Radiating low back pain in general practice: incidence, prevalence, diagnosis, and long-term clinical course of illness

OBJECTIVE

The aim of this study was to calculate the incidence and prevalence of radiating low back pain, to explore the long-term clinical course of radiating low back pain including the influence of radiculopathy (in a subsample of the study population) and non-radiating low back pain thereon, and to describe general practitioners' (GPs') treatment strategies for radiating low back pain.

DESIGN

A historic prospective cohort study.

SETTING

Dutch general practice.

SUBJECTS

Patients over 18 years of age with a first episode of radiating low back pain, registered by the ICPC code L86.

MAIN OUTCOME MEASURES

Incidence and prevalence, clinical course of illness, initial diagnoses established by the GPs, and treatment strategies.

RESULTS

Mean incidence was 9.4 and mean prevalence was 17.2 per 1000 person years. In total, 390 patients had 1193 contacts with their GPs; 50% had only one contact with their GP. Consultation rates were higher in patients with a history of non-radiating low back pain and in patients with a diagnosis of radiculopathy in the first five years. In this study's subsample of 103 patients, L86 episodes represented radiculopathy in 50% of cases. Medication was prescribed to 64% of patients, mostly NSAIDs. Some 53% of patients were referred, mainly to physiotherapists and neurologists; 9% of patients underwent surgery.

CONCLUSION

Watchful waiting seems to be sufficient general practice care in most cases of radiating low back pain. Further research should be focused on clarifying the relationship between radicular radiating low back pain, non-radicular radiating low back pain, and non-radiating low back pain.

Skin autofluorescence as proxy of tissue AGE accumulation is dissociated from SCORE cardiovascular risk score, and remains so after 3 years

BACKGROUND

Skin autofluorescence (SAF), as a proxy of AGE accumulation, is predictive of cardiovascular (CVD) complications in i.a. type 2 diabetes mellitus and renal failure, independently of most conventional CVD risk factors. The present exploratory substudy of the Groningen Overweight and Lifestyle (GOAL)-project addresses whether SAF is related to Systematic COronary Risk Evaluation (SCORE) risk estimation (% 10-year CVD-mortality risk) in overweight/obese persons in primary care, without diabetes/renal disease, and if after 3-year treatment of risk factors (change in, Δ) SAF is related to ΔSCORE.

METHODS

In a sample of 65 participants from the GOAL study, with a body mass index (BMI) >25-40 kg/m2, hypertension and/or dyslipidemia, but without diabetes/renal disease, SAF and CVD risk factors were measured at baseline, and after 3 years of lifestyle and pharmaceutical treatment.

RESULTS

At baseline, the mean SCORE risk estimation was 3.1±2.6%, mean SAF 2.04±0.5AU. In multivariate analysis SAF was strongly related to age, but not to other risk factors/SCORE. After 3 years ΔSAF was 0.34±0.45 AU (p<0.001). ΔSAF was negatively related to Δbodyweight but not to ΔSCORE%, or its components. At follow-up, SAF was higher in 11 patients with a history of CVD compared to 54 persons without CVD (p=0.002).

CONCLUSIONS

Baseline and 3-year-Δ SAF are not related to (Δ)SCORE, or its components, except age, in the studied population. ΔSAF was negatively related to Δweight. As 3-year SAF was higher in persons with CVD, these results support a larger study on SAF to assess its contribution to conventional risk factors/SCORE in predicting CVD in overweight persons with low-intermediate cardiovascular risk.

Patients' preferences for post-treatment breast cancer follow-up in primary care vs. secondary care: a qualitative study

OBJECTIVE

To explore patients' preferences for follow-up in primary care vs. secondary care.

METHODS

A cross-sectional design was employed, involving semi-structured interviews with 70 female patients with a history of early-stage breast cancer. Using descriptive content analysis, interview transcripts were analysed independently and thematically by two researchers.

FINDINGS

Patients expressed the strongest preference for annual visits (31/68), a schedule with a decreasing frequency over time (27/68), and follow-up > 10 years, including lifelong follow-up (20/64). The majority (56/61) preferred to receive follow-up care from the same care provider over time, for reasons related to a personal doctor-patient relationship and the physician's knowledge of the patient's history. About 75% (43/56) preferred specialist follow-up to other follow-up models. However, primary care-based follow-up would be accepted by 57% (39/68) provided that there is good communication between GPs and specialists, and sufficient knowledge among GPs about follow-up. Perceived benefits of primary care-based follow-up referred to the personal nature of the GP-patient relationship and the easy access to primary care. Perceived barriers included limited oncology knowledge and skills, time available, motivation among GPs to provide follow-up care and patients' confidence with the present specialist follow-up.

CONCLUSIONS

More than half of the patients were open to primary care-based follow-up. Patients' confidence with this follow-up model may increase by using survivorship care plans to facilitate communication across the primary/secondary interface and with patients. Training GPs to improve their oncology knowledge and skills might also increase patients' confidence.

Are lower urinary tract symptoms in men associated with cardiovascular diseases in a primary care population: a registry study

BACKGROUND

Although lower urinary tract symptoms (LUTS) seem to be related to cardiovascular disease (CVD) in men, it is unclear whether this relationship is unbiased. In order to investigate this relationship, we used longitudinal data for establishing the possible predictive value of LUTS for the development of CVD in a primary care population.

METHODS

We performed a registry study using data from the Registration Network Groningen (RNG). All data from men aged 50 years and older during the study period from 1 January 1998 up to 31 December 2008 were collected. Cox proportional hazard regression analysis was used to determine the association between the proportions of CVD (outcome) and LUTS in our population.

RESULTS

Data from 6614 men were analysed. The prevalence of LUTS increased from 92/1000 personyears (py) in 1998 up to 183/1000 py in 2008. For cardiovascular diseases the prevalence increased from 176/1000 py in 1998 up to 340/1000 py in 2008. The incidence numbers were resp. 10.2/1000 py (1998) and 5.1/1000 py (2008) for LUTS, and 12.9/1000 py (1998) and 10.4/1000 py (2008) for CVD. Of all men, 23.2% reported CVD (41.1% in men with LUTS vs 19.5% in men without LUTS, p < 0.01). The hazard ratio of LUTS for cardiovascular events, compared to no LUTS, in the adjusted multivariate model, was 0.921(95% CI: 0.824 - 1.030; p = 0.150).

CONCLUSION

Based on the results, LUTS is not a factor that must be taken into account for the early detection of CVD in primary care.

