Inter-Rater and Intra-Rater Reliability of the Occupational Therapy Diagnosis

A registration form based on the International Classification of Impairments, Disabilities, and Handicaps (ICIDH) was developed and its reliability as a registration of occupational therapy (OT) diagnosis was assessed. Fifty patients from a psychiatric hospital and 57 patients from a rehabilitation center participated in this study. Reliability was determined using two measures: the percentage of agreement and Cohen's kappa. Findings of this study indicate that the reliability of the assessments of functional deficits of the patients by occupational therapists is satisfactory to very good. In the rehabilitation center all items, and in the psychiatric hospital 88% of the items, had a kappa value higher than .45. This implies that the registration form can be used in survey research.

Europe's strong primary care systems are linked to better population health but also to higher health spending

Strong primary care systems are often viewed as the bedrock of health care systems that provide high-quality care, but the evidence supporting this view is somewhat limited. We analyzed comparative primary care data collected in 2009-10 as part of a European Union-funded project, the Primary Health Care Activity Monitor for Europe. Our analysis showed that strong primary care was associated with better population health; lower rates of unnecessary hospitalizations; and relatively lower socioeconomic inequality, as measured by an indicator linking education levels to self-rated health. Overall health expenditures were higher in countries with stronger primary care structures, perhaps because maintaining strong primary care structures is costly and promotes developments such as decentralization of services delivery. Comprehensive primary care was also associated with slower growth in health care spending. More research is needed to explore these associations further, even as the evidence grows that strong primary care in Europe is conducive to reaching important health system goals.

International developments in revenues and incomes of general practitioners from 2000 to 2010

BACKGROUND

The remuneration system of General Practitioners (GPs) has changed in several countries in the past decade. The aim of our study was: to establish the effect of these changes on the revenues and income of GPs in the first decade of the 21st century.

METHODS

Annual GP revenue and practice costs were collected from national institutes in the eight countries included in our study (Belgium, Denmark, Finland, France, Germany, The Netherlands, Sweden, The United Kingdom (UK)) from 2000-2010. The data were corrected for inflation and purchasing power. Data on the remuneration systems and changes herein were collected from the European Observatory Health Systems Reviews and country experts.

RESULTS

Comprehensive changes in the remuneration system of GPs were associated with considerable changes in GP income. Incremental changes mainly coincided with a gradual increase in income after correction for inflation. Average GP income was higher in countries with a strong primary care structure.

CONCLUSIONS

The gap between the countries where GPs have a lower income (Belgium, Sweden, France and Finland) and the countries where GPs have a higher income (Netherlands, Germany and the UK) continues to exist over time and appeared to be related to dimensions of primary care, such as governance and access. New payment forms, such as integrated care payment systems, and new health care professionals that are working for GPs, increasingly blur the line between practice costs and income, making it more and more important to clearly define expenditures on GPs, to remain sight on the actual income of GPs.

Political, cultural and economic foundations of primary care in Europe

This article explores various contributing factors to explain differences in the strength of the primary care (PC) structure and services delivery across Europe. Data on the strength of primary care in 31 European countries in 2009/10 were used. The results showed that the national political agenda, economy, prevailing values, and type of healthcare system are all important factors that influence the development of strong PC. Wealthier countries are associated with a weaker PC structure and lower PC accessibility, while Eastern European countries seemed to have used their growth in national income to strengthen the accessibility and continuity of PC. Countries governed by left-wing governments are associated with a stronger PC structure, accessibility and coordination of PC. Countries with a social-security based system are associated with a lower accessibility and continuity of PC; the opposite is true for transitional systems. Cultural values seemed to affect all aspects of PC. It can be concluded that strengthening PC means mobilising multiple leverage points, policy options, and political will in line with prevailing values in a country.

The relationship between avoidable hospitalization and accessibility to primary care: a systematic review

BACKGROUND

Avoidable hospitalization (AH) has been widely studied as a possible measure of the performance of primary health care (PHC). However, studies examining the relationship between the efficiency and quality of PHC and AH have found mixed results. Our study aims at highlighting those factors related to the relationship between AH and accessibility to PHC in different countries.

METHODS

We conducted a systematic search for peer-reviewed studies published between 1990 and October 2010 in English, German, French, Italian or Spanish and indexed primary electronic databases.

RESULTS

The final analysis was conducted on the basis of 51 papers. Of them, 72.5% revealed a significant inverse association between the indicator of PHC accessibility and rates of AH. Indicators of PHC calculated at individual level are more likely to reveal contradictory aspects of the relationship between rates of AH and indicators of quality and PHC accessibility.

CONCLUSIONS

Most studies confirmed the expected relationship between indicators of PHC accessibility and hospitalization for ambulatory care sensitive conditions (ACSCs), showing lower hospitalization rates for ACSC in areas with greater access to PHC. The findings support the use of ACSC hospitalization as an indicator of primary care quality, with the precaution of applying appropriate adjustment factors.

