Towards healthy settings for people with intellectual disabilities

People with intellectual disabilities (ID) depend on their environment for support to live healthily. The characteristics of healthy settings for people with ID are unknown. This study aims to conceptualize healthy settings for people with ID by conducting an international and multidisciplinary concept mapping study. As theoretical framework the settings approach, an ecological model with a whole system focus toward health promotion, was used. The integrative mixed-methods approach of this study involved concept mapping with researchers specialized in healthcare for people with ID and researchers specialized in healthy settings. The 41 participants generated statements that were later sorted and rated. Findings encompass 13 clusters relating to the social environment, the physical environment and societal preconditions. Specific factors of healthy settings for people with ID include: (i) universal design of the physical environment, (ii) the role of care professionals in the social environment to empower people with ID, (iii) possibilities for care providers to contribute to a health-promoting setting and (iv) preconditions that allow people to engage in society. These factors can be used in strategies to apply the approach in practice and give directions to put in place policies on developing enabling environments and decreasing health inequities.

Impact of Q-fever fatigue syndrome on patients' work status

Background

Chronic illnesses can increase the risk of unemployment, but evidence on the specific impact of Q-fever fatigue syndrome (QFS) on work is lacking.

Aims

The aim of this study was to describe and quantify the impact of QFS on work.

Methods

Changes in work status from 1 year prior to 4 years after acute Q-fever infection of QFS patients were retrospectively collected with a self-report questionnaire measuring employment status and hours of paid work per week. In addition, information on work ability, job satisfaction and need for recovery after work was collected in 2016. Data were compared to participants from the general population.

Results

The proportion of employed QFS patients from 1 year prior to 4 years after acute infection decreased from 78 to 41%, while remaining relatively constant in the general population (82 to 78%). Working QFS patients showed a decrease in mean hours of paid work from 35 to 22 h per week, which is significantly steeper compared to the general population (31–28 h per week) (P < 0.001). QFS patients showed a significantly lower work ability (P < 0.001), lower job satisfaction (P = 0.006) and greater need for recovery (P < 0.001) compared to the general population.

Conclusions

The number of QFS patients with paid work decreased over the years, while patients who continue to work experience lower work ability, job satisfaction and increased need for recovery. Occupational physicians should be aware of the occurrence and severity of the impact of QFS on work, even after many years.

Situations in which mothers experience difficulty stimulating healthy EBRB in school-aged children

Background

Parental support is an important element in overweight prevention programs for children. The purpose of this study was to examine everyday life situations in which mothers encounter difficulties encouraging healthy energy balance-related behavior in their school-age children.

Methods

We formed four focus groups containing 6-9 participants each. The participants were mothers of Dutch, Turkish, or Moroccan descent with a child 8-13 years of age. All focus group sessions were recorded, transcribed, and coded. Content was analyzed conventionally using ATLAS.ti 6.

Results

Twenty-seven difficult everyday life situations were identified in 14 settings. The five most frequently reported situations were a daily struggle regarding eating vegetables, eating breakfast on time before going to school, eating candy and snacks between meals, and spending excessive time watching television and using the computer. A perceived loss of parental control, the inability to establish rules and the failure to consistently enforce those rules were the most commonly cited reasons for why the mothers experience these situations as being difficult.

Conclusions

We identified five difficult everyday life situations related to healthy energy balance-related behavior. These five difficult situations were used as the input for developing a web-based parenting program designed to prevent children from becoming overweight. We reasoned that if we use these situations and the underlying reasons, many parents would recognize these situations and are willing to learn how to deal with them and complete the e-learning.

Key messages

The identified everyday-life-situations in which mothers experience difficulty stimulating healthy EBRBs in their children age 8-13 were used as input for our e-learning program to prevent overweight. Mothers who live in low-SES neighborhoods were easily willing to participate in focus groups and discuss EBRB-related topics.

