Multiattribute utility scores for predicting family physicians' decisions regarding sinusitis

To examine whether multiattribute utility (MAU) scores can be used to predict family physicians' decisions regarding patients suspected to have sinusitis and rhinitis, 100 randomly selected family physicians from the Leiden area (The Netherlands) were asked to rank a set of six attributes regarding their importance, yielding attribute weights. Next, the physicians were asked to rate the degrees to which five decision alternatives optimized each attribute, yielding utilities, regarding three case vignettes about a patient suspected to have acute maxillary sinusitis and rhinitis, with a brief clinical history. By combining attribute weights and utilities, a MAU score was calculated for each decision alternative regarding each case vignette. Finally, for each case vignette the physicians' treatment preferences were assessed by means of an open-ended question. For the clear-cut sinusitis case, management strategies and highest MAU scores were concordant for 80% of the physicians. Regarding the dubious sinusitis and rhinitis case, concordance was 50%. The latter was associated with small differences in values between the highest MAU scores. Because agreement among the physicians regarding the management strategies and weight ranks was high and there was little variation in the highest MAU scores, the kappas between the reported management strategies and weight ranks were poor (0.24 and lower). It is concluded that MAU scores may be used to predict family physicians' decisions regarding the management of patients suspected of having sinusitis where there are significant differences in values between the highest MAU scores.

The prognosis of non-critical limb ischaemia: a systematic review of population-based evidence

BACKGROUND

Peripheral arterial occlusive disease (PAOD) is the most common peripheral vascular disorder in the elderly. A clear picture of the disease's course, especially in patients with non-critical limb ischaemia (Fontaine stages I and II), is essential for the general practitioner, who plays a key role in the diagnosis and management of PAOD.

AIM

To evaluate the population-based evidence on the course and prognosis of PAOD.

METHODS

An exhaustive literature search yielded 16 population-based studies on the prognosis of PAOD. The methodological qualities of the studies were assessed according to eight criteria.

RESULTS

Thirteen studies of high methodological quality show that data on the course, cardiovascular morbidity, and mortality of asymptomatic PAOD are scarce. Only a small group of asymptomatic patients seem to develop intermittent claudication symptoms. However, asymptomatic patients appear to have the same increased risk for cardiovascular morbidity and mortality when compared with claudicants. No data were available on prognostic factors for intermittent claudication and cardiovascular morbidity in asymptomatic patients. The course, cardiovascular morbidity, and mortality of symptomatic PAOD are better documented. A small group of claudicants experience symptom progression. Smoking, hypertension, increasing age, and diabetes are the most relevant risk factors for intermittent claudication. Claudicants are at a higher risk for developing other cardiovascular diseases, resulting in a significantly increased mortality mainly owing to coronary heart disease. Intermittent claudication and a low ankle-brachial pressure index are significant predictors of mortality. Men had intermittent claudication and symptom progression more often than women. Cardiovascular (co-)morbidity was common in both male and female PAOD patients, but male PAOD patients had a higher mortality compared with female PAOD patients.

CONCLUSION

Given the current knowledge on the prognosis of PAOD in the general population, an important task for (secondary) prevention is reserved for the general practitioner. Further research is required to document the course and prognosis of asymptomatic PAOD patients.

General practice registration networks in the Netherlands: a brief report

In the Netherlands, several general practice registrations exist. Groups of general practitioners register elements of patient care according to agreed-upon criteria, and these data are collected in a central database. By means of a questionnaire the authors interviewed the managers of all nine computerized registration networks extensively about the possibilities and limitations of their registration. In addition, respondents answered some questions with data from the central database of their network. Various items are collected by nearly all the registration networks, while other items are collected by only one network. Answering questions with data from the central database turned out to be difficult. Organization and manpower are the main obstacles.

Utility of ultrasound of the upper urinary tract in elderly men with indicators of obstructive symptoms or abnormal flow: how often can silent hydronephrosis be detected in general practice?

BACKGROUND AND OBJECTIVE

While the prevalence of hydronephrosis is very low in obduction studies, a prevalence of 3-13% is reported for patients with an obstruction who are listed for prostatectomy. In order to evaluate the usefulness of transabdominal ultrasound in primary care, we determined the occurrence of hydronephrosis in males with symptoms of urinary obstruction in a general practice setting.