[Hypothyroidism after radiotherapy of the neck area: monitoring of thyroid function is important]

We present three patients with primary hypothyroidism after previous radiotherapy of the neck area. Myxoedema coma occurred in one of these patients. Lifelong follow-up of thyroid function is recommended after radiotherapy of the neck. Monitoring of thyroid function should be performed at least once a year by the radiation oncologist or by the general practitioner.

Survival of stroke patients after introduction of the 'Dutch Transmural Protocol TIA/CVA'

Background

Earlier research showed that healthcare in stroke could be better organized, aiming for improved survival and less comorbidity. Therefore, in 2004 the Dutch College of General Practitioners (NHG) and the Dutch Association of Neurology (NVN) introduced the ‘Dutch Transmural Protocol TIA/CVA’ (the LTA) to improve survival, minimize the risk of stroke recurrence, and increase quality of life after stroke. This study examines whether survival improved after implementation of the new protocol, and whether there was an increase in contacts with the general practitioner (GP)/nurse practitioner, registration of comorbidity and prescription of medication.

Methods

From the primary care database of the Registration Network Groningen (RNG) two cohorts were composed: one cohort compiled before and one after introduction of the LTA. Cohort 1 (n = 131, first stroke 2001–2002) was compared with cohort 2 (n = 132, first stroke 2005–2006) with regard to survival and the secondary outcomes.

Results

Comparison of the two cohorts showed no significant improvement in survival. In cohort 2, the number of contacts with the GP was significantly lower and with the nurse practitioner significantly higher, compared with cohort 1. All risk factors for stroke were more prevalent in cohort 2, but were only significant for hypercholesterolemia. In both cohorts more medication was prescribed after stroke, whereas ACE inhibitors were prescribed more frequently only in cohort 2.

Conclusion

No major changes in survival and secondary outcomes were apparent after introduction of the LTA. Although, there was a small improvement in secondary prevention, this study shows that optimal treatment after introduction of the LTA has not yet been achieved.

The midregional fragment of pro-A-type natriuretic peptide, blood pressure, and mortality in a prospective cohort study of patients with type 2 diabetes (ZODIAC-25)

OBJECTIVE

Evidence that midregional fragment of pro-A-type natriuretic peptide (MR-proANP) is a marker of mortality in patients with type 2 diabetes is limited. Therefore, we aimed to investigate the capabilities of MR-proANP in predicting mortality. We also investigated whether MR-proANP influences the relationship between blood pressure and mortality in old age.

RESEARCH DESIGN AND METHODS

In 1998, 1,143 primary care patients with type 2 diabetes participated in the ZODIAC study. Because blood was drawn for 867 patients (76%) and confounders were missing for 19 patients, the final study sample comprised 848 patients. After a follow-up time of 10 years, we used Cox proportional hazard models to evaluate the relationship between MR-proANP and (cardiovascular) mortality. Harrell C statistic was used to compare models with and without MR-proANP. The regression analyses were repeated without MR-proANP for patients aged older than 75 years.

RESULTS

Median MR-proANP in the total study sample was 75 pmol/L (interquartile range, 48-124 pmol/L). During follow-up, 354 (42%) out of 848 patients had died, of whom 152 (43%) deaths were attributable to cardiovascular factors. MR-proANP was independently associated with all-cause and cardiovascular mortality, irrespective of age. During old age, there was a significant inverse relationship between blood pressure and mortality. This relationship did not change after adjustment for MR-proANP.

CONCLUSIONS

MR-proANP is independently associated with mortality in patients with type 2 diabetes. MR-proANP did not influence the inverse relationship between blood pressure and mortality in elderly patients.

Discharge of breast cancer patients to primary care at the end of hospital follow-up: a cross-sectional survey

AIM

The present study explored (a) the discharge of breast cancer patients to primary care by specialists, at the end of hospital follow-up and (b) the experiences and views of general practitioners (GPs) regarding transfer of follow-up to the primary care setting.

METHODS

A cross-sectional survey was performed by sending a self-administered questionnaire to 960 GPs working in the three northern provinces of the Netherlands. Data were analysed using descriptive statistics.

RESULTS

Of 949 eligible questionnaires, 502 were returned, providing an adjusted response rate of 53%. In the year before the survey took place, one or more patients aged >60 years, and 5 years after breast-conserving therapy, were discharged to 22% of GPs (n=112) for follow-up. According to 56% of these GPs, transfer of follow-up was communicated by the hospital. The initiative to arrange follow-up visits and mammography appointments was mainly taken by patients. In this survey, 40% of GPs (n=200) were willing to accept exclusive responsibility for follow-up earlier than 5 years after completion of active treatment. Perceived barriers in current and future primary care-based follow-up included: communication with breast cancer specialists, patients' preference for specialist follow-up, GPs' oncology knowledge and skills and the organisation of follow-up in general practice.

CONCLUSIONS

Primary care-based follow-up might be improved if breast cancer specialists discharge patients more actively to their GPs. Survivorship care plans are needed to facilitate communication across the primary/secondary interface and with patients. Training of GPs and developing administrative tools may be helpful in arranging follow-up care and using guidelines in general practice.

Cost-effectiveness of cardiovascular risk management by practice nurses in primary care

BACKGROUND

Cardiovascular disease (CVD) is largely preventable and prevention expenditures are relatively low. The randomised controlled SPRING-trial (SPRING-RCT) shows that cardiovascular risk management by practice nurses in general practice with and without self-monitoring both decreases cardiovascular risk, with no additional effect of self-monitoring. For considering future approaches of cardiovascular risk reduction, cost effectiveness analyses of regular care and additional self-monitoring are performed from a societal perspective on data from the SPRING-RCT.

METHODS

Direct medical and productivity costs are analysed alongside the SPRING-RCT, studying 179 participants (men aged 50-75 years, women aged 55-75 years), with an elevated cardiovascular risk, in 20 general practices in the Netherlands. Standard cardiovascular treatment according to Dutch guidelines is compared with additional counselling based on self-monitoring at home (pedometer, weighing scale and/ or blood pressure device) both by trained practice nurses. Cost-effectiveness is evaluated for both treatment groups and patient categories (age, sex, education).

RESULTS

Costs are €98 and €187 per percentage decrease in 10-year cardiovascular mortality estimation, for the control and intervention group respectively. In both groups lost productivity causes the majority of the costs. The incremental cost-effectiveness ratio is approximately €1100 (95% CI: -5157 to 6150). Self-monitoring may be cost effective for females and higher educated participants, however confidence intervals are wide.

CONCLUSIONS

In this study population, regular treatment is more cost effective than counselling based on self-monitoring, with the majority of costs caused by lost productivity.

TRIAL REGISTRATION

Trialregister.nl identifier: http://NTR2188.