Degree of consistency of parental dietary and sedentary behavior rules as indicators for overweight

Background

To increase our understanding of the effect of parenting on the child’s likelihood of becoming overweight, we attempted to identify typologies based on how consistently parents apply dietary and sedentary behavior rules, and we examined whether these typologies are associated with energy balance-related behaviors in children and/or with the prevalence of overweight children.

Methods

Data were obtained from a cross-sectional survey of the Community Health Service in Nijmegen, the Netherlands in which a total of 4,865 parents of children aged 4-12 years participated. Data were collected using validated self-report questionnaires. To identify typologies based on how consistently parents apply dietary and sedentary behavior rules, we performed latent class analyses. We then performed regression analyses to examine the correlation between these typologies and socio-demographic characteristics, dietary and sedentary behaviors, and overweight.

Results

Latent class analyses revealed the existence of the following four distinct, stable classes/typologies; parents who have: (1) no dietary behavior rules, plus indulgent sedentary behavior rules; (2) indulgent dietary behavior rules, plus no sedentary behavior rules; (3) overall indulgent rules; (4) overall strict rules. Children of parents with overall strict rules (class 4) had significantly healthier dietary and sedentary behaviors compared to the children of parents in the other three classes. Children 8-12 years of age with parents in class 2 were the most likely to be overweight; compared to the children of parents in classes 1, 3, and 4, the parents in class 2 had the lowest level of education and the higher number of Turkish and Moroccan immigrants.

Conclusions

These results underscore the need for parents to establish strict rules for their children, particularly regarding sedentary behaviour in order to minimize the child’s likelihood of becoming overweight.

Key messages

The results underscore the need for parents to establish strict rules for their children, particularly regarding sedentary behaviour in order to minimize the child’s likelihood of becoming overweight. These results may contribute to making healthcare professionals aware that children of parents who do not apply sedentary behavior rules are more likely to become overweight.

A set of pedagogical recommendations for improving the integrated approach to childhood obesity

Background

Studies increasingly emphasize the importance of the parents’ role in interventions designed to prevent overweight in children. The aim of this study was to develop a unified set of recommendations for healthy parenting practices that can be applied by all professionals who work with children age 4-13 years and can contribute to strengthening the integrated approach to childhood overweight.

Methods

A modified Delphi procedure was used to reach consensus regarding what these pedagogical recommendations should encompass. The 30 panelists were professionals and researchers who work with children in the domains of health care, overweight, parenting, education, nutrition, and/or sports. The procedure consisted of: i) extracting existing pedagogical recommendations from national guidelines and professional protocols, ii) appraising and prioritizing these recommendations in terms of relevance through two rounds of questionnaires, and iii) meeting to discuss and approve the set of recommendations.

Results

Consensus was reached for one set of eleven pedagogical theme-based recommendations designed to support and instruct parents how to stimulate healthy energy balance-related behaviors in their child. Each recommendation contained information regarding: i) which behaviors are important, ii) why this is important, and iii) how parents can stimulate this behavior by applying parenting skills. The eleven themes were: modeling, positive parenting, breakfast, varied diet, sugar-sweetened beverages, snacks, physical activity, playing sports, quantity of screen time, screen time during meals, and sleep.

Conclusions

We developed a set of recommendations for healthy parenting that can be used by various professionals working with children age 4-13 and can contribute to creating an integrated approach to childhood overweight. We also developed a web-based app called “Recommendations for Healthy Parenting” as a convenient tool for following these recommendations.

Key messages

Our set of recommendations for healthy parenting can be used by various professionals who work with school-aged children, thereby helping strengthen the integrated approach to childhood overweight. We developed and released a Dutch web app entitled “11 Recommendations for Healthy Parenting” to provide a convenient tool for easily communicating these recommendations to parents.

The effectiveness of a web-based Dutch parenting program to prevent overweight in children age 9-13

Background

We developed a web-based parenting program for parents entitled “Making a healthy deal with your child”. This e-learning program can be incorporated into existing prevention programs, thereby improving these interventions by reinforcing the role of parenting and providing parents with practical tools for use in everyday situations in order to stimulate a healthy lifestyle.

