and prescriptions.

RESULTS

The incidence of NSAP was 25.0 (95% confidence interval [CI], 23.7-26.3) per 1,000 person years. Most children (92.7%) with newly diagnosed NSAP (N = 1,480) consulted their doctor for this condition once or twice. Factors independently associated with NSAP were female sex (odds ratio [OR] = 1.4; 95% CI, 1.3-1.5), nongastrointestinal-nonspecific somatic symptoms (OR = 1.3; 95% CI, 1.1-1.5), and health care use (OR = 1.04; 95% CI, 1.03-1.05). When NSAP was diagnosed at the first visit, 3% of the patients were referred to specialist care, and 1% received additional testing. Family physicians prescribed medication in 21.3% of the visits for NSAP.

CONCLUSIONS

Childhood NSAP is a common problem in family practice. Most patients visit their doctor once or twice for this problem. Family physicians use little additional testing and make few referrals in their management of childhood NSAP. Despite the lack of evidence for effectiveness, family physicians commonly prescribe medication for NSAP.

Primary prevention of cardio-metabolic diseases in general practice: a Dutch survey of attitudes and working methods of general practitioners

BACKGROUND

To study the attitudes and working methods of general practitioners (GPs) in primary prevention of cardiovascular diseases, diabetes mellitus and chronic kidney diseases.

METHODS

A questionnaire with questions about attitude and working methods in the primary prevention of cardiovascular diseases, diabetes mellitus and chronic kidney diseases in general practice was sent to a representative sample of 1,100 Dutch GPs. The questionnaire was developed in collaboration with experts in general practice, cardiovascular disease, diabetes and kidney disease.

RESULTS

A total of 330 GPs completed and returned the questionnaire (30% response). Only a quarter of the GP's actively invite patients for preventive measurements. Preventive measures are mainly performed by the GP when a patient asks for it or when patients visit a GP for other complaints. The main reasons for performing preventive tests were a positive family history, obesity and smoking. Most GPs consider detection of these diseases as worthwhile, but detection should particularly focus on the group of patients with the highest risk on these diseases.

CONCLUSION

GPs have a positive attitude towards primary prevention of cardiovascular diseases, diabetes mellitus and chronic kidney diseases, but primary prevention should be focused on patients at risk.

Lactose malabsorption and intolerance: a systematic review on the diagnostic value of gastrointestinal symptoms and self-reported milk intolerance

BACKGROUND

When lactose malabsorption gives rise to symptoms, the result is called 'lactose intolerance'. Although lactose intolerance is often bothersome for patients, once recognized it may be managed by simple dietary adjustments. However, diagnosing lactose intolerance is not straightforward, especially in primary care.

AIM

To summarize available evidence on the diagnostic performance of gastrointestinal symptoms and self-reported milk (lactose) intolerance in primary care, and the relationship between lactose malabsorption and intolerance.

DATA SOURCES

PubMed, EMBASE and reference screening.

STUDY SELECTION

Studies were selected if the design was a primary diagnostic study; the patients were adults consulting because of non-acute abdominal symptoms; the diagnostic test included gastrointestinal symptoms and/or self-reported milk intolerance. A total of 26 primary diagnostic studies were included in the review.

DATA EXTRACTION

Quality assessment and data extraction were performed by two reviewers independently. They adhered to the most recent guidelines for conducting a diagnostic review as described in the Cochrane Diagnostic Reviewers' Handbook.

RESULTS

The diagnostic performance of diarrhea, abdominal pain, bloating, flatulence and self-reported milk intolerance was highly variable. A non-Caucasian ethnic origin was associated with the presence of lactose malabsorption. Both lactose malabsorbers and lactose absorbers reported symptoms during the lactose hydrogen breath test.

CONCLUSION

Our review shows that high-quality studies on the diagnosis of lactose malabsorption and intolerance in primary care are urgently needed. An important prerequisite would be to clearly define the concept of lactose intolerance, as well as how it should be assessed.

[The fat doctor and the fat patient--can a doctor also be allowed to transgress?]

OBJECTIVE

Evaluation of opinions of patients with regard to an unhealthy lifestyle of the doctor and assessment as to whether or not this is dependent on the patient's own lifestyle (healthy or unhealthy).

DESIGN

Descriptive questionnaire study.

METHOD

An online questionnaire was sent to 1000 members of a panel. They were asked to score a set of statements about their trust in a doctor who smokes, drinks or is overweight and the willingness to follow the advice of such a doctor. The items were scored on a 5-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = neither agree nor disagree, 4 = agree, 5 = strongly agree).

RESULTS

The respondents found it very important that doctors should serve as a role model. A striking finding was that two-thirds would follow the advice of a doctor who does not serve as a role model. Furthermore, smoking, drinking and overweight respondents were shown to have more trust in a smoking, drinking or overweight doctor than non-smokers, non-drinkers or respondents who are not overweight. Regarding the willingness to follow a doctor's advice, we found that drinking and overweight respondents were more likely to follow the advice of a drinking or overweight doctor than non-drinkers or respondents who are not overweight. We did not find a significant difference between smokers and non-smokers and their willingness to follow the advice from a smoking doctor.

CONCLUSION

Respondents found it important that doctors serve as a role model. Yet, a majority of the respondents would follow the advice of a doctor who does not serve as a role model. Respondents who struggle with the same unhealthy lifestyle habits as their doctor reported that they are more likely to follow his or her advice than respondents who do not have these unhealthy lifestyle habits.

Morbidity is related to a green living environment

BACKGROUND

As a result of increasing urbanisation, people face the prospect of living in environments with few green spaces. There is increasing evidence for a positive relation between green space in people's living environment and self-reported indicators of physical and mental health. This study investigates whether physician-assessed morbidity is also related to green space in people's living environment.

METHODS

Morbidity data were derived from electronic medical records of 195 general practitioners in 96 Dutch practices, serving a population of 345,143 people. Morbidity was classified by the general practitioners according to the International Classification of Primary Care. The percentage of green space within a 1 km and 3 km radius around the postal code coordinates was derived from an existing database and was calculated for each household. Multilevel logistic regression analyses were performed, controlling for demographic and socioeconomic characteristics.

RESULTS

The annual prevalence rate of 15 of the 24 disease clusters was lower in living environments with more green space in a 1 km radius. The relation was strongest for anxiety disorder and depression. The relation was stronger for children and people with a lower socioeconomic status. Furthermore, the relation was strongest in slightly urban areas and not apparent in very strongly urban areas.

CONCLUSION

This study indicates that the previously established relation between green space and a number of self-reported general indicators of physical and mental health can also be found for clusters of specific physician-assessed morbidity. The study stresses the importance of green space close to home for children and lower socioeconomic groups.

Systematic review: accuracy of symptom-based criteria for diagnosis of irritable bowel syndrome in primary care

BACKGROUND

Despite the trend towards making a positive diagnosis of irritable bowel syndrome (IBS), many health care providers approach IBS as a diagnosis of exclusion.

AIM

To summarize available evidence on the diagnostic performance of symptom-based IBS criteria in excluding organic diseases, and of individual signs and symptoms in diagnosing IBS and to additionally assess the influence of sources of heterogeneity on diagnostic performance.

METHODS

We searched PubMed and EMBASE and screened references. Studies were selected if the design was a primary diagnostic study; the patients were adults consulting because of non-acute abdominal symptoms; the diagnostic test included an externally validated set of IBS criteria, signs, or symptoms. Data extraction and quality assessment were performed by two reviewers independently. The review adhered to the most recent guidelines as described in the Cochrane Diagnostic Reviewers' Handbook.

RESULTS

A total of 25 primary diagnostic studies were included in the review. The performance of symptom-based criteria in the exclusion of organic disease was highly variable. Patients fulfilling IBS criteria had, however, a lower risk of organic diseases than those not fulfilling the criteria.

CONCLUSIONS

With none of the criteria showing sufficiently homogeneous and favourable results, organic disease cannot be accurately excluded by symptom-based IBS criteria alone. However, the low pre-test probability of organic disease especially among patients who meet symptom-based criteria in primary care argues against exhaustive diagnostic evaluation. We advise validation of the new Rome III criteria in primary care populations.

Increased cardiovascular disease in patients with inflammatory arthritis in primary care: a cross-sectional observation

OBJECTIVE

To compare the prevalence of cardiovascular disease (CVD) in patients with inflammatory arthritis and control subjects registered in primary care.

METHODS

Conditional logistic regression analyses were used to compare the CVD prevalence in patients and controls, aged 50-75 years.

RESULTS

Overall, the CVD prevalence was 66.1 per 1000 patients in inflammatory arthritis and 37.3 per 1000 patients in controls, resulting in an odds ratio of 1.83 (95% confidence interval 1.33-2.51).