A promising approach in comparative research on care for the elderly

Long-term care (LTC) in the form of care provided in nursing homes, homes for the aged and home care is considered an appropriate answer to the growing needs of the aging populations of the industrialized world. However, the provision of and expenditures on LTC vary considerably between these industrialized countries. Although one would expect LTC to be subject to many internationally comparative studies, including all European countries, this is not the case. A paper presented by Damiani et al. in BMC Health Services Research contains an internationally comparative model regarding the development of LTC in Europe (2003 to 2007). They achieve an intriguing compromise between depth and width in the sparsely populated domain of internationally comparative research on LTC by characterizing countries' LTC and interpreting the large north/south differences found. Their results also show that 'cash for care' schemes form a substantial alternative to traditional LTC provision. An additional time series analysis showed that many countries seem to be engaged in reorganizing the LTC sector. This study widens knowledge in a neglected area of health services research and should serve as a source of inspiration for further studies.

Imagining the impact of different consent systems on organ donation: the decisions of next of kin

Next of kin play an important role in organ donation. The aim of this study was to assess the extent to which explicitness of consent to organ donation by the deceased impacts the likelihood that next of kin will agree to organ donation of the deceased by using hypothetical cases. Results indicate that that people say they are more willing to agree to donate organs of those who explicitly consented to donate than those whose permission to donate is presumed. The degree of explicitness for the consent to donate by the deceased appears to influence the next of kin's decision about whether to agree to donation. This variation might explain the absence of differences in efficiency between various types of consent systems.

Labour intensity of guidelines may have a greater effect on adherence than GPs' workload

Background

Physicians' heavy workload is often thought to jeopardise the quality of care and to be a barrier to improving quality. The relationship between these has, however, rarely been investigated. In this study quality of care is defined as care 'in accordance with professional guidelines'. In this study we investigated whether GPs with a higher workload adhere less to guidelines than those with a lower workload and whether guideline recommendations that require a greater time investment are less adhered to than those that can save time.

Methods

Data were used from the Second Dutch National survey of General Practice (DNSGP-2). This nationwide study was carried out between April 2000 and January 2002.

A multilevel logistic-regression analysis was conducted of 170,677 decisions made by GPs, referring to 41 Guideline Adherence Indicators (GAIs), which were derived from 32 different guidelines. Data were used from 130 GPs, working in 83 practices with 98,577 patients. GP-characteristics as well as guideline characteristics were used as independent variables. Measures include workload (number of contacts), hours spent on continuing medical education, satisfaction with available time, practice characteristics and patient characteristics. Outcome measure is an indicator score, which is 1 when a decision is in accordance with professional guidelines or 0 when the decision deviates from guidelines.

Results

On average, 66% of the decisions GPs made were in accordance with guidelines. No relationship was found between the objective workload of GPs and their adherence to guidelines. Subjective workload (measured on a five point scale) was negatively related to guideline adherence (OR = 0.95). After controlling for all other variables, the variation between GPs in adherence to guideline recommendations showed a range of less than 10%.

84% of the variation in guideline adherence was located at the GAI-level. Which means that the differences in adherence levels between guidelines are much larger than differences between GPs. Guideline recommendations that require an extra time investment during the same consultation are significantly less adhered to: (OR = 0.46), while those that can save time have much higher adherence levels: OR = 1.55). Recommendations that reduce the likelihood of a follow-up consultation for the same problem are also more often adhered to compared to those that have no influence on this (OR = 3.13).

Conclusion

No significant relationship was found between the objective workload of GPs and adherence to guidelines. However, guideline recommendations that require an extra time investment are significantly less well adhered to while those that can save time are significantly more often adhered to.

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.

[Entry into general practice training: no relation with focus on primary care in the undergraduate curriculum]

OBJECTIVE

To investigate differences between medical faculties in the proportion of graduates entering general practice (GP) training, and to analyse whether this is related to the degree of orientation towards general practice of Dutch medical undergraduate curricula.

DESIGN

Retrospective cohort study.

METHODS

Several databases were used to investigate which percentage of medical graduates per faculty entered the GP training programme between 1989 and 2001. The coordinators of general practice education in the undergraduate curriculum of the eight Dutch faculties of medicine filled in a questionnaire about the degree of orientation toward general practice of their curriculum and the extent to which medical students came into contact with primary care.

RESULTS

The number of medical graduates per faculty in the period 1989-2001 varied between 1682 and 2443. On average, 23.5% of the students entered GP training. The medical faculties of Maastricht University, Radboud University Nijmegen and VU University Amsterdam showed the strongest orientation towards general practice. Leiden University, the University of Amsterdam and University of Groningen were the least oriented, and Utrecht University and Erasmus University Rotterdam were in between. There was no clear correlation between the orientation of the curriculum towards general practice and the percentage of medical graduates entering general practice training.

CONCLUSION

There were small differences between faculties in the proportion of graduates entering a GP training programme during a 10-year period. Although there were differences between curricula in the degree of orientation towards general practice, this had little effect on the number of medical graduates entering general practice training. Presumably, other factors such as personal preferences and the employment situation are more important.