Methods

The effectiveness was studied in a two-armed cluster randomized controlled trial. We recruited 548 parent-child dyads of children 9-13 years in the Netherlands who participated in an existing school-based overweight prevention program. Primary outcomes included the child’s dietary and sedentary behavior, and level of physical activity. Secondary outcomes included general parenting style, specific parenting practices (set of rules, modeling, monitoring), and parental self-efficacy. Multilevel multiple regression analyses in Mplus were conducted.

Results

87% of the parent-child dyads participated in the study and 47% of the parents in the intervention group completed 2 or more episodes of the e-learning. The score that parents gave to the e-learning is a 7.Main effect analyses showed in the intention-to-treat analyses that the the parents in the intervention group have more strict rules regarding eating snacks (0.046) and children of parents in the intervention group drink more milk (p = 0.018) and less sugar sweetened beverages (p = 0.024). The completers only analyses showed that the children of parents in the intervention group eat more vegetables and fruit, drink more water and less sugar sweetened beverages, and had less screentime than the children in the control group.

Conclusions

The e-learning program showed small indications to be effective. A second effectiveness study is currently being investigated. If the e-learning proves to be effective it can be easily incorporated into existing overweight prevention programs for children, as well as activities regarding Youth Health Care.

Key messages

The e-learning can easily incorporated into existing overweight prevention programs for children. www.gezondeafsprakenmetjekind.nl

Potential effective elements in combined lifestyle interventions for overweight children

Background

Combined Lifestyle Interventions (CLIs), offered in primary care, aim to prevent childhood overweight/obesity. Combined means the intervention focuses on optimalising nutrition behaviour, physical activity and mental health, provided by a multidisciplinary team. Although the effectiveness of CLIs is still not clear, CLIs are already implemented in daily practice in the Netherlands. These CLIs are not uniformly designed and have variations in protocols to suit the needs of their community. Due to the many different CLIs it is difficult to investigate their effectiveness. To be able to investigate effectiveness of GLIs, we first need to unravel the ’black boxes’ of CLIs and identify their (potential) effective elements.

Methods

First, we carried out a literature study on elements that may contribute to the effectiveness of a GLI (the so called potential elements). Next, we organized an online brainstorm session, where experts such as researchers and paramedics could add or specify potential elements. We made all elements measurable, with help of experts. These elements were incorporated into a tool to check presence of potential elements in CLIs. This tool was tested on reliability by comparing the results of four researchers who assessed protocols of six CLIs.

Results

42 experts participated in the brainstorm session. The literature study and brainstorm session together resulted in 54 potential elements for CLIs for overweight/obese children, categorized in four themes: organization, content, role of parents and role of experts. For all six protocols, a minimum of 85% of the potential elements in the tool have been scored the same by the four assessors.

Conclusions

We developed a reliable tool to determine potential effective elements in a CLI. In future studies, this tool can be used to identify specific elements that are effective in CLIs for overweight/obese children by comparing the tool with health effects of CLIs.

Key messages

We were able to develop a reliable instrument to better analyze the factors that contribute to positive health effects of combined lifestyle interventions for children with overweight or obesity. the developed tool with potential effective elements must be filled in for more CLIs, where after we can find corresponding elements in the most effective CLIs.

Clinical course and complications following diagnostic bronchoalveolar lavage in critically ill mechanically ventilated patients

Background

Flexible, fibreoptic bronchoscopy (FFB) and bronchoalveolar lavage (BAL) have been used for diagnostic purposes in critically ill ventilated patients. The additional diagnostic value compared to tracheal aspirations in ventilator-associated pneumonia (VAP) has been questioned. Nevertheless, BAL can provide extra information for the differential diagnosis of respiratory disease and good antibiotic stewardship. These benefits should outweigh potential hazards caused by the invasiveness of this diagnostic technique. The focus of the present study was on the clinical course and complications of patients following BAL procedures up to 24 h.