METHOD

A micturition questionnaire (a modified Boyarsky) was sent to all men of 55 years or more who were registered in 10 general practices in Maastricht, and was followed by an examination at their general practice. Men with obstructive symptoms and/or with a free-flow abnormality were examined in the hospital with transabdominal ultrasound in order to detect dilatation of the upper urinary tract. This ultrasound was repeated approximately 15 months later.

RESULTS

At the first measurement, none of the examined men (n = 178) had hydronephrosis, and this was still the case for 94 men 15 months later.

CONCLUSION

Renal ultrasound is not necessary in general practice for men with uncomplicated obstructive complaints.

Risk factors and cardiovascular diseases associated with asymptomatic peripheral arterial occlusive disease. The Limburg PAOD Study. Peripheral Arterial Occlusive Disease

OBJECTIVES

To describe the risk-factor profile and cardiovascular comorbidity of asymptomatic peripheral arterial occlusive disease (PAOD).

DESIGN

A cross-sectional survey. Asymptomatic PAOD was defined as an ankle-brachial pressure index < 0.95, measured on two consecutive occasions, without intermittent claudication. Logistic regression analyses were performed to investigate independent associations between age, gender, smoking status, hypertension, obesity, diabetes, hypercholesterolaemia, physical activity, a family history of cardiovascular disease, the occurrence of ischaemic heart disease and cerebrovascular disease (CeVD) and asymptomatic PAOD.

SETTING

18 general practices in the province of Limburg, the Netherlands.

SUBJECTS

A total of 3650 subjects, aged 40-78 years.

MAIN RESULTS

Asymptomatic PAOD was present in 8.6% (n = 314) and symptomatic disease in 3.8% (n = 138) of the participants. Age, smoking status, hypertension, and diabetes were significantly associated with asymptomatic PAOD. The ratio of asymptomatic to symptomatic PAOD was higher among the younger age groups. Male gender, hypertension and smoking status were stronger associated with symptomatic PAOD compared with asymptomatic PAOD. Asymptomatic subjects had more IHD and CeVD comorbidity compared with the healthy population.

CONCLUSION

Our findings suggest that the risk-factor profile and cardiovascular comorbidity of asymptomatic subjects is comparable to claudicants. Preventive efforts could be made to diminish the influence of especially smoking, diabetes and hypertension in asymptomatic subjects.

Economic evaluation of cholesterol-related interventions in general practice. An appraisal of the evidence

STUDY OBJECTIVE

To investigate and evaluate published data on cost effectiveness of cholesterol lowering interventions, and how this information could be interpreted in a rational approach of cholesterol management in general practice.

DESIGN

A systematic review of the literature.

SETTING

No restriction on setting.

MATERIALS

Papers reporting on the cost effectiveness or cost utility of prevention of (recurrent) coronary heart disease by reduction of hypercholesterolaemia in adults.

MAIN RESULTS

Thirty nine studies, most cost effectiveness analyses, were included. In 24 studies drug interventions only were analysed. Costs of screening to target cholesterol lowering interventions to persons with hypercholesterolaemia were considered in nine studies. Adjustments of the efficacy of the intervention for community effectiveness were described in seven studies. In four studies life years gained were adjusted for quality of life. Despite large variation in the outcomes, there is a constant tendency towards a less favourable cost effectiveness ratio for intervening in persons without coronary heart disease compared with persons with coronary heart disease and for women compared with men.

CONCLUSIONS

There is lack of data on cost effectiveness of cholesterol lowering interventions in the general practice setting. The cost effectiveness of cholesterol lowering in general practice deteriorates when all relevant costs are taken into account and when efficacy is corrected for community effectiveness. Cholesterol lowering intervention is more cost effective in men compared with women and in patients with coronary heart disease compared with persons without coronary heart disease. Considerations from cost effectiveness analyses should be incorporated into the development and implementation of national cholesterol guidelines for general practitioners. Standardisation of cost effectiveness studies is important for future economic evaluations.

Arrhythmias in general practice: diagnostic value of patient characteristics, medical history and symptoms

BACKGROUND

Complaints possibly caused by arrhythmias are frequently seen in general practice. It is unclear to what extent such complaints can differentiate between arrhythmias and other pathology in general practice.