The impact of donor policies in Europe: a steady increase, but not everywhere

BACKGROUND

Transplantable organs are scarce everywhere. Therefore, countries have developed policies to support the efficient use of potential donors. Nevertheless, the shortage of organs remains. Were these policies in vain? The aim of this study is to assess the impact of donor policies on donor procurement in 10 Western European countries from 1995 to 2005.

METHOD

To assess the impact of the donor policies we studied the conversion of potential donors into effectuated donors. 80% of the donors died from CVAs or a (traffic) accident. We considered these mortality rates to be a good proxy for potential donors. Here we call the conversion of potential donors into actual donors 'the donor efficiency rate by proxy'.

RESULTS

The mortality rates for CVA and (traffic) accidents have decreased in the countries under study. At the same time, in most countries the donor efficiency rates have steadily increased. The variance in donor efficiency rates between countries has also increased from 1995 to 2005. Four countries introduced a new consent system or changed their existing system, without (visible) long-term effects.

CONCLUSION

The overall increase in donor efficiency means that the efforts to improve donor policies have paid off. However, substantial differences between countries were found. The success of donor policies in terms of the number of absolute donors is blurred by the success of policies on traffic safety and CVA treatment. It remains unclear which specific policy measures are responsible for the increase in donor efficiency rates. This increase is not related to having a presumed consent system. Furthermore, an analysis of countries that introduced a new consent system or changed their system showed no effect on donor efficiency.

Changes in the pattern of service utilisation and health problems of women, men and various age groups following a destructive disaster: a matched cohort study with a pre-disaster assessment

Objectives

Female gender and young age are known risk factors for psychological morbidity after a disaster, but this conclusion is based on studies without a pre-disaster assessment. The aim of this study in family practice was to investigate if these supposed risk factors would still occur in a study design with a pre-disaster measurement.

Methods

A matched cohort study with pre-disaster (one year) and post-disaster (five years) data. Community controls (N = 3164) were matched with affected residents (N = 3164) on gender, age and socioeconomic status. Main outcome measures were utilization rates measured by family practice attendances and psychological, musculoskeletal and digestive health problems as registered by the family practitioner using the International Classification of Primary Care (ICPC).

Results

Affected residents of female and male gender and in five age groups all showed increases in utilization rates in the first post-disaster year and in psychological problems when compared to their pre-disaster baseline levels. The increases showed no statistically significant changes, however, between women and men and between all age groups.

Conclusion

Gender and age did not appear to be disaster-related risk factors in this study in family practice with a pre-disaster base line assessment, a comparison group and using existing registries. Family practitioners should not focus specifically on these risk groups.

The impact of clerkships on students' specialty preferences: what do undergraduates learn for their profession?

OBJECTIVE

Clinical experiences and gender have been shown to influence medical students' specialty choices. It remains unclear, however, which aspects of experiences make students favour some specialties and reject others. This study aimed to clarify the effects of clerkships on specialty choice and to identify explanatory factors.

METHODS

We carried out a longitudinal cohort study to collect data on career preferences and attitudes towards future careers among 3 cohorts of students before and after clerkships in surgery (n = 200), internal medicine (n = 277) and general practice (n = 184). Regression analyses were performed to identify the determinants of career choice and the role of gender.

RESULTS

Exposure to clinical settings encourages students to opt for a career in the corresponding specialty. Men were more stimulated than women by the general practice clerkship. Gender had no clear role as a predictor of career preference. The major predictor of career choice in all 3 specialties was positive evaluation of work-intrinsic factors. A preference for working with acute patients and technology-oriented work, prestige orientation and insignificance of a controllable lifestyle were determinants of a preference for surgery. Students with a preference for general practice had almost opposite preferences. Those who chose internal medicine favoured a controllable lifestyle.

DISCUSSION

Factors other than gender appear to drive specialty decisions. Work content, type of patients and lifestyle options play major roles. Consequently, along with teaching about the practice of medicine, the matching of specialty preferences with reality is an essential outcome of clerkships.

A cohort study of the long-term impact of a fire disaster on the physical and mental health of adolescents

The literature on adult trauma survivors demonstrates that those exposed to traumatic stress have a poorer physical health status than nonexposed individuals. Studies on physical health effects in adolescent trauma survivors, in contrast, are scarce. In the current study, it was hypothesized that adolescents who have been involved in a mass burn incident (N = 124) will demonstrate more physical and mental health problems than an unaffected cohort from the same community (N = 1,487). Health data were extracted from electronic medical records, covering 1-year prefire and 4-years postfire. When compared to the prefire baseline, survivors showed significantly larger increases in mental, respiratory, and musculoskeletal problems than community controls during the first year after the fire, but not during the later years.

Physical and mental health problems in parents of adolescents with burns--a controlled, longitudinal study

OBJECTIVE

Caregiving has been described in the literature as a risk factor for ill health in the carer. This controlled, prospective study examines the course of physical and mental health problems in parents of adolescent survivors of a mass burn incident.

METHODS

Health information was extracted from electronic medical records. Continuous data were available for 1 year before and 4 years after the fire. Cohorts comprised 273 parents of survivors with burns, 199 parents of survivors without burns, and 1756 controls. Post-fire increases in health problems were compared by means of logistic regression.