Methods

Hundred sixty-four FFB guided BAL procedures for suspected pneumonia were analysed in an observational study. The clinical course of patients was monitored by respiratory and haemodynamic data before BAL, 1 and 24 h after BAL. Complications were defined and registered. Factors associated with complications were analysed by logistic regression.

Results

Clinical course: a decrease in average pO₂/FiO₂ ratio 1 h after BAL from 29 kPa (218 mmHg) to 25 kPa (189 mmHg) (p < 0.05) was observed which fully recovered within 24 h. Respiratory complications: the incidence of procedure related hypo-oxygenation (SaO₂ ≤ 88 %) and/or bronchospasm was 9 %; a decrease of >25 % PaO₂/FiO₂ ratio 1 h after BAL was found in 29 % of patients; no bleeding or pneumothorax were registered. Haemodynamic complications: there were no cases of hypertension and cardiac rhythm disturbances; haemodynamic instability within the first 24 h after BAL was recorded in 22 %; this was correlated with a cardiovascular diagnosis at admission (OR 2.9; 95 % CI 1.2 - 6.7) and the presence of cardiovascular co-morbidity (OR 3.5; 95 % CI 1.5 – 8.3). The incidence of bacteraemia was 7 %. There was no case of procedure related death.

Discussion

Frequently occurring haemodynamic and respiratory instability but no cases of cardiac rhythm disturbances, bleeding, pneumothorax or procedure related death were attributable to diagnostic FFB and BAL. The procedures should be conducted under careful supervision by experienced physicians. Only a randomized controlled trial that compares diagnostic FFB and BAL with a non-invasive strategy could ultimately establish the safety profile and clinical utility of these procedures in critically ill ventilated patients.

Malnutrition and socio-demographic factors associated with pulmonary tuberculosis in Timor and Rote Islands, Indonesia

OBJECTIVE

To identify nutritional and socio-demographic factors for the development of tuberculosis (TB) in Timor and Rote Island, Indonesia, so that intervention programmes can be developed to address these factors.

METHODS

In a case-control study, we enrolled new sputum smear-positive pulmonary TB patients as cases, and neighbours matched for sex and age as controls. Data obtained included history of TB, socio-demographic factors and nutritional status.

RESULTS

In the study, 121 TB patients and 371 controls participated. The mean age was 30 years: 56.3% were male and 43.7% female. Of the TB patients, 87% had malnutrition compared to 33% among controls. The mean body mass index (BMI) of the patients was significantly lower than that of the controls (16.1 +/- 2.3 kg/m(2) vs. 19.4 +/- 3.0 kg/m(2)). Factors associated with the development of TB were BMI (OR 0.5, 95%CI 0.4-0.6), family history of TB (OR 3.2, 95%CI 1.6-6.4), living in an extended family (OR 2.7, 95%CI 1.5-4.8), being non-indigenous to Timor and Rote Islands (OR 2.9, 95%CI 1.2-6.8) and being unemployed (OR 3.8, 95%CI 1.7-8.6).

CONCLUSION

Among patients with active pulmonary TB, the prevalence of malnutrition was very high. Malnutrition, which is a general problem for the whole community and particularly among people not indigenous to Timor and Rote, should be addressed in the fight against TB.

Vitamin A deficiency and other factors associated with severe tuberculosis in Timor and Rote Islands, East Nusa Tenggara Province, Indonesia

BACKGROUND

Plasma zinc and vitamin A concentrations have been reported to be low in tuberculosis (TB) patients in some studies, although it is not clear whether this constitutes a risk for a more severe clinical presentation among TB patients. The acute phase reaction may also deplete zinc and vitamin A in the plasma. Therefore, we further studied these associations.

METHODS

We carried out a cross-sectional study among newly diagnosed sputum smear-positive TB patients in East Nusa Tenggara. The patients were categorized as either mild TB when Karnofsky Score (KS) > or =80 or severe TB (KS <80). Body mass index (BMI), mid upper arm circumference (MUAC), chest radiograph, and the results of hemoglobin, erythrocyte sedimentation rate, albumin, C-reactive protein (CRP), zinc and vitamin A in plasma were correlated with TB category.