Discontinuation of reimbursement of benzodiazepines in the Netherlands: does it make a difference?

Background

In an attempt to control chronic benzodiazepine use and its costs in the Netherlands, health care insurance reimbursement of this medication was stopped on January 1^st 2009. This study investigates whether benzodiazepine prescriptions issued by general practitioners changed during the first two years following implementation of this regulation.

Methods

Registry study based on data from all benzodiazepine users derived from the Registration Network Groningen. This general practice-based research network collects longitudinal data on the primary care administered to about 30,000 patients. Based on the number of quarterly accumulated prescription days, a comparison was made of benzodiazepine prescriptions issued between 2007/2008 and 2009/2010. Also investigated was which type of user (i.e. short-term or long-term) showed the most change.

Results

Information on benzodiazepine prescriptions among 5,200 patients from 16 consecutive trimesters between 2007 and 2010 was available for analysis. A significant reduction in prescription days was observed between 2007/2008 and 2009/2010. Overall, an estimated 1.73 (CI:-1.94 to -1.53; p<0.001) days were less prescribed per trimester after the termination of reimbursement. In particular, short-term users experienced a reduction in prescription days in 2009 and 2010. The number of long-term users decreased by 2.3%, while the number of individuals that did not use increased by 4.2%.

Conclusions

A total reduction of almost 14 prescription days was observed over eight trimesters after implementation of the regulation to terminate the reimbursement of benzodiazepines. Short-term users were mainly responsible for this reduction in prescription days in 2009 and 2010. Although long-term users did not alter their benzodiazepine use in 2009 and 2010, the number of long-term users decreased slightly.

Randomized controlled trial on cardiovascular risk management by practice nurses supported by self-monitoring in primary care

Background

Treatment goals for cardiovascular risk management are generally not achieved. Specialized practice nurses are increasingly facilitating the work of general practitioners and self-monitoring devices have been developed as counseling aid. The aim of this study was to compare standard treatment supported by self-monitoring with standard treatment without self-monitoring, both conducted by practice nurses, on cardiovascular risk and separate risk factors.

Methods

Men aged 50–75 years and women aged 55–75 years without a history of cardiovascular disease or diabetes, but with a SCORE 10-year risk of cardiovascular mortality ≥5% and at least one treatable risk factor (smoking, hypertension, lack of physical activity or overweight), were randomized into two groups. The control group received standard treatment according to guidelines, the intervention group additionally received pro-active counseling and self-monitoring (pedometer, weighing scale and/ or blood pressure device). After one year treatment effect on 179 participants was analyzed.

Results

SCORE risk assessment decreased 1.6% (95% CI 1.0–2.2) for the control group and 1.8% (1.2–2.4) for the intervention group, difference between groups was .2% (−.6–1.1). Most risk factors tended to improve in both groups. The number of visits was higher and visits took more time in the intervention group (4.9 (SD2.2) vs. 2.6 (SD1.5) visits p < .001 and 27 (P₂₅ –P₇₅:20–33) vs. 23 (P₂₅ –P₇₅:19–30) minutes/visit p = .048).

Conclusions

In both groups cardiovascular risk decreased significantly after one year of treatment by practice nurses. No additional effect of basing the pro-active counseling on self-monitoring was found, despite the extra time investment.

Trial registration

trialregister.nl NTR2188

Recognition of anxiety disorders by family physicians after rigorous medical record case extraction: results of the Netherlands Study of Depression and Anxiety

OBJECTIVE

Previous studies reported low and inconsistent rates of recognition of anxiety disorders by family physicians (FPs). Our objectives were to examine (a) which combination of indications within medical records most accurately reflects recognition of anxiety disorders and (b) whether patient and FP characteristics were related to recognition.

METHOD

A cross-sectional comparison was made between FPs' registration and a structured diagnostic interview, the Composite International Diagnostic Interview, according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. Seven definitions of recognition were tested using diagnostic codes, medication data, referral data and free text in medical records. Data were derived from the Netherlands Study of Depression and Anxiety. A total of 816 patients were included.

RESULTS

Recognition ranged between 9.1% and 85.8%. A broader definition was associated with a higher recognition rate, but led to more false positives. The best definition comprised diagnostic codes for anxiety disorders and symptoms, strong free-text indications, medication and referral to mental health care. Generalized anxiety disorder was best recognized by this definition. Recognition was better among patients with increased severity, comorbid depression and older age.

CONCLUSION

FPs recognized anxiety disorders better than previously reported when all medical record data were taken into account. However, most patients were nonspecifically labeled as having a mental health problem.

A prospective observational study of quality of diabetes care in a shared care setting: trends and age differences (ZODIAC-19)

OBJECTIVE

The Zwolle Outpatient Diabetes project Integrating Available Care (ZODIAC) study was initiated in 1998 to investigate the effects of shared care for patients with type 2 diabetes mellitus (T2DM) in the Netherlands, and to reduce the number of diabetes-related complications. Benchmarking the performance of diabetes care was and is an important aspect of this study. We aimed to investigate trends in diabetes care, within the ZODIAC study for a wide variety of quality indicators during a long follow-up period (1998-2008), with special interest for different age groups.

DESIGN

Prospective observational cohort study.

SETTING

Primary care, Zwolle, The Netherlands.

PARTICIPANTS

Patients with T2DM.

METHODS

A dataset of quality measures was collected annually during the patient's visit to the practice nurse or general practitioner. Linear time trends from 1998 to 2008 were estimated using linear mixed models in which we adjusted for age and gender. Age was included in the model as a categorical variable: for each follow-up year all participants were categorised into the categories <60, 60-75 and >75 years. Differences in trends between the age categories were investigated by adding an interaction term to the model.

RESULTS

The number of patients who were reported to participate increased in the period 1998-2008 from 1622 to 27 438. All quality indicators improved in this study, except for body mass index. The prevalence albuminuria decreased in an 11-year-period from 42% to 21%. No relevant differences between the trends for the three age categories were observed. During all years of follow-up, mean blood pressure and body mass index were the lowest and highest, respectively, in the group of patients <60 years (data not shown).

CONCLUSIONS

Quality of diabetes care within the Dutch ZODIAC study, a shared care project, has considerably improved in the period 1998-2008. There were no relevant differences between trends across various age categories.

Maintenance of lifestyle changes: 3-year results of the Groningen Overweight and Lifestyle study

OBJECTIVE

This study aims to evaluate the three-year effect of lifestyle counseling by a nurse practitioner (NP) on physical activity (PA) and dietary intake compared with usual care by a general practitioner (GP).