RESULTS

Parents of burn victims were more likely to present mental health problems during the first 2 years after the incident, when compared to the baseline. Moreover, they were more likely to present cardiovascular health problems in every year following the disaster, compared to the baseline. Increases observed in mental and cardiovascular health problems were significantly larger in parents of burn victims compared to controls. Risk factors for presenting mental health problems were female gender of the parent and a large burn size in the child. Lower socioeconomic status and female gender of the parent predicted cardiovascular health problems.

CONCLUSION

Evidence gained in longitudinal studies informs on which health problems are most likely to develop in parental caregivers. In the interest of both parent and child, a family-oriented approach is proposed.

Gender shift in realisation of preferred type of GP practice: longitudinal survey over the last 25 years

Background

An increasing number of newly trained Dutch GPs prefer to work in a group practice and as a non-principal rather than in a single-handed practice. In view of the greater number of female doctors, changing practice preferences, and discussions on future workforce problems, the question is whether male and female GPs were able to realise their initial preferences in the past and will be able to do so in the future.

Methods

We have conducted longitudinal cohort study of all GPs in the Netherlands seeking a practice between 1980 and 2004. The Netherlands Institute of Health Services Research (NIVEL) in Utrecht collected the data used in this study by means of a postal questionnaire. The overall mean response rate was 94%.

Results

Over the past 20 years, an increasing proportion of GPs, both male and female, were able to achieve their preference for working in a group practice and/or in a non-principal position. Relatively more women than men have settled in group practices, and more men than women in single-handed practices; however, the practice preference of men and women is beginning to converge. Dropout was highest among the GPs without any specific practice preference.

Conclusion

The overwhelming preference of male and female GPs for working in group practices is apparently being met by the number of positions (principal or non-principal) available in group practices. The preference of male and female GPs regarding the type of practice and job conditions is expected to converge further in the near future.

Disaster-related stress as a prospective risk factor for hypertension in parents of adolescent fire victims

Life stress has been related to hypertension in various studies, but well-designed research carried out in disaster settings is scarce. Moreover, most research focuses on the primary victims and disregards effects on their caregivers. In a prospective, population-based cohort study, the authors tested the hypothesis that parents of adolescents who had been involved in the Volendam, Netherlands, pub fire on January 1, 2001 (n = 418) were more at risk of developing hypertension than parents from the same community whose children had not been involved in the fire (n = 1,462). Only residents without prior evidence of hypertension were included. The follow-up period covered 4 years (2001-2004). Assessment of hypertension was based on the records of family practitioners and pharmacies. The odds of developing new hypertension were 1.48 times higher in parents of fire victims than in control parents during the follow-up period (odds ratio = 1.48, 95% confidence interval: 1.09, 2.02). All analyses controlled for age, gender, socioeconomic status, family practice, history of chronic disease, and number of contacts with the family practitioner during follow-up. Since hypertension is an important risk factor for cardiovascular morbidity, it is important to provide interventions that help people fight the negative effects of disaster-related stress.

Carpal tunnel syndrome in general practice (1987 and 2001): incidence and the role of occupational and non-occupational factors

BACKGROUND

Most studies on the incidence of the carpal tunnel syndrome and the relation of this disorder with occupation are population-based. In this study we present data from general practice.

AIM

To compare incidence rates of carpal tunnel syndrome in 1987 with those in 2001, and to study the relationship between carpal tunnel syndrome and occupation.

DESIGN OF STUDY

Analysis of the data of the first and second Dutch National Survey of General Practice, conducted in 1987 and 2001, respectively.

SETTING

General practices in The Netherlands.

METHOD

One hundred and three general practices in 1987 with 355 201 listed patients, and 96 practices with 364 998 listed patients in 2001, registered all patients who presented with a new episode of carpal tunnel syndrome. Patient and GP populations were representative for The Netherlands.

RESULTS

The crude incidence rate was 1.3 per 1000 (95% confidence interval [CI] = 1.0 to 1.5) in 1987, and 1.8 per 1000 (95% CI = 1.7 to 2.0) in 2001. In males it was 0.6 (95% CI = 0.5 to 0.7) and 0.9 (95% CI = 0.8 to 1.0) respectively; in females 1.9 (95% CI = 1.7 to 2.1) and 2.8 (95% CI = 2.6 to 3.1). At both study periods, peak incidence rate occurred in the 45-64-year age group: in 2001 this peak reached 4.8 per 1000 (95 CI = 4.1 to 5.4) for females and 1.6 (95 CI = 1.2 to 2.0) for males. Women who performed unskilled and semi-skilled work had 1.5 times greater risk of acquiring carpal tunnel syndrome than women with higher-skilled jobs (P <0.001). In men no relationship of this kind was found.

CONCLUSION

In 2001 the crude incidence rate of carpal tunnel syndrome was 1.5 times higher than in 1987, but the difference was not statistically significant after subdividing by age and sex. In both years the female:male ratio was 3:1. Incidence rates were related to the job level of women, but not of men.