OBJECTIVES

We aimed to assess the value of symptoms (a) in diagnosing arrhythmias in general practice and (b) in identifying patients with clinically relevant arrhythmias.

METHOD

During a 2-year period, a structured history from 762 patients with new complaints possibly related to an arrhythmia was taken by the GP, and a transtelephonic electrocardiogram (ECG) was made.

RESULTS

In 28.3% of the patients, arrhythmias were detected and 8.8% were clinically relevant. Several patient characteristics, symptoms and medical history findings have high predictive values in diagnosing arrhythmias. In the logistic regression analysis, age and, to a lesser extent, male gender, palpitations and dyspnoea during consultation and the use of cardiovascular drugs are associated with the presence of arrhythmias. In detecting clinically relevant arrhythmias the same parameters apart from gender are important, as well as a history of arrhythmias. The use of central nervous system medication and frequent psychosomatic complaints are negatively associated with the presence of clinically relevant arrhythmias.

CONCLUSIONS

In general practice, patient characteristics, symptoms and medical history findings can be used in the detection of arrhythmias and the assessment of their severity. They can help in the decision of whether to make an ECG recording.

Morbidity in responders and non-responders in a register-based population survey

BACKGROUND

Non-response analysis is often restricted to the influence of age, sex and socio-economic status on response status. In this study the health status of responders and non-responders was also compared.

RESULTS

Responders were comparable to non-responders with regard to the number of diagnosed disorders as well as to the prevalences of disorders within body systems. Non-responders only showed psychological disorders more often.

CONCLUSION

It is useful to assess the relation between non-response and morbidity patterns in other studies as well, in order to detect selective non-response and bias.

Multimorbidity in general practice: prevalence, incidence, and determinants of co-occurring chronic and recurrent diseases

Increasing numbers of people are found to have two or more diseases at the same time, which is termed multimorbidity. We studied the prevalence, incidence, and determinants of multimorbidity and the statistical clustering of chronic and recurrent diseases in a general practice setting. Prevalence of multimorbidity increased with all age groups from 10% in the 0-19-year-old age group up to 78% in subjects aged 80 and over. Increasing age, lower level of education, and public health insurance were related to the occurrence of morbidity, but even more strongly to the occurrence and degree of multimorbidity. The one-year incidence of multimorbidity (the new occurrence of two or more diseases in one year) was related to increasing age, public health insurance, and the presence of prevalent diseases at baseline. Statistical clustering of diseases was stronger than expected, especially among the younger subjects.

The predictive value of influenza symptomatology in elderly people

OBJECTIVE

We aimed to determine the complex of symptoms which has the highest predictive value for the diagnosis of influenza.

METHOD

A questionnaire study with questions regarding the symptomatology of influenza among patients aged 60 and older (n = 1838). Thirty-four participating GPs recorded the symptomatology of patients who came to their general practice with influenza-like complaints. The validity of the diagnostic conclusion of the GP, as well as the diagnostic validity of the criteria of the International Classification of Health Problems in Primary Care (ICHPPC-2) and the Sentinel Stations in The Netherlands, was determined with the help of the predictive value and odds ratio, using serologically confirmed influenza as the gold standard. The same method was used to determine which complex of symptoms has the highest predictive value for influenza. The results were verified using logistic regression analysis.

RESULTS

The predictive value of the diagnostics of the GP amounted to 35%. The predictive values of the diagnostics according to the criteria of the two classification methods were 24% (Sentinel Stations) and 18% (ICHPPC-2). Of the individual symptoms, the combination of fever, coughing and acute onset had the highest predictive value (30.3%) for the diagnosis of influenza.

CONCLUSION

It is recommended that the criteria of the Sentinel Stations in The Netherlands and the ICHPPC-2 be adapted in the following way: influenza is likely if, out of the entire complex of symptoms, at least fever, coughing and an acute onset occur.