METHODS

At baseline, subjects were randomly allocated to the NP group (n = 225) or to the GP group (n = 232). The NP group received a low-intensive lifestyle intervention for three years by the NP and the GP group received one consultation by the GP and thereafter usual care. PA and dietary intake were assessed with questionnaires at baseline, 1 year follow-up and 3 year follow-up.

RESULTS

After three years, leisure-time activity increased and favorable improvements towards a healthy diet were made for both groups. These three-year changes in PA and diet did not differ significantly between groups. Changes in PA and dietary habits after one year were practically maintained after 3 years, because only small relapses were found.

CONCLUSION

After three years, subjects were more physically active and had a healthier diet compared to baseline. Lifestyle counseling by NP resulted in similar lifestyle changes compared to GP consultation.

PRACTICE IMPLICATIONS

NPs could also advice patients at cardiovascular risk by lifestyle counseling, to possibly reduce GP barriers.

Quality of life of elderly ischaemic stroke patients one year after thrombolytic therapy. A comparison between patients with and without thrombolytic therapy

Background

An observational study to examine whether thrombolytic therapy in stroke patients realizes better quality of life outcomes compared to patients without thrombolytic therapy one year after stroke. We also examined whether daily functioning, mental functioning and activities improved after thrombolytic treatment.

Methods

A total of 88 stroke patients were interviewed at home one year post-stroke. Health-related quality of life (HRQOL) was assessed using the RAND-36, disability with the Barthel Index, depression and anxiety with the Hospital Anxiety and Depression Scale, and a questionnaire about patient way of life was completed. People aged under 60, moving to a nursing home or with a haemorrhage were excluded.

Results

The thrombolysis group (TG) had more severe stroke (higher NIHSS) scores and were younger than the group without thrombolytic therapy (WTG). The primary outcome was HRQOL, which was high and nearly identical in both groups, however the TG had significantly better HRQOL for the ‘mental health’ and ‘vitality’ scales. Patients who stopped or reduced their hobbies because of stroke had a significantly worse HRQOL.

One year after stroke, more patients in the TG were totally or severely ADL dependent (12% TG and 0% WTG, p = 0.022). The level of dependence decreased in the TG (p = 0.042) and worsened in the WTG (p < 0.001) after one year. Being more dependent is related to diminishing daily occupations in both groups. In the TG the level of dependence had less impact on visiting family and friends and going on holiday. The prevalence of anxiety disorder and depression was low compared to other studies and there is no significant difference between the two groups.

Conclusion

No major differences in the primary outcome (HRQOL) could be found between the two groups. In addition, no essential difference could be found in mental functioning and participation. We expected that patients undergoing thrombolytic therapy would have worse quality of life because of the greater initial severity of their stroke. Therefore, thrombolytic therapy seems to be of great importance in achieving better quality of life in ischemic stroke patients who respond to this therapy.

The influence of overweight/obesity on patient-perceived physical functioning and health-related quality of life after primary total hip arthroplasty

Background

Overweight/obesity in patients after total hip arthroplasty (THA) is a growing problem and is associated with postoperative complications and a negative effect on functional outcome. The objective of this study is to determine to what extent overweight/obesity is associated with physical functioning and health-related quality of life 1 year after primary THA.

Methods

A retrospective analysis of prospectively collected data from 653 patients who had undergone a primary THA was conducted. Physical functioning, health-related quality of life, body mass index (BMI), comorbidity, and postoperative complications were assessed by means of a questionnaire and from medical records. To determine to what extent overweight/obesity is associated with physical functioning and health-related quality of life after THA, a structural equation model (SEM) analysis was conducted.

Results

The association of BMI corrected for age, gender, complications, and comorbidity with physical functioning is −0.63. This means that an increase in 1 kg/m² BMI leads to a reduction of 0.63 points in the physical functioning score as measured with the Western Ontario and McMaster Universities Osteoarthritis Index (100-point scale). The prevalence of complications or comorbidity leads to a reduction of, respectively, 5.63 and 7.25 (one or two comorbidities) and 14.50 points in the case of more than two comorbidities on the physical functioning score. The same pattern is observed for health-related quality of life.

Conclusions

The influence of overweight/obesity on physical functioning and health-related quality of life is low. The impact of complications and comorbidity is considerable. Refusing a patient a THA solely on the basis of overweight or obesity does not seem justified.

Outcomes for depression and anxiety in primary care and details of treatment: a naturalistic longitudinal study

BACKGROUND

There is little evidence as to whether or not guideline concordant care in general practice results in better clinical outcomes for people with anxiety and depression. This study aims to determine possible associations between guideline concordant care and clinical outcomes in general practice patients with depression and anxiety, and identify patient and treatment characteristics associated with clinical improvement.

METHODS

This study forms part of the Netherlands Study of Depression and Anxiety (NESDA).Adult patients, recruited in general practice (67 GPs), were interviewed to assess DSM-IV diagnoses during baseline assessment of NESDA, and also completed questionnaires measuring symptom severity, received care, socio-demographic variables and social support both at baseline and 12 months later. The definition of guideline adherence was based on an algorithm on care received. Information on guideline adherence was obtained from GP medical records.

RESULTS

721 patients with a current (6-month recency) anxiety or depressive disorder participated. While patients who received guideline concordant care (N=281) suffered from more severe symptoms than patients who received non-guideline concordant care (N=440), both groups showed equal improvement in their depressive or anxiety symptoms after 12 months. Patients who (still) had moderate or severe symptoms at follow-up, were more often unemployed, had smaller personal networks and more severe depressive symptoms at baseline than patients with mild symptoms at follow-up. The particular type of treatment followed made no difference to clinical outcomes.

CONCLUSION

The added value of guideline concordant care could not be demonstrated in this study. Symptom severity, employment status, social support and comorbidity of anxiety and depression all play a role in poor clinical outcomes.

Process Evaluation of a Lifestyle Intervention in Primary Care

The Groningen Overweight and Lifestyle (GOAL) intervention effectively prevents weight gain. The present study describes a process evaluation in which 214 participants in the intervention group received a structured questionnaire within 7 months (a median of 5 months) after the end of the intervention. The authors investigated the content of the intervention (on basis of the participants’ recall), the participants’ satisfaction of the intervention, the participants’ satisfaction with the nurse practitioners (NPs), and the determinants of the participants’ satisfaction. In general, the results show that the content corresponded well with the protocol for the intervention, except for the number of telephone calls and the percentage of participants with individualized goals for a healthy lifestyle. The overall satisfaction of the participants was high, and success and perceived success and a low educational level were important determinants for a higher overall satisfaction grade. Furthermore, the NP was considered to be an expert and motivational to learning and keeping up a healthy lifestyle. The authors therefore conclude that the GOAL study is feasible and indicates that the NP is well equipped to treat these patients. However, it is recommended to reinforce the advice given and the lifestyle goals after the first contact sessions.