Internet-based monitoring of influenza-like illness (ILI) in the general population of the Netherlands during the 2003-2004 influenza season

BACKGROUND

An internet-based survey of influenza-like illness (ILI)--the Great Influenza Survey or GIS--was launched in the Netherlands in the 2003-2004 influenza season. The aim of the present study was to validate the representativeness of the GIS population and to compare the GIS data with the official ILI data obtained by Dutch GPs participating in the Dutch Sentinel Practice Network.

METHOD

Direct mailings to schools and universities, and repeated interviews on television and radio, and in newspapers were used to kindle the enthusiasm of a broad section of the public for GIS. Strict symptomatic criteria for ILI were formulated with the assistance of expert institutes and only participants who responded at least five times to weekly e-mails asking them about possible ILI symptoms were included in the survey. Validation of GIS was done at different levels: 1) some key demographic (age distribution) and public health statistics (prevalence of asthma and diabetes, and influenza vaccination rates) for the Dutch population were compared with corresponding figures calculated from GIS; 2) the ILI rates in GIS were compared with the ILI consultation rates reported by GPs participating in the Dutch Sentinel Practice Network.

RESULTS

13,300 persons (53% of total responders), replied at least five times to weekly e-mails and were included in the survey. As expected, there was a marked under-representation of the age groups 0-10 years and 81->90 years in the GIS population, although the similarities were remarkable for most other age groups, albeit that the age groups between 21 and 70 years were slightly overrepresented. There were striking similarities between GIS and the Dutch population with regard to the prevalence of asthma (6.4% vs. 6.9%) and the influenza vaccination rates, and to a lesser degree for diabetes (2.4% vs. 3.5%). The vaccination rates in patients with asthma or diabetes, and persons older than 65 years were 68%, 85%, and 85% respectively in GIS, while the corresponding percentages in the Dutch population were 73%, 85% and 87%. There was also a marked similarity between the seasonal course of ILI measured by GIS and the GPs. Although the ILI rate in GIS was about 10 times higher, the curves followed an almost similar pattern, with peak incidences occurring in the same week.

CONCLUSION

The current study demonstrates that recruitment of a high number of persons willing to participate in on-line health surveillance is feasible. The information gathered proved to be reliable, as it paralleled the information obtained via an undisputed route. We believe that the interactive nature of GIS and the appealing subject were keys to its success.

Treatment of heart failure in Dutch general practice

Background

To study the relation between the prescription rates of selected cardiovascular drugs (ACE-inhibitors and Angiotensin receptor blockers, beta-blockers, diuretics, and combinations), sociodemographic factors (age, gender and socioeconomic class) and concomitant diseases (hypertension, coronary heart disease, cerebrovascular accident, heart valve disease, atrial fibrillation, diabetes mellitus and asthma/COPD) among patients with heart failure cared for in general practice.

Methods

Data from the second Dutch National Survey in General Practice, conducted mainly in 2001. In this study the data of 96 practices with a registered patient population of 374.000 were used.

Data included diagnosis made during one year by general practitioners, derived from the electronic medical records, prescriptions for medication and sociodemographic characteristics collected via a postal questionnary (response 76%)

Results

A diagnosis of HF was found with 2771 patients (7.1 in 1000). Their mean age was 77.7 years, 68% was 75 years or older, 55% of the patients were women. Overall prescription rates for RAAS-I, beta-blockers and diuretics were 50%, 32%, 86%, respectively, whereas a combination of these three drugs was prescribed in 18%. Variations in prescription rates were mainly related to age and concomitant diseases.

Conclusion

Prescription is not influenced by gender, to a small degree influenced by socioeconomic status and to a large degree by age and concomitant diseases.

Disaster and subsequent healthcare utilization: a longitudinal study among victims, their family members, and control subjects

BACKGROUND

The impact of disasters on primary healthcare utilization is largely unknown. Moreover, it is often overlooked how disaster affects those closest to the primary victims, their family members.

OBJECTIVE

The objective of this study was to examine the long-term effects of a catastrophic fire on primary healthcare utilization.

RESEARCH DESIGN

We conducted a prospective, population-based cohort study covering 1 year pre- and 3 years postfire. Utilization data were extracted from primary care records.

SUBJECTS

Subjects consisted of 286 disaster victims, 802 family members of disaster victims, 3722 community control subjects, and 10,230 patients from a national reference population.

MEASURES

As outcome measures, we studied 1) the annual number of contacts in primary care and 2) the annual number of contacts for problems related to mental health. Determinants are injury characteristics of victims and bereavement. All analyses control for age, gender, and insurance status.

RESULTS

Being an uninjured victim who witnessed the disaster increases the number of contacts by a factor of 1.55 during the first year postfire (95% confidence interval [CI], 1.35-1.78). Uninjured victims contact the family practitioner more often for mental health-related problems than adolescent community control subjects (incidence rate ratio [IRR], 4.54; 95% CI, 1.69-12.20). In adult family members, the loss of a child predicts overall utilization (IRR, 1.88; 95% CI, 1.35-2.63) and utilization for mental health (IRR, 8.69; 95% CI, 2.10-35.92) during the first year postfire.

CONCLUSION

Attention should be paid to the primary care needs of bereaved individuals and those who have witnessed the disaster.