The prevalence of low bone mineral density in Dutch perimenopausal women: the Eindhoven perimenopausal osteoporosis study

The aim of this study was to estimate the prevalence of osteopenia and osteoporosis in perimenopausal women, and to assess determinants of low bone mineral density (BMD). All women born between 1941 and 1947 (aged between 46 and 54 years) living in the city of Eindhoven were invited to participate in the study: 5896 white Dutch women, representing 73% of the total number of Dutch women in this age group, were studied. Of these, 24% were using estrogen preparations and 19% had undergone hysterectomy, with or without oophorectomy. All women were interviewed and bone mineral density (BMD) of the lumbar spine was measured by dual-energy X-ray absorptiometry (DXA). Osteopenia and osteoporosis were defined according to the criteria proposed by a WHO working group. In the population studied the prevalence of osteopenia and osteoporosis was 27.3% and 4.1%, respectively. With progression from premenopause to menopause, the prevalence of osteoporosis increased from 0.4% to 12.7%, and that of osteopenia from 14.5% to 42.8%. An increased risk for low BMD (osteopenia and osteoporosis) was associated with age, menopausal status and smoking, while alcohol consumption, high body mass index (BMI) and use of estrogens had a protective effect. This study of a large population-based cohort of perimenopausal women revealed a high prevalence of low bone mass and, therefore, a higher risk for osteoporotic fractures. The data further suggest that, when issues on the long-term efficacy and safety of preventive treatments are resolved, it may be possible to identify women at higher risk who are most likely to benefit from screening strategies.

Gender-related differences in non-epileptic attacks: a study of patients' cases in the literature

Gender-related differences for disorders of consciousness other than true epilepsy usually point to a larger number of women suffering especially from non-epileptic attacks or pseudoseizures. Recently, sexual abuse has been suggested as a possible cause for this increased prevalence in women. It has, however, not been very clear if women have a different phenomenology of these type of seizures from men. In the present study, patients' cases as published in the literature are analysed in a detailed way, using a working classification by Betts et al to look for gender-specificity. Of the 62 cases, 76% concern women and 24% men; a percentage comparable to those published elsewhere. Ages range from 14 to 77 years-of-age, but 89% of patients are younger than 40. Sexual abuse was proven in 18 cases, all women. The phenomenology of the attacks was divided into tonic-clonic type and complex partial type of attack, or a combination of the two. Also, special types of attacks (swoons, tantrums, abreactive attacks and forthright simulation) were looked for. Males tended to suffer especially from tonic-clonic type seizures (80% of cases), while in women as many tonic-clonic type as complex partial type attacks were observed. Special types of attacks were observed at the same frequency in both sexes. The group of sexual abuse victims did not differ from the total group of women in this respect. The clinically more impressive nature of a tonic-clonic-type attack, that is more easily suspected to be 'real', might make this type of seizure a more male form of acting out. A prospective study on the incidence and phenomenology of pseudo-epileptic seizures in the general population is suggested to answer the new questions raised in this survey.

Fitting a routine health-care activity into a randomized trial: an experiment possible without informed consent?

Due to possible methodological and practical problems, many researchers refrain from using a randomized controlled trial design to evaluate procedures already embedded in routine health care. We performed a randomized controlled trial on the effects of routine individual feedback on test ordering behavior of family physicians. The trial started after 4 years of feedback and lasted for 2.5 years. With some adaptations a randomized trial proved to be possible. In evaluating health-care procedures that cannot be blinded in a traditional way, asking full and study-specific informed consent may conflict with the validity of the design. In such studies, an alternative procedure is to be considered. Our trial, with doctors as study subjects, was held on an already accepted routine procedure (feedback). This made it possible to refrain from obtaining study-specific informed consent. Consequently, a Hawthorne effect and contamination of the trial arms through information leakage could be avoided. Justification and general criteria for not obtaining full and study-specific informed consent are worked out. In health-care research on the performance of doctors or on interventions into the quality of care, obtaining a general informed consent in advance is an acceptable alternative approach.

Primary-care-based randomised placebo-controlled trial of antibiotic treatment in acute maxillary sinusitis

BACKGROUND

The value of antibiotics in acute rhinosinusitis is uncertain. Although maxillary sinusitis is commonly diagnosed and treated in general practice, no effectiveness studies have been done on unselected primary-care patients. We used a randomised, placebo-controlled design to test the hypothesis that there would be an improvement associated with amoxycillin treatment for acute maxillary sinusitis patients presenting to general practice.

METHODS

Adult patients with suspected acute maxillary sinusitis were referred by general practitioners for radiographs of the maxillary sinus. Those with radiographic abnormalities (n = 214) were randomly assigned treatment with amoxycillin (750 mg three times daily for 7 days; n = 108) or placebo (n = 106). Clinical course was assessed after 1 week and 2 weeks, and reported relapses and complications were recorded during the following year.