Two-year course of depressive and anxiety disorders: results from the Netherlands Study of Depression and Anxiety (NESDA)

BACKGROUND

Whether course trajectories of depressive and anxiety disorders are different, remains an important question for clinical practice and informs future psychiatric nosology. This longitudinal study compares depressive and anxiety disorders in terms of diagnostic and symptom course trajectories, and examines clinical prognostic factors.

METHODS

Data are from 1209 depressive and/or anxiety patients residing in primary and specialized care settings, participating in the Netherlands Study of Depression and Anxiety. Diagnostic and Life Chart Interviews provided 2-year course information.

RESULTS

Course was more favorable for pure depression (n=267, median episode duration = 6 months, 24.5% chronic) than for pure anxiety (n=487, median duration = 16 months, 41.9% chronic). Worst course was observed in the comorbid depression-anxiety group (n=455, median duration > 24 months, 56.8% chronic). Independent predictors of poor diagnostic and symptom trajectory outcomes were severity and duration of index episode, comorbid depression-anxiety, earlier onset age and older age. With only these factors a reasonable discriminative ability (C-statistic 0.72-0.77) was reached in predicting 2-year prognosis.

LIMITATION

Depression and anxiety cases concern prevalent - not incident - cases. This, however, reflects the actual patient population in primary and specialized care settings.

CONCLUSIONS

Their differential course trajectory justifies separate consideration of pure depression, pure anxiety and comorbid anxiety-depression in clinical practice and psychiatric nosology.

The costs of guideline-concordant care and of care according to patients' needs in anxiety and depression

AIM

To describe the direct and indirect costs for people with anxiety and depressive disorders where guidelines are adhered to and patients' perceived needs are fully met.

METHOD

Data were derived from the Netherlands Study of Depression and Anxiety. At baseline, adult patients were interviewed and they completed questionnaires to measure DSM-IV diagnoses, socio-demographic characteristics and perceived need for care. Actual care data were also derived from electronic medical records. Criteria for guideline adherence were based on general practice guidelines, issued by the Dutch College of General Practitioners. Direct and indirect costs were inferred from the Perceived Need for Care Questionnaire administered at baseline, and the Trimbos and iMTA questionnaire on Costs associated with Psychiatric illness administered at 1-year follow-up.

RESULTS

For 568 patients with a current anxiety or depressive disorder a complete dataset on health care use and absenteeism was available. Guideline adherence was significantly associated with increased care use and corresponding costs, while fully met perceived need was unrelated to costs. Socio-demographic characteristics, severity of symptoms and guideline adherence all affected the societal costs of patients with fully met perceived needs compared with patients with perceived unmet needs.

CONCLUSION

It appears that guideline-concordant care for anxiety and depression costs more than non-concordant care, while care that has fulfilled all of a patient's needs seems not to be more expensive than care that has not met all perceived needs. However, randomized controlled trials should first confirm this conclusion.

Self-reported adverse drug events and the role of illness perception and medication beliefs in ambulatory heart failure patients: A cross-sectional survey

BACKGROUND

Identifying patients with heart failure (HF) who are at risk of experiencing symptomatic adverse drug events (ADEs) is important for improving patient care and quality of life. Several demographic and clinical variables have been identified as potential risk factors for ADEs but limited knowledge is available on the impact of HF patients' beliefs and perceptions on their experience of ADEs.

OBJECTIVE

The purpose of the study was to identify the relationship between HF patients' illness perception and medication beliefs and self-reported ADEs.

DESIGN

A cross-sectional survey was performed between November 2008 and March 2009.

SETTINGS

One university medical centre, two regional hospitals and 20 general practitioners in the Netherlands participated in the study.

PARTICIPANTS

495 patients with HF were included.

METHODS

Patients completed the validated Revised Illness Perception Questionnaire (IPQ-R) and the Beliefs about Medication Questionnaire (BMQ) which collected data on their illness perception and medication beliefs. In addition, data on ADEs as experienced in the previous four weeks were collected through an open-ended question and a symptom checklist. Multivariate logistic regression was performed to identify factors associated with these ADEs.

RESULTS

In total, 332 (67%) patients had experienced ADEs in the previous four weeks, of whom 28% reported dry mouth, 27% dizziness and 19% itchiness as the most prevalent. In the adjusted multivariate analysis, disease-related symptoms (illness identity) (OR for 1-5 symptoms 3.57; 95% CI 2.22-5.75, OR for >5 symptoms 7.37; 95% CI 3.44-15.8), and general beliefs about medication overuse (OR 1.07; 95% CI 1.01-1.13) were independently associated with experiencing ADEs, whereas none of the demographic or clinical factors were significant.

CONCLUSIONS

HF patients who perceive a high number of disease symptoms and have negative medication beliefs are at higher risk of experiencing self-reported ADEs. We suggest that future studies and interventions to improve ADE management should focus on negative medication beliefs and assisting patients in differentiating disease symptoms from ADEs.

Referral of patients with depression to mental health care by Dutch general practitioners: an observational study

BACKGROUND

Depression is a common illness, often treated in primary care. Guidelines provide recommendations for referral to mental health care. Several studies investigated determinants of referral, none investigated guideline criteria as possible determinants.We wanted to evaluate general practitioner's referral of depressed patients to mental health care and to what extent this is in agreement with (Dutch) guideline recommendations.

METHODS

We used data of primary care respondents from the Netherlands Study of Depression and Anxiety with major depressive disorder in the past year (n = 478). We excluded respondents with missing data (n = 134). Referral data was collected from electronic patient files between 1 year before and after baseline and self report at baseline and 1-year follow-up. Logistic regression was used to describe association between guideline referral criteria (e.g. perceived need for psychotherapy, suicide risk, severe/chronic depression, antidepressant therapy failure) and referral.

RESULTS

A high 58% of depressed patients were referred. Younger patients, those with suicidal tendency, chronic depression or perceived need for psychotherapy were referred more often. Patients who had used ≥2 antidepressants or with chronic depression were more often referred to secondary care. Referred respondents met on average more guideline criteria for referral. However, only 8-11% of variance was explained.

CONCLUSION

The majority of depressed patients were referred to mental health care. General practitioners take guideline criteria into account in decision making for referral of depressed patients to mental health care. However, other factors play a part, considering the small percentage of variance explained. Further research is necessary to investigate this.