The course of post-disaster health problems of victims with pre-disaster psychological problems as presented in general practice

BACKGROUND

Survivors of disaster with pre-disaster psychological problems are believed to be at risk for presenting post-disaster psychological and physical morbidity. Up till now this statement is based on cross-sectional studies with self-reported data and without pre-disaster measurement.

OBJECTIVE

To monitor post-disaster health care utilization and morbidity presented in general practice after a man-made disaster by victims and controls with and without pre-disaster psychological problems.

METHODS

A controlled cohort study with pre-disaster (1 year) and post-disaster (two-and-a-half years) data. Victims (N = 2518) of an exploding fireworks depot in a residential area and matched controls (N = 2512), representing patients in 30 general practices, were included. Main outcome measures were utilization measured by GP attendances, and psychological and physical problems registered by the GP using the International Classification of Primary Care.

RESULTS

Only victims without pre-disaster psychological problems demonstrated a significant increase in utilization in the first half year post-disaster. Victims with pre-disaster psychological problems did not. Being a victim (OR = 6.13; 95% CI = 4.84-7.77) had a greater effect than pre-disaster psychological problems (OR = 4.96; 95% CI = 3.96-6.21) on presenting post-disaster psychological problems. Pre-disaster psychological problems had more effect (OR = 1.93; 95% CI = 1.79-2.08) than the effect of being a victim (OR = 1.25; 95% CI = 1.18-1.32) on the development of post-disaster physical symptoms.

CONCLUSION

Post-disaster increases in utilization and psychological morbidity were observed. Post-disaster psychological problems were more influenced by the disaster, while post-disaster physical symptoms were more influenced by pre-disaster psychological problems. GPs should concentrate on the pre-disaster health history of victims of man-made disasters in their practices.

Direct access in primary care and patient satisfaction: A European study

OBJECTIVE

This study addressed the question to what extent gate-keeping or direct access to health care services influences the satisfaction with GP-services by the population in 18 European countries ("old" EU-countries plus Norway, Iceland and Switzerland).

METHODS

Two datasets were collected. Firstly, country experts were asked to indicate for 17 different health care providers whether they were directly accessible. A direct accessibility scale was computed from the percentage of services that were directly accessible. Secondly, for patient satisfaction the EUROPEP study was used. This dataset contained information about patient satisfaction with general practitioners services in 14 European countries.

RESULTS

If more health care providers were directly accessible in a country, patients showed a higher satisfaction with general practice than in countries where more referrals were required (Pearson's r = 0.54, p = 0.05). Satisfaction with organisational aspects of general practice (concerning amongst others waiting time and possibilities to make appointments) correlates significantly with a high score on our direct accessibility measure (Pearson's r = 0.67, p = 0.01). Satisfaction with patient physician communication (Pearson's r = 0.46, p = 0.10) and medical technical content of the care (Pearson's r = 0.41, p = 0.14) are not influenced by direct accessibility.

CONCLUSIONS

Direct accessibility appeared to be important for patients. Apparently, if patients have freedom of choice for the type of health care provider, they evaluate the GP-services more positively. However, this mainly concerns satisfaction with organisational aspects of GP-services; the accessibility does not influence patient's judgement about the actual care provided by their GP.

The epidemiology of suicide and attempted suicide in Dutch General Practice 1983-2003

BACKGROUND

Many patients attempting or committing suicide consult their general practitioner (GP) in the preceding period, indicating that GPs might play an important role in prevention. The aim of the present study was to analyse the epidemiology of suicidal behaviour in Dutch General Practice in order to find possible clues for prevention.

METHOD

Description of trends in suicide and suicide attempts occurring from 1983-2003 in the Dutch General Practice Sentinel Network, representing 1% of the Dutch population. The data were analysed with regard to: 1) suicidal behaviour trends and their association with household situation; 2) presence of depression, treatment of depression and referral rate by GPs; 3) contact with GP before suicide or suicide attempt and discussion of suicidal ideation.

RESULTS

Between 1983 and 2003 the annual number of suicide and suicide attempts decreased by 50%. Sixty percent of the patients who committed or attempted suicide were diagnosed as depressed, of whom 91% were treated by their GP with an antidepressant. Living alone was a risk factor for suicide (odds ratio 1.99; 95% CI 1.50 to 2.64), whereas living in a household of 3 or more persons was a relative risk for a suicide attempt (odds ratio 1.81; 95% CI 1.34 to 2.46). Referral to a psychiatrist or other mental health professionals occurred in 65% of the cases. GPs recalled having discussed suicidal ideation in only 7% of the cases, and in retrospect estimated that they had foreseen suicide or suicide attempts in 31% and 22% of the cases, respectively, if there had been contact in the preceding month.

CONCLUSION

With regard to the prescription of antidepressants and referral of suicidal patients to a psychiatrist, Dutch GPs fulfil their role as gatekeeper satisfactorily. However, since few patients discuss their suicidal ideation with their GP, there is room for improvement. GPs should take the lead to make this subject debatable. It may improve early recognition of depressed patients at risk and accelerate their referral to mental health professionals.