RESULTS

A total of 300 TB patients participated in the study (63% male and 37% female), and were categorized as mild TB (53%) or severe TB (47%). Vitamin A, hemoglobin and plasma albumin were significantly lower, and CRP was significantly higher, in severe TB than in mild TB, and the active lesion area on the chest radiograph was greater among severe TB patients. In a multiple regression analysis, after adjustment for CRP, low vitamin A (beta=3.2, 95%CI (confidence interval) 1.6-4.9, P=0.000) but not zinc, correlated with the severity of TB. MUAC was better than BMI as a predictor of TB severity (beta=1.3, 95%CI 0.6-6.2, P=0.000).

CONCLUSIONS

Severe TB was associated with vitamin A deficiency. MUAC can be applied as a measure of TB severity.

Primary groin irradiation vs primary groin surgery for early vulvar cancer

BACKGROUND

Despite changes in technique, morbidity after surgical treatment for vulvar cancer is considerable and mainly related to the groin dissection. Primary radiotherapy to the groin is expected to result in lower morbidity. However, studies on the efficacy of primary radiotherapy for the groins in terms of groin recurrences and survival show conflicting results.

OBJECTIVES

To determine whether the effectiveness and safety of primary radiotherapy to the inguino-femoral lymph nodes is comparable with surgery

SEARCH STRATEGY

The literature search was carried out using the criteria set by the Cochrane Gynaecological Cancer Group. A MEDLINE and EMBASE search using the Mesh Heading 'vulvar neoplasms' and textword 'vulva' was performed. Publications on the effectiveness of primary radiotherapy treatment of early squamous cell carcinoma of the vulva were selected.

TYPE OF STUDY

Randomized clinical trials, case-control and observational studies of primary radiotherapy of the groin Type of participants: Patients with early squamous cell cancer of the vulva Type of interventions: inguino-femoral lymph node dissection and primary radiotherapy of the inguino-femoral lymph nodes. Type of outcome measurements: incidence of groin recurrences, survival and morbidity

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed study quality and extracted results

MAIN RESULTS

Out of nine reviewed papers only three met the selection criteria. From these studies, (one randomised controlled trial [RCT] one case-control and one observational study) it became clear from the RCT that the incidence of groin recurrences after primary radiotherapy is higher compared with surgery. survival was also worse in the radiotherapy group. The other two studies showed a higher than expected number of groin recurrences after primary radiotherapy. Morbidity after primary radiotherapy was lower compared with surgery. The conclusion of the RCT was criticized on the grounds of the depth of the radiotherapy administered. The depth of 3 cm used in the RCT, is too shallow to administer an optimal dose to the deeper groin nodes.

REVIEWER'S CONCLUSIONS

As shown in an RCT, primary radiotherapy to the groin results in less morbidity but also in a higher number of groin recurrences compared with surgery. Although the technique of radiotherapy in the RCT was criticized, other uncontrolled data do not give evidence for a similar or better groin control for radiotherapy when compared to surgery. This means that surgery is still to be considered the cornerstone of therapy for the groin nodes in women with vulvar cancer. Individual patients not fit enough to withstand surgery can be treated with primary radiotherapy.

Hormone replacement therapy: changes in frequency and type of prescription by Dutch GPs during the last decade of the millennium

OBJECTIVE

The present study was conducted in order to determine the change of frequency and type of hormone replacement therapy (HRT) regimen newly prescribed by Dutch GPs.

METHODS

A comparison was made of two data sets (multi-stage random samples) collected in 1987/88 and from 1995 to 1998 concerning women 40 years and older who were newly prescribed HRT.

RESULTS

Compared with 1987/88, 50% more patients were newly prescribed HRT in 1998 (2.0 in 1987/88 and 3.0 in 1998 per 1000 registered women, P < 0.01). The age distribution remained about the same, with a peak between 50 and 54 years in each year of registration. Unopposed oestrogens (including plasters) were prescribed less frequently (1.3 per thousand in 1987/88 versus 0.7 per thousand in 1998, P < 0.001), and combinations of oestrogen and progestogen more frequently in 1998 (0. 2 per thousand in 1987/88 versus 1.8 per thousand in 1998, P < 0. 01). Sequential therapy was prescribed slightly more frequently than continuous therapy (65% sequential therapy in 1995; 55% in 1998). The most frequent reason for starting HRT in 1995-1998 was climacteric symptoms (89-98%), followed by osteoporosis prevention (16-28%) and early menopause (13-25%). Rarely were preventive goals the only reason (6%) for prescribing HRT.

CONCLUSIONS

The number of HRT prescriptions increased by 50% over the last decade of the millennium. The age distribution remained the same. There was a tendency to shift from prescribing unopposed oestrogens to combinations of oestrogens and progestogens. Alleviation of climacteric symptoms was the main reason for prescribing HRT throughout the registration period. Prescription of HRT for prevention of osteoporosis and/or cardiovascular disease has so far not been adopted on a large scale by Dutch GPs.

The elimination of selected chronic diseases in a population: the compression and expansion of morbidity

OBJECTIVES

This study evaluates the effect of eliminating a specific disease on the mortality, long-term disability, and overall health status of a population. Primarily, it examines whether elimination leads to a compression of morbidity.

METHODS

The Sullivan method was used to calculate disability-free life expectancy. Cause-deleted disability prevalence was estimated with a multiple logistic regression model that used data from the Dutch National Survey of General Practice. Cause-deleted probabilities of dying were derived with the cause-elimination life-table technique, assuming independence among competing causes of death.

RESULTS

Eliminating disabling nonfatal diseases such as arthritis/back complaints results in a decline in life expectancy with disability--that is, an absolute compression of morbidity. Eliminating highly fatal diseases such as cancer leads to an increase in the number of years and the proportion of life with disability--that is, a relative expansion of morbidity.

CONCLUSIONS

While eliminating fatal diseases leads to an increase in disability-free life expectancy, life expectancy with disability may increase as well. This represents an increasing burden to society. On the other hand, eliminating nonfatal disabling diseases leads to absolute compression of morbidity.

Do out-of-office laboratory tests affect diagnoses in general practice?

OBJECTIVE

To find out whether the GP diagnosis changed by out-of-office laboratory test results and whether his diagnosis became more certain.

DESIGN

Descriptive study.

SETTING

Dutch survey of morbidity and interventions in general practice: stratified random sample of 161 GPs with a total list of 335,000 patients.

SUBJECTS

2,081 episodes of illness with at least one consultation with clinical chemistry, haematology, or serology tests and at least one follow-up consultation.

MAIN OUTCOME MEASUREMENTS

Change in ICPC component or chapter between the consultation in which a laboratory test was ordered and the follow up contact; change in exact ICPC code in cases with important diseases (infectious diseases, haematological disorders, endocrine abnormalities, auto-immune processes and malignancies (n = 330)); change in certainty of a diagnosis and change in somatic/psychosocial orientation.

RESULTS

After laboratory tests done in the first consultation the ICPC component changed in 46% of the diagnoses. Of the diagnoses made in first consultations without laboratory tests 41% changed in the follow up consultation. The diagnosis after laboratory tests was the same as before in 51% of the consultations with important diseases. Certainty about a diagnosis increased significantly after laboratory tests (p < 0.001). An abnormal laboratory result did not affect the clinical certainty of the general practitioner or the percentage of altered diagnoses.

CONCLUSION

The usefulness of tests should be assessed not only in terms of the number of diagnoses changed or of the percentage of abnormal results, but also in terms of the changed certainty concerning a diagnosis.

Cholesterol management in Dutch general practice. A comparison with national guidelines. Dutch College of General Practitioners

OBJECTIVE

To examine cholesterol diagnosis and treatment by Dutch general practitioners (GPs) in the period before publication of national guidelines, in order to develop implementation strategies based on discrepancies found between daily practice and the guidelines.

DESIGN

Data of the 'Dutch National Survey of General Practice', in which GPs were involved in extensive consultation registration, were used. Patients were included for analysis if serum cholesterol, or the ICPC-code lipid metabolism disorder, or cholesterol-lowering treatment was registered.

SETTING

General practice.

PARTICIPANTS

161 GPs, 177 practice-nurses.

OUTCOME MEASURES

Reasons for consultation, diagnoses, therapy, inter-doctor variation.

RESULTS

The main discrepancies between daily practice and the guidelines concerned indications for cholesterol measurement, repeated measurements to diagnose hypercholesterolaemia, and attention for diet advice. A remarkable inter-doctor variation in diagnosis, and less so in treatment, was also found.

CONCLUSION

The inter-doctor variation justifies the publication of the standard guidelines. Implementation strategies should aim at indications for cholesterol testing, repeating measurements for diagnosis, and advice on diet.

Prescription of antibiotics and prescribers' characteristics. A study into prescription of antibiotics in upper respiratory tract infections in general practice

There is a growing concern about rational prescribing of antibiotics. That is why a secondary analysis of prescribing antibiotics in upper respiratory tract infections has been conducted by means of a nationwide study of morbidity and interventions in The Netherlands. The mean percentage of antibiotic prescriptions varied from about 20% for acute otitis media and acute upper respiratory tract infections to about 70% for sinusitis and tonsillitis. Only attitude--toward prescribing antibiotics in sore throat--and years of settlement were important predictor variables. The other characteristics studied--type of practice, list size, frequency of use of Het Farmacotherapeutisch Kompas, containing national pharmacotherapeutical guidelines, and urbanization level were not. The importance of attitude, however, was less for general practitioners who went into practice after 1975. This means that the influence of a personal characteristic as attitude might have become less influential since the introduction of vocational training for general practice.

List size, composition of practice and general practitioners' workload in The Netherlands

Workload of general practitioners plays an important role in discussions about list size and remuneration in health care systems with fixed patient lists and capitation payments, such as in the Netherlands and in the United Kingdom. Against the background of the fairness of differences in income level between GPs the question is posed to what extent differences in list size reflect differences in workload and to what extent differences in patient characteristics influence workload. Both list size and practice composition relate to the demand led character of general practice. Data collected in the National Study of Morbidity and Interventions in General Practice are used. Central to this study is a three month recording of all contacts of 161 general practitioners (and their locums, assistant GPs and trainees) in the Netherlands. For each practice a patient register has been made to relate contacts to the practice population. The participating GPs kept a detailed diary covering 24 hr a day during one week. As indicators of workload several contact rates, hours worked in practice per week (in direct patient care and in other activities) and average length of office consultations are used. Demand related characteristics have the strongest relation to the number of hours worked by GPs, particularly the number of hours spent in patient-related activities. Rates of contacts, with the exception of the office contact rate, are not related to list size, but mainly to practice composition. The average length of consultations is negatively related to list size and some characteristics of the practice population.

Dutch general practice care for patients with epilepsy: results from the Dutch National Survey of Morbidity and Interventions

This study aimed to assess the share which Dutch general practice has in the care of patients with epilepsy. During a 3-month period 400,000 patient contacts in 103 general practices with a total list of 335,000 patients were registered, 1536 of these, concerning 1059 patients, concerned epilepsy. Contacts with patients with known epilepsy in Dutch General Practice were handled mainly by the practice nurse and most involved repeat prescriptions. Patients suspected of having epilepsy had more attention from the General Practitioner. The involvement of General Practitioners in the care of epilepsy was found to be small, but not unimportant. GPs are in a crucial position as regards the detection of epilepsy. They can enlarge their role in respect of patients with known epilepsy and improve continuity of care.