FINDINGS

After 2 weeks, symptoms had improved substantially or disappeared in 83% of patients in the study group and 77% of patients taking placebo. Amoxycillin did not influence the clinical course of maxillary sinusitis nor the frequency of relapses during the 1-year follow-up. Radiographs had no prognostic value, nor were they an effect modifier. Side-effects were recorded in 28% of patients given amoxycillin and in 9% of those taking placebo (p < 0.01). The occurrence of relapses was similar in both groups (21 vs 17%) during the follow-up year.

INTERPRETATION

Antibiotic treatment did not improve the clinical course of acute maxillary sinusitis presenting to general practice. For these patients, an initial radiographic examination is not necessary and initial management can be limited to symptomatic treatment. Whether antibiotics are necessary in more severe cases warrants further study.

Diagnostic value of signs and symptoms associated with peripheral arterial occlusive disease seen in general practice: a multivariable approach

OBJECTIVES

To assess the diagnostic values of single and combined data from the history, physical examination, and medical record with regard to peripheral arterial occlusive disease (PAOD) in patients with leg complaints; to construct a multivariable model for the clinical diagnosis of PAOD by primary care physicians.

SETTING

18 general practice centers in The Netherlands.

DESIGN

Cross-sectional comparison of signs, symptoms, and data from the medical record with the independently assessed ankle-brachial systolic pressure index (ABPI; cutoff point < 0.90); analysis: bivariate, multiple logistic regression (MLR).

POPULATION

2,455 individuals with leg complaints, aged 40.7-78.4 years; ABPI < 0.90 present in 9.2% of legs (11.7% of individuals).

OUTCOME MEASURES

Clinical variables: sensitivity, specificity, positive and negative predictive values (PV+, PV-), diagnostic odds ratio (OR); models: likelihood ratio test, area under the receiver operating characteristic curve (AUC).

RESULTS

Bivariate analysis: highest sensitivity: age more than 60 years (77.3%); highest specificity: wounds or sores on toes and foot (99.7%); highest PV+: typical intermittent claudication (IC) (45.0%) (abnormal foot pulses 41.3%); highest PV-: strong pulses of both foot arteries (97.7%). MRL: the best-performing model (AUC 0.89) consisted of ten clinical variables: gender (OR 1.5), age more than 60 (OR 2.2); IC (OR 3.5); palpation of the skin temperature of the feet (OR 2.5), palpation of both foot pulses [OR 16.4 (abnormal) and 7.0 (doubtful)], auscultation of the femoral artery (OR 3.5); previous diagnosis of IHD (OR 1.7) or diabetes (OR 1.6), history of smoking (OR 2.1), and elevated blood pressure (OR 1.5). The range of predicted probabilities was 0.4-98%. The Hosmer-Lemeshow goodness-of-fit test indicated good overall fit (p = 52).

CONCLUSIONS

Palpation of both foot pulses is the key procedure for the clinical diagnosis of PAOD. Traditional clinical evaluation enables the general practitioner to exclude the diagnosis of PAOD in many individuals with a high degree of certainly, to establish the diagnosis in a small group of patients, and to define a limited group of patients where supplementary noninvasive testing is appropriate. The MLR model can be used as a diagnostic checklist and as a reference for the physician's clinical hypothesis.

[Home visits by community health nurses can contribute to the family practitioner's knowledge of elderly patients]

OBJECTIVE

To determine to what extent the general practitioner (GP) is aware of the health status and functioning of his elderly patients and in which areas this knowledge can be completed with the aid of community nurses.

DESIGN

Cross-sectional, descriptive.

SETTING

Department of General Practice. State University Limburg, Maastricht, the Netherlands.

METHODS

A random sample of 59 patients aged 79 years and over, belonging to the population of a primary health care centre, were visited by community nurses. One patient was lost. The nurses inventoried the patients health complaints and their daily functioning by means of a structured questionnaire. Data from these home visits were compared with data from the same questionnaire, regarding the same patients, which the three GPs of the health centre had filled in on the basis of their medical records.

RESULTS

Of the complaints recorded by the community nurses. 34% were not known to the general practitioners. This concerned mainly symptoms of depression, urinary incontinence, disabilities and handicaps of the musculoskeletal system. sleep disturbances, daily functioning and ability to cope. The main determinants of the ability to cope were impaired walking and to a lesser degree symptoms of depression.

CONCLUSION

A structured interview of elderly patients by a community nurse yields substantial information about health problems.

The diagnostic value of the measurement of the ankle-brachial systolic pressure index in primary health care

We investigated the value of the ankle-brachial systolic pressure index (ABPI) as a test for the diagnosis of peripheral arterial occlusive disease (PAOD) in general practice. ABPI measurements on 231 legs of 117 subjects performed in three general practice centers (GPC) were compared with the diagnostic conclusions of a Vascular Laboratory. The optimum cutoff value for the ABPI, its accuracy and diagnostic value were estimated. In a subpopulation of 51 subjects for whom repeated measurements were available, we checked whether taking the mean of three consecutive ABPIs for test outcome would enhance diagnostic performance. Receiver Operating Characteristic analysis showed that overall performance of the GPC ABPI was good (area under the curve approximately 0.9). Performing repeated ABPI measurements was superior to performing a single measurement. The optimum cutoff value for the ABPI was 0.97, associated with a diagnostic odds ratio (OR) of 17 and an accuracy of 81%. In a somewhat more selected subpopulation, the optimum cutoff value was 0.92 (OR 70, accuracy 90%). On the basis of our results, we suggest the following rule of thumb: if the ABPI < 0.8 or if the mean of three ABPIs < 0.9, it is highly probable that PAOD is present (PV+ > or = 95%); if the ABPI > 1.1 or if the mean of three ABPIs > 1.0, PAOD can be ruled out (PV- > or = 99%). In conclusion, in primary health care, the ABPI measurement can be a useful supplementary test in ambiguous diagnostic situations with regard to PAOD.

Comparison of appropriateness of cholesterol testing in general practice with the recommendations of national guidelines: an audit of patient records in 20 general practices

OBJECTIVE

To compare the profiles of those patients selected by general practitioners for measurement of serum cholesterol with the recommended profiles for opportunistic cholesterol testing described in the national practice guidelines published by the Dutch College of General Practitioners.

DESIGN

Retrospective audit of general practitioners' records.

MATERIALS

Practice records of 3577 adult patients systematically sampled from 20 general practices.

MAIN MEASURES

With criteria set by the national guidelines, the proportion of patients per practice (a) for whom cholesterol testing would be considered justified, and (b) for whom cholesterol testing would be considered unjustified, and the proportion of patients within each of these groups who had had a cholesterol measurement recorded.

RESULTS

Cholesterol tests were performed on 415 (11.7%) of the 3577 patients. National guidelines on the management of hypercholesterolaemia state that a positive cardiovascular risk profile is an indication for cholesterol measurement. Just under one fifth (668) of the patients in this study were recorded as having a positive cardiovascular risk profile, but only 31% of these had had their cholesterol measured. Of the patients without recorded evidence of a positive cardiovascular risk profile cholesterol had been measured in 8%. Restricting the analyses to the age group 18-65 (n = 3060) of whom 12.5% had a positive risk profile, did not improve the results. In practices with a computerised information system 37% of patients with recorded evidence of a positive cardiovascular risk profile had had their cholesterol measured.

CONCLUSIONS

Cholesterol testing was not targeted as selectively as recommended by the national guidelines. The major problem was failure to test those likely to benefit. Improving the targeting of cholesterol measurements would undoubtedly increase the workload of general practitioners. If the national guidelines are to have an effect on health promotion the first step must be to increase the proportion of patients with positive cardiovascular risk profiles who get their cholesterol tested. A major factor in successfully selecting cases seems to be that practices are equipped with a computerised medical information system.

One-year prognosis of abdominal complaints in general practice: a prospective study of patients in whom no organic cause is found

BACKGROUND

Data on the one-year prognosis of patients with non-organic, non-acute abdominal complaints in primary care are lacking. Knowledge of prognostic determinants could be helpful in management and health education.

AIM

To describe the prognosis after one year of non-organic abdominal complaints in general practice, and to show how this relates to socio-demographic factors, medical history and psychological problems.

METHODS

The one-year prognosis of patients with non-organic abdominal complaints in a primary care setting was analysed in a prospective study (n = 756). Clinical and psychological factors were measured and their relative risks regarding unfavourable prognosis were calculated one year after the first consultation.

RESULTS

In 68% of the patients examined, the abdominal complaints had either improved or disappeared by the end of the first year. Female sex and depressive mental state were associated with an unfavourable prognosis. Clinical symptoms that were significantly associated with persisting complaints were a combination of abdominal pain, flatulence and bowel irregularities; a specific description of the character of the pain by the patient; looser stools at the onset of the pain; long duration or recurrence, pyrosis; absence of visible distension; and epigastric localization of the pain or tenderness.

CONCLUSIONS

The prognosis after one year of non-acute abdominal pain in general practice is better than that reported from studies of outpatient populations. Female sex, depressive mood and some clinical parameters are associated with persistent complaints one year after presentation.

Routine individual feedback on requests for diagnostic tests: an economic evaluation

The authors assessed the economic cor sequences of routine individual feedback on test requests provided to 85 family physicians in a region with 187,000 inhabitants. In a retrospective study as part of a quasi-experiment, cost trends in a region where feedback was provided over a seven-year period were compared with cost trends elsewhere in The Netherlands without feedback. Data on variable costs were obtained for 400 individual tests that accounted for 90% of all requests. Differences in request trends thus were transformed to savings in costs of diagnostic testing, taking account of the extra costs of providing the feedback. Expenditures for diagnostic testing declined after the start of the feedback, despite the costs of providing the feedback. The savings increased as the feedback continued. Compared with the trend elsewhere without feedback, over seven years a total net sum of 1.4 million U.S. dollars was saved. Routine individual feedback is therefore economically worthwhile.

Unlocking patients' records in general practice for research, medical education and quality assurance: the Registration Network Family Practices

General practitioners (GPs) possess a wealth of information on the health of their patients. Hence, they are in a unique position to gather information for research, education or management. The chief goal of the Registration Network Family Practices is to establish a computerized database containing certain patient characteristics and all relevant health problems excluding minor, temporary illnesses. The database can be seen as a dynamic population sampling frame of chronic and/or severe morbidity, also including risk factors and psychosocial problems. The best way to make use of the Registration Network Family Practices is by researchers identifying and sampling patients with particular health problems. The database contained patient characteristics and problemlists of 61,887 persons, on September 1, 1995. At that time 214,389 health problems had been entered in the database. The database is increasingly being used as a source of information for studies by researchers and students. Researchers find the database a useful tool, but they have to keep in mind that data on the process of care are not directly available. Furthermore, there is a limit to the number of studies which can be performed in the network practices, due to time limitations and the burden on the doctors and patients.

Factors predicting differences among general practitioners in test ordering behaviour and in the response to feedback on test requests

BACKGROUND

In a population of 85 general practitioners diagnostic test ordering behaviour has been changed by means of repeated individual feedback provided since 1985.

OBJECTIVES

We studied practitioner and practice characteristics which may explain differences in test ordering behaviour and in the extent to which general practitioners tend to change their behaviour according to the feedback.

METHOD

In order to trace such variables, 75 general practitioners were interviewed. In our study request data from individual general practitioners were related to data from several questionnaires.

RESULTS

We found no practice characteristics which were of influence on the number of test requests by the general practitioner. Explanatory practitioner characteristics for this were found to be years of experience and working hours per week in practice.

CONCLUSIONS

More years of experience as a general practitioner and a shorter duration of consultations correlated with a better response to advice given in the feedback.

Smoking in Dutch pregnant women and birth weight

In this study 796 ambulatory singular pregnant women were questioned about their smoking habits both before and during pregnancy (ambispective). Important covariates such as parity, blood pressure, maternal weight gain, salt- and alcohol consumption and length of gestation were taken into account. At the beginning of pregnancy 52% of the questioned women smoked; 36% smoked in the seventh/eighth month of pregnancy. A dose-response relationship was found between the number of cigarettes smoked per day and birth weight. For those pregnant women who still smoked after 7 months of pregnancy an average birth weight loss of 24 g was found per cigarette per day. Even after controlling for covariates, there still remains an independent influence of smoking on birth weight loss on the average of 19 g for each cigarette smoked per day.