Gender-related differences in general practice preferences: longitudinal evidence from the Netherlands 1982-2001

The proportion of female doctors is increasing. Yet, there is little evidence that demonstrates changing career preferences over a long period, nor do we know the long-term impact of changing male-female ratios in medicine. We explored this within the GP profession. By means of a longitudinal cohort study (postal questionnaires) among all graduated GPs in the Netherlands between 1982 and 2001 we explored trends in career preferences and investigated whether practice preferences of men and women differ over the years. Preference of becoming a GP has significantly decreased among men. GPs prefer group practice more than solo practice. Female doctors were more likely to prefer a small practice and to associate. Men prefer to take over an established practice. Main reasons to abstain from practicing as a GP for men were having found another job or not having found a practice according to their preferences. Main reasons for women were having decided for another job and family life. We conclude that male and female GPs select differently on practice setting. Preferences change through the years but tend to converge. Gender differences are likely due to the circumstance that career choices for men are more influenced by fluctuating labour markets, while female choices are more based on family circumstances. We expect that as more women will become a GP the demand for small group practices will increase. Also, as many female GPs abstain from practicing after having finished a vocational GP training program it will be essential to create work facilities to keep them available for the GP labour market.

Home care needs of patients with long-term conditions: literature review

BACKGROUND

There is a widely felt need to improve the match between long-term patients' care needs and actual use of home care. As this match is not always adequate, it is important to know what factors influence it.

AIM

The aim of this paper is to provide insight into long-term patients' need and actual use of home care, and the factors influencing these.

METHOD

A literature review was carried out, based on database searches in PubMed, CINAHL and the Nivel online library catalogue. A total of 114 papers were retrieved, but only 13 clearly dealt with use of professional home care (rather than informal home care or residential care) by people with long-term conditions.

RESULTS

There is a dearth of publications on factors influencing the match between care need and actual use of professional home care among people with long-term conditions. Most of the 13 publications reviewed concerned determinants of professional home care use, rather than the match between patients' felt needs and the home care delivered. From these studies, a profile of people with long-term conditions who used home care emerged. In general, older, non-white women, with multiple chronic diseases and impairments, and who had recently had inpatient care, tended to make more use of professional home care.

CONCLUSION

Future research in this field is recommended, particularly into system- and patient-related characteristics that may be responsible for the mismatch between care need and use.

Research utilization and the impact of health promotion policy

OBJECTIVES

The conditions under which research utilization leads to policy impact are an important issue in health promotion. This analysis tests the assumption that utilization is positively associated with policy impact only if both political will (i.e., policy opportunities) and social strategies (in intervention and implementation) are present.

METHODS

A survey of 719 policymakers involved in four policies was conducted in six European countries. Policy impact (output, i.e., program implementation, and outcome, i.e., effects on behavior) and its proposed determinants were analyzed.

RESULTS

Regression analyses reveal limited cross-national differences in research utilization, but show comparably high use in policies with a pathogenic focus. Utilization is associated with impact only if political will is lacking; for outcome, this tends to depend on social strategies. Political will is the strongest determinant of impact.

CONCLUSIONS

Research utilization is not supporting health promotion policy impact if political will is favorable, but if it is poor; political will itself is the crucial determinant of impact. The study contributes to the "research utilization"-field by showing that research utilization may partially compensate for lack of, rather than depend on, political will.

Health policy perception and health behaviours: a multilevel analysis and implications for public health psychology

Associations of health policy perception with health behaviours are analysed. Policy perception is differentiated in information about programmes and appraisal of health policy's contribution to policy goals, and conceptualized on the level of: (1) individuals; and (2) populations (as a social climate indicator). Survey data from the Biomed2-Project MAREPS gathered in Belgium, Finland, Germany, The Netherlands, Spain and Switzerland (N= 3343) show that at the individual level, only policy information is associated with utilizing mammography, quitting smoking, physical activity and political participation in creating healthy environments. In contrast, multilevel regression analyses show that policy appraisal is related to physical activity and political participation as a social climate factor. Implications for integrating health psychology and public health within public health psychology are discussed.

Determinants of health policy impact: comparative results of a European policymaker study

OBJECTIVES

This article will use a new theoretical framework for the analysis of health policy impact introduced by Rütten et al. (2003). In particular, it will report on a comparative European study of policymakers' perception and evaluation of specific determinants of the policy impact, both in terms of output (implemented measures) and outcome (health behaviour change). Policy determinants investigated are goals, resources, obligations and opportunities as related to the policymaking process.

METHODS

Theory is applied to a comparative analysis of prevention and health promotion policy in Belgium, Finland, Germany. The Netherlands, Spain and Switzerland. The study is MED2-part of a project that has developed a Methodology for the Analysis of the Rationality and Effectiveness of Prevention and Health Promotion Strategies (MAREPS) within the EU-BIO-program. A mail survey of 719 policymakers on the executive and administrative level selected by a focused sample procedure was conducted. This survey used policymakers' experience and evaluative expertise to analyse determinants of policy output and outcome.