CONCLUSION

Inflammatory arthritis patients registered in primary care are associated with an increased cardiovascular burden, which emphasizes the need for cardiovascular risk management in the primary care setting.

Management of urinary incontinence in general practice: data from the Second Dutch National Survey

OBJECTIVE

The aim of this study was to provide insight into the referral pattern of newly diagnosed patients with urinary incontinence in general practice and into the prescription of medication and incontinence pads by general practitioners (GPs). We also examined the influence of gender and age of patient/GP on these patterns.

METHODS

Data were obtained from the Second Dutch National Survey of General Practice. We used registered new episodes for urinary incontinence of patients of 25 years and older in the year 2001 and examined the initial management.

RESULTS

Twelve per cent of the patients were referred to a physiotherapist, 2.4% to a gynaecologist and 2.9% to a urologist. Medication was prescribed to 9.8% and 12.7% received incontinence pads. The number of female patients referred decreased significantly after 60 years of age and the number of incontinence pads and medication prescribed was higher in this age patient group. Gender of the GP did not influence the prescription or referral rate. Male patients were significantly less frequently referred than female patients.

CONCLUSION

The lower referral rate and higher prescription rate of incontinence pads and medication at older age indicate that GPs are not sufficiently aware of the benefits of pelvic floor muscle training and bladder training at older age. We did not find an influence of gender of the GP on management of urinary incontinence, unlike previous research. GPs were reluctant in prescribing medication, which is in agreement with national and international guidelines.

Setting and registry characteristics affect the prevalence and nature of multimorbidity in the elderly

OBJECTIVE

The aim of the study was to investigate how settings and registry characteristics affect the prevalence and nature of multimorbidity in elderly individuals.

STUDY DESIGN AND SETTING

We used data from three population-based studies, two general practitioner registries, one hospital discharge register, and one nursing home registry to estimate the prevalence of multimorbidity. Individuals aged 55 years and over were included.

RESULTS

Multimorbidity was most prevalent in nursing homes (82%), followed by the general population and general practitioner registries (56%-72%) and the hospital setting (22%). There were large differences in the nature of multimorbidity between settings. Combinations of hypertension, heart disease, and osteoarthritis were dominant in the population-based setting, whereas hypertension in combination with osteoarthritis, obesity, disorders of lipid metabolism, and diabetes dominated in the general practitioner setting. In the hospital setting, combinations of heart diseases had the highest prevalence. Combinations of dementia, hypertension, and stroke were dominant within the nursing home setting.

CONCLUSION

This study shows that setting and registry characteristics have an important influence on the outcome of multimorbidity studies. We recommend provision of at least information about the setting, the (list of) conditions included, the data collection method, and the time frame used, when reporting about the size and nature of multimorbidity.

Changes in the prevalence of chronic disease and the association with disability in the older Dutch population between 1987 and 2001

BACKGROUND

most studies of older populations in developed countries show a decrease in the prevalence of disabilities, and an increase in chronic diseases over the past decades. Data in the Netherlands, however, mostly show an increase in the prevalence of chronic diseases and mixed results with regard to the prevalence of disability. This study aims at comparing changes in the prevalence, as well as the association between chronic diseases and disability between 1987 and 2001 in the older Dutch population using data representative of the general population. Most studies, so far, have only dealt with self-reported diseases, but in this study, we will use both self-reported and GP-registered diseases.

STUDY DESIGN

data from the first (1987) and second (2001) Dutch National Survey of General Practice were used. In 1987, 103 general practices, compared to 104 in 2001, participated. Approximately 5% of the listed persons aged 18 years and over was asked to participate in an extensive health interview survey. An all-age random sample was drawn by the researchers from the patients listed in the participating practices (in 1987 n = 2, 708; in 2001 n = 3, 474). Both surveys are community based, with an age range between 55 and 97 years. Data on chronic diseases were based on GP registries and self-report.

RESULTS

the prevalence of disability and of asthma/COPD, cardiac disease, stroke, and osteoarthritis decreased between 1987 and 2001, while the prevalence of diabetes increased. Changes were largely similar for GP-registered and self-reported diseases. Cardiac disease, asthma/COPD, and depression led to less disability, whereas low back pain and osteoarthritis led to more disability.

CONCLUSIONS

in general, there were reductions in GP-registered chronic diseases as well as in self-reported diseases and disability. Results suggest that the disabling impact of fatal diseases decreased, while the impact of non-fatal diseases increased.