Structured diabetes care leads to differences in organization of care in general practices: the healthcare professional and patient perspective

Background

Care for patients with chronic diseases is challenging and requires multifaceted interventions to appropriately coordinate the entire treatment process. The effect of such interventions on clinical outcomes has been assessed, but evidence of the effect on organization of care is scarce.

The aim is to assess the effect of structured diabetes care on organization of care from the perspective of patients and healthcare professionals in routine practice, and to ascertain whether this effect persists

Methods

In a quasi-experimental study the effect of structured care (SC) was compared with care-as-usual (CAU). Questionnaires were sent to healthcare professionals (SC n = 31; CAU n = 11) and to patients (SC n = 301; CAU n = 102). A follow-up questionnaire was sent after formal support of the intervention ended (2007).

Results

SC does have an effect on the organization of care. More cooperation between healthcare professionals, less referrals to secondary care and more education were reported in the SC group as compared to the CAU group. These changes were found both at the healthcare professional and at the patient level. Organizational changes remained after formal support for the intervention support had ended.

Conclusion

According to patients and healthcare professionals, structured care does have a positive effect on the organization of care. The use of these two sources of information is important, not only to assess the value of changes in care for the patient and the healthcare provider but also to ascertain the validity of the results found.

Preventing weight gain by lifestyle intervention in a general practice setting: three-year results of a randomized controlled trial

BACKGROUND

Weight regain after initial loss of weight is common, which indicates a need for lifestyle counseling aimed at preventing weight gain instead of weight loss. This study was conducted to determine whether structured lifestyle counseling by nurse practitioners (NPs) group compared with usual care by general practitioners (GP-UC) in overweight and obese patients can prevent (further) weight gain.

METHODS

A randomized controlled trial in 11 general practice locations in the Netherlands of 457 patients (body mass index, 25-40 [calculated as weight in kilograms divided by height in meters squared]; mean age, 56 years; 52% female) with either hypertension or dyslipidemia or both. The NP group received lifestyle counseling with guidance of the NP using a standardized software program. The GP-UC group received usual care from their GP. Main outcome measures were changes in body weight, waist circumference, blood pressure, and fasting glucose and blood lipid levels after 3 years.

RESULTS

In both groups, approximately 60% of the participants achieved weight maintenance after 3 years. There was no significant difference in mean (SD) weight change and change of waist circumference between the NP and GP-UC groups (weight change: NP group, -1.2% [5.8%], and GP-UC group, -0.6% [5.6%] [P = .37]; and change of waist circumference: NP group, -0.8 [7.1] cm, and GP-UC group, 0.4 [7.2] cm [P = .11]). A significant difference occurred for mean (SD) fasting glucose levels (NP group, -0.02 [0.49] mmol/L, and GP-UC group, 0.10 [0.53] mmol/L [P = .02]) (to convert to milligrams per deciliter, divide by 0.0555) but not for lipid levels and blood pressure.

CONCLUSIONS

Lifestyle counseling by NPs did not lead to significantly better prevention of weight gain compared with GPs. In the majority in both groups, lifestyle counseling succeeded in preventing (further) weight gain.

TRIAL REGISTRATION

trialregister.nl Identifier: NTR1365.

Perceived wellbeing of patients one year post stroke in general practice--recommendations for quality aftercare

Background

Annually, 41,000 people in the Netherlands have strokes. This has multiple physical and psychosocial consequences. Most patients return home after discharge from hospital. Quality aftercare by general practitioners is important to support patients at home. The purpose of this study is to examine the wellbeing of patients who returned home immediately after discharge from hospital, one year post stroke, in comparison with the general Dutch population of the same age and to determine factors that could influence wellbeing.

Methods

All the stroke patients from the Department of Neurology, Martini Hospital Groningen in the period November 2006 to October 2007 were included. People aged under 65 years or with haemorrhaging were excluded. All the patients (N = 57) were interviewed at home using the following questionnaires: Barthel Index, SF-36, HADS, CSI and a questionnaire about their way of life.

Results

31% of the patients in this study experienced a decrease in functional status after one year. Nevertheless, there was no significant difference between the median Barthel Index value at discharge from hospital and one year post stroke. ADL independence correlated with a better quality of life. The health-related quality of life was high. Stroke patients have almost the same quality of life as the 'average' Dutch elderly population. Where patients can no longer fully participate in society, their perceived quality of life is also lower. In this study there is an indication of a high prevalence of depression and anxiety disorders in stroke patients. This negatively affects the quality of life a year after stroke. Although caregiver strain was low for the partners of stroke patients, a reduced quality of life is correlated to greater burden.

Conclusions

This study provides valuable insight into the wellbeing of patients living at home one year post stroke. Physical functioning and quality of life are comparable to the general population of the same age, but improvements in mental functioning can be envisaged. In addition, more attention should be paid to maintaining the patients' activities. The wellbeing of these stroke patients could be increased further if greater attention is paid to these aspects of life. This seems to be applicable to general practice.

Identifying targets to improve treatment in type 2 diabetes; the Groningen Initiative to aNalyse Type 2 diabetes Treatment (GIANTT) observational study

PURPOSE

Assessment of quality of cardiometabolic risk management in diabetes in primary care.

METHODS

In a descriptive cohort study including 95 Dutch general practices, we assessed medication treatment in relation to the level of control for HbA1c, systolic blood pressure (SBP) and LDL-cholesterol (LDL-c) in 2007. We also applied a prospective measure of treatment quality by assessing treatment modifications in not well-controlled patients. In a subpopulation of 23 practices, we studied trends in these quality indicators from 2004 (2059 patients) to 2007 (2929 patients).

RESULTS

In 2007, averages for HbA1c, SBP and LDL-c were 6.9%, 142 mmHg and 2.3 mmol/l, respectively. Of the patients with an HbA1c >  8.5%, 16% were treated with one oral drug class and 50% used insulin. In 27% of these patients, therapy modification occurred subsequently. During the 4-year period, a slight decrease in average HbA1c was observed, but no changes in treatment level. In 2007, 56% of the patients had an SBP ≥ 140 mmHg, 19% of whom were not using antihypertensives. In the 13% with an SBP > 160 mmHg, 23% received a therapy modification. During the 4-year period, the average SBP decreased with 6 mmHg but the treatment level showed no substantial increase. In 2007, 39% had an LDL-c level ≥ 2.5 mmol/l, 49% of whom were not using statins. Of the patients with an LDL-c > 3.5 mmol/l, only 9% received a therapy modification.

CONCLUSIONS

The decreasing population averages of HbA1c, SBP and LDL-c values suggest improvement in quality of care. However, the relatively few therapy modifications observed in insufficiently controlled patients show room for improvement.

[Appropriate care for anxiety and depression]

OBJECTIVE

To evaluate care received for anxiety and depression, to identify which patient-, GP- and practice factors obstruct delivery of care in accordance with Dutch College of General Practitioners' (NHG) practice guidelines, and to evaluate the costs and effects of guideline-concordant care.

DESIGN

Descriptive study.

METHODS

During the baseline assessment of the Netherlands study of depression and anxiety--which has followed a large number of adults with and without psychiatric complaints since 2004--various questionnaires and diagnostic interviews were completed. At one year follow-up, the severity of symptoms of anxiety and depression, overall functioning or dysfunction, healthcare use and absenteeism from employment over the past year were assessed. Data from electronic medical patient records were studied to determine whether NHG practice guidelines had been followed.

RESULTS

Of the 721 patients with an anxiety or depressive disorder, 57% (n = 413) indicated receiving some form of care; two-thirds of this group received appropriate care according to NHG practice guidelines (n = 281). At patient level the severity of depressive symptoms, the self-evaluated need for care, a high level of education and accessibility of care were most strongly associated with guideline adherence; at general practitioner level, collaboration with other mental health professionals was most strongly associated with guideline adherence. On average, all patients had symptoms that were less serious than a year previously, irrespective of which care they had received. Guideline-concordant care was significantly more expensive.

CONCLUSION

Half of the patients who had not received care did not think that they needed it. Of those who had received care, those with more severe symptoms and greatest need for care were most likely to have received guideline-concordant care. Both patients and general practitioners seemed well able to assess whether care was needed or not.

Perceived need for mental health care and barriers to care in the Netherlands and Australia

PURPOSE

This study of Australian and Dutch people with anxiety or depressive disorder aims to examine people's perceived needs and barriers to care, and to identify possible similarities and differences.

METHODS

Data from the Australian National Survey of Mental Health and Well-Being and the Netherlands Study of Depression and Anxiety were combined into one data set. The Perceived Need for Care Questionnaire was taken in both studies. Logistic regression analyses were performed to check if similarities or differences between Australia and the Netherlands could be observed.

RESULTS

In both countries, a large proportion had unfulfilled needs and self-reliance was the most frequently named barrier to receive care. People from the Australian sample (N = 372) were more likely to perceive a need for medication (OR 1.8; 95% CI 1.3-2.5), counselling (OR 1.4; 95% CI 1.0-2.0) and practical support (OR 1.8; 95% CI 1.2-2.7), and people's overall needs in Australia were more often fully met compared with those of the Dutch sample (N = 610). Australians were more often pessimistic about the helpfulness of medication (OR 3.8; 95% CI 1.4-10.7) and skills training (OR 3.0; 95% CI 1.1-8.2) and reported more often financial barriers for not having received (enough) information (OR 2.4; 95% CI 1.1-5.5) or counselling (OR 5.9; 95% CI 2.9-11.9).

CONCLUSIONS

In both countries, the vast majority of mental health care needs are not fulfilled. Solutions could be found in improving professionals' skills or better collaboration. Possible explanations for the found differences in perceived need and barriers to care are discussed; these illustrate the value of examining perceived need across nations and suggest substantial commonalities of experience across the two countries.

Characteristics of general practice care: what do senior citizens value? A qualitative study

Background

In view of the increasing number of senior citizens in our society who are likely to consult their GP with age-related health problems, it is important to identify and understand the preferences of this group in relation to the non-medical attributes of GP care. The aim of this study is to improve our understanding about preferences of this group of patients in relation to non-medical attributes of primary health care. This may help to develop strategies to improve the quality of care that senior citizens receive from their GP.

Methods

Semi-structured interviews (N = 13) with senior citizens (65-91 years) in a judgement sample were recorded and transcribed verbatim. The analysis was conducted according to qualitative research methodology and the frame work method.

Results

Continuity of care providers, i.e. GP and practice nurses, GPs' expertise, trust, free choice of GP and a kind open attitude were highly valued. Accessibility by phone did not meet the expectations of the interviewees. The interviewees had difficulties with the GP out-of-office hours services. Spontaneous home visits were appreciated by some, but rejected by others. They preferred to receive verbal information rather than collecting information from leaflets. Distance to the practice and continuity of caregiver seemed to conflict for respondents.

Conclusions

Preferences change in the process of ageing and growing health problems. GPs and their co-workers should be also aware of the changing needs of the elderly regarding non-medical attributes of GP care. Meeting their needs regarding non-medical attributes of primary health care is important to improve the quality of care.

Patients with shoulder complaints in general practice: consumption of medical care

OBJECTIVE

To describe the medical consumption [general practitioner (GP) consultation, referrals, medication consumption] of patients with shoulder complaints in general practice.

METHODS

Data were obtained from a primary-care medical registration network. All patients aged ≥18 years with new shoulder complaints who consulted their general practitioner in 1998 were included, and were followed 10 years beyond the initial consultation.

RESULTS

A total of 526 incident cases were identified (average age 47 years, 65% women and average follow-up 7.6 years). Nearly half of the patients consulted their GP only once. For 79% of those patients, a wait-and-see policy or a prescription for NSAIDs sufficed. During follow-up, 65% of all patients were prescribed medication. Medication consumption was significantly higher among men than women, and higher for the 45- to 64-year age group compared with the younger group. A total of 199 patients were referred, of which 84% was to a physiotherapist and 16% to secondary care. Only two patients had surgery, performed by an orthopaedic surgeon. The GP recorded a diagnosis in only 14% of patients; rotator cuff disorder being the most common.

CONCLUSIONS

Nearly half of patients with a new shoulder complaint consult their GP only once. Medical consumption in general practice is highest for male shoulder patients and the 45- to 64-year age group. Shoulder problems are mainly an issue for primary care.

The effectiveness of family-based cognitive-behavior grief therapy to prevent complicated grief in relatives of suicide victims: the mediating role of suicide ideation

Grief interventions are more effective for high risk individuals. The presence of suicide ideation following suicide bereavement was examined to determine whether it indicates a high risk status. Using data from a randomized controlled trial (n = 122) on the effectiveness of cognitive-behavior therapy, the effect of suicide ideation on the effectiveness of grief therapy on the bereavement outcome at 13 months post loss was examined. Results show that suicide ideators more often have a history of mental disorder and suicidal behavior than non-ideators, and suicide ideation indicates a high risk for adverse bereavement outcome. Grief therapy likely reduces the risk of maladaptive grief reactions among suicide ideators. Therefore, suicide ideators may benefit from grief therapy following a loss through suicide.

Guideline recommendations for long-term treatment of depression with antidepressants in primary care--a critical review

BACKGROUND

Long-term treatment with antidepressants is considered effective in preventing recurrence of major depressive disorder (MDD). It is unclear whether this is true for primary care.

OBJECTIVES

We investigated whether current guideline recommendations for long-term treatment with antidepressants in primary care are supported by evidence from primary care.

METHODS

Data sources for studies on antidepressants: PubMed, Cochrane Library, Embase, PsycInfo, Cinahl, articles from reference lists, cited reference search.

SELECTION CRITERIA

adults in primary care, continuation or maintenance treatment with antidepressants, with outcome relapse or recurrence, (randomized controlled) trial/naturalistic study/review.

LIMITS

published before October 2009 in English.

RESULTS

Thirteen depression guidelines were collected. These guidelines recommend continuation treatment with antidepressants after remission for all patients including patients from primary care, and maintenance treatment for those at high risk of recurrence. Recommendations vary for duration of treatment and definitions of high risk. We screened 804 literature records (title, abstract), and considered 27 full-text articles. Only two studies performed in primary care addressed the efficacy of antidepressants in the long-term treatment of recurrent MDD. A double-blind RCT comparing mirtazapine (n = 99) and paroxetine (n = 98) prescribed for 24 weeks reported that in both groups 2 patients relapsed. An open study of 1031 patients receiving sertraline for 24 weeks, who were naturalistically followed-up for up to two years, revealed that adherent patients had a longer mean time to relapse.

CONCLUSIONS

No RCTs addressing the efficacy of maintenance treatment with antidepressants as compared to placebo were performed in primary care. Recommendations on maintenance treatment with antidepressants in primary care cannot be considered evidence-based.

Patient factors associated with guideline-concordant treatment of anxiety and depression in primary care

OBJECTIVE

To identify associations of patient characteristics (predisposing, enabling and need factors) with guideline-concordant care for anxiety and depression in primary care.

DESIGN

Analysis of data from the Netherlands Study of Depression and Anxiety (NESDA).

PARTICIPANTS

Seven hundred and twenty-one patients with a current anxiety or depressive disorder, recruited from 67 general practitioners (GPs), were included.

MEASURES

Diagnoses according to the Diagnostic and Statistic Manual of Mental Disorders, fourth edition (DSM-IV) were made using a structured and widely validated assessment. Socio-demographic and enabling characteristics, severity of symptoms, disability, (under treatment for) chronic somatic conditions, perceived need for care, beliefs and evaluations of care were measured by questionnaires. Actual care data were derived from electronic medical records. Criteria for guideline-concordant care were based on general practice guidelines, issued by the Dutch College of General Practitioners.

RESULTS

Two hundred and eighty-one (39%) patients received guideline-concordant care. High education level, accessibility of care, comorbidity of anxiety and depression, and severity and disability scores were positively associated with receiving guideline-concordant care in univariate analyses. In multivariate multi-level logistic regression models, significant associations with the clinical need factors disappeared. Positive evaluations of accessibility of care increased the chance (OR = 1.31; 95%-CI = 1.05-1.65; p = 0.02) of receiving guideline-concordant care, as well as perceiving any need for medication (OR = 2.99; 95%-CI = 1.84-4.85; p < 0.001), counseling (OR = 2.25; 95%-CI = 1.29-3.95; p = 0.005) or a referral (OR = 1.83; 95%-CI = 1.09-3.09; p = 0.02). A low educational level decreased the odds (OR = 0.33; 95%-CI = 0.11-0.98; p = 0.04) of receiving guideline-concordant care.

CONCLUSIONS

This study shows that education level, accessibility of care and patients' perceived needs for care are more strongly associated with the delivery of guideline-concordant care for anxiety or depression than clinical need factors. Initiatives to improve GPs' communication skills around mental health issues, and to improve recognition of people suffering from anxiety disorders, could increase the number of patients receiving treatment for depression and anxiety in primary care.

Patient's need for choice and information across the interface between primary and secondary care: a survey

OBJECTIVE

Hospitals in The Netherlands have recently made certain performance data public, allowing patients to choose the location of their care. The objective of this study is to assess (a) patient preferences and experiences concerning the transition between primary and secondary health care, (b) patients' needs for choice and information and how these are influenced by personal and morbidity factors.

METHODS

Two different types of questionnaires were used. The first questionnaire concerns the importance that patients attach to the care provided. The second questionnaire concerns the actual experiences of the patient with the care provided. For the selection of patients, we used the databases of the registration networks of the Departments of General Practice of the Universities of Groningen and Leiden. The questionnaires were returned by 513 patients (Importance 69%) and 1404 patients (Experience 65%).

RESULTS

Many patients prefer the GP advising them regarding which hospital or specialist they should be referred to: a quarter of the patients preferred that the GP decided for them. Patients with a curable condition and patients aged between 25 and 65, highly educated and with stable personal characteristics as measured by a purposive scale, more often wished to use information from internet or newspapers to make a decision. The amount of information that was needed on illness or treatment varied greatly. Young people, older people, and those with less stable personal characteristics more often desired only practical information.

CONCLUSIONS

In spite of making performance data of different health care institutions public, only a limited number of patients want to use this information on a limited number of health problems.

PRACTICE IMPLICATIONS

Care providers should take differences into account concerning patients' need for information on their illness.

[Quality of the treatment of type 2 diabetes: results from the GIANTT project 2004-2007]

OBJECTIVE

To describe the quality of diabetes care at the primary care level using the risk factors HbA1c, blood pressure and LDL cholesterol.

DESIGN

Descriptive cohort study.

METHOD

Using data collected electronically from 124 Dutch general practitioners from the province of Groningen (north Netherlands), we assessed the medication treatment level in relation to the level of control for HbA1c, blood pressure and LDL cholesterol (adequate, moderate or inadequate control). Furthermore, we assessed treatment adjustments between 2004 and 2007 in insufficiently controlled patients (HbA1c value, systolic blood pressure or LDL cholesterol concentration too high).

RESULTS

Data were available for 9646 patients in 2007. The averages for HbA1c, systolic blood pressure and LDL cholesterol were 6.9%, 142 mmHg and 2.3 mmol/l, respectively. Of the patients with an HbA1c > 8.5%, 16% were treated with one oral drug and 50% used insulin. In 27% of these patients, the treatment was subsequently modified. Between 2004 and 2007, a slight decrease in average HbA1c was observed, but no changes in treatment level. Systolic blood pressure was >or= 140 mmHg in 56% of the patients, 19% of whom were not using antihypertensive drugs. Between 2004 and 2007 the average systolic blood pressure decreased by 