RESULTS

Regression analyses reveal differential predictive power of policy goals, resources, obligations, as well as of political, organisational and public opportunities. For instance, whereas resources, concreteness of goals, and public opportunities have significant importance for health outcome of policy, obligations and organisational opportunities significantly predict policy output.

CONCLUSIONS

Results are discussed in terms of rationality and effectiveness of health policy. They indicate that six sensitising constructs derived from the theoretical framework represent equivalent structures across nations. They comprise a validated instrument that can be used for further comparative health policy research.

Determinants of health policy impact: a theoretical framework for policy analysis

This paper addresses the role of policy and evidence in health promotion. The concept of von Wright's "logic of events" is introduced and applied to health policy impact analysis. According to von Wright (1976), human action can be explained by a restricted number of determinants: wants, abilities, duties, and opportunities. The dynamics of action result from changes in opportunities (logic of events). Applied to the policymaking process, the present model explains personal wants as subordinated to political goals. Abilities of individual policy makers are part of organisational resources. Also, personal duties are subordinated to institutional obligations. Opportunities are mainly related to political context and public support. The present analysis suggests that policy determinants such as concrete goals, sufficient resources and public support may be crucial for achieving an intended behaviour change on the population level, while other policy determinants, e.g., personal commitment and organisational capacities, may especially relate to the policy implementation process. The paper concludes by indicating ways in which future research using this theoretical framework might contribute to health promotion practice for improved health outcomes across populations.

One-time physical therapist consultation in primary health care

BACKGROUND AND PURPOSE

One-time physical therapist consultation, prior to possible referral for physical therapy intervention, may enhance the quality of patient care, particularly if the referring physician is uncertain as to whether intervention by a physical therapist will be beneficial. The purpose of this study was to describe the use of consultation by a group of primary care physicians (PCPs) who could refer patients for a one-time consultation.

SUBJECTS AND METHODS

A 7-month observational study was conducted in the Netherlands with 59 pairs of randomly selected PCPs and physical therapists practicing in primary health care. Data were collected for the PCPs, the physical therapists, and the patients. Self-administered questionnaires (completed at the start and at the completion of the study), consultation request and report forms, and treatment referral records from health insurance agencies were used to obtain data. National reference data on patients referred by PCPs for intervention by a physical therapist were used to compare the data of patients referred by PCPs for a one-time consultation. The number and nature of consultation requests were determined as well as patient characteristics. The PCPs' satisfaction with the outcome and process of a one-time consultation and its impact on PCPs' management decisions also were described.

RESULTS

The number of referrals for a one-time consultation was 352 (X=5.9 per PCP, SD=5.4, range=0-20), resulting in a mean referral rate of 4.7 per 1,000 patients (SD=4.6). Characteristics of patients referred for a one-time consultation differed from national reference data of patients referred by their PCP for intervention by a physical therapist.

DISCUSSION AND CONCLUSION

The results show that PCPs used the opportunity for a one-time physical therapist consultation and were satisfied with the outcome and process of consultation. The findings suggest that a one-time consultation is an appropriate and beneficial component of PCPs' patient management process.

Conditions for research in general practice. Can the Dutch and British experiences be applied to other countries, for example Spain?

The aim of this study is to identify conditions for research as part of professional development in general practice. Based on the work of Andrew Abbott, who studied the dynamics of professional development, five conditions were identified. These are: the creation of associations among professionals; control of work; the establishment of specialised education; the development of professional knowledge; and the creation of organised structures for professional work. Two countries with a well-established research tradition in general practice (the UK and the Netherlands) and one country where GP research development is still limited (Spain) were evaluated on the basis of these conditions. The conditions identified as favourable were as follows: the existence of a scientific association; a peer-reviewed journal; a defined population resulting in a population denominator for practices; a gatekeeping system; chairs and departments of general practice at universities; the integration of education centres and research centres; GPs working in group practices or health centres; a certain degree of independence from the Ministry of Health; and financial support for practicing GPs to conduct research activities. We showed that most conditions for the successful scientific progress of general practice in Spain are present. However there is still a gap between academia and general practice and a lack of research organisation and support.

An evaluation of the new home-care needs assessment policy in the Netherlands

The aim of the present study was to describe the realisation of the new-style needs assessment in the Netherlands and how it is evaluated. Furthermore, judgements about the new way of assessing (chronic) patients' needs with respect to home care are presented. Data were gathered by means of a postal survey of all assessment agencies, home-care organisations and health insurers. The new-style assessment, as regulated by the Needs Assessment Decree, implies that home-care needs should be objectively assessed independently of the availability of care supply and integrally with other types of (long-term) care. This study shows that all the organisational structures required to realise these goals are present. However, according to factual and evaluative data, many practical aspects of these structures appear to be deficient. The national assessment forms, an instrument for gaining objectivity, are judged impracticable by half of the assessment agencies. Mandating arrangements threaten independent as well as integral needs assessment. Whether the new-style assessment is evaluated positively or negatively depends upon the type of organisation under study. On the one hand, assessment agencies are positive about their achievements. On the other, home-care organisations are generally negative about the functioning and advantages of the new style of needs assessment. Health insurers' opinions are in between those of assessment agencies and home-care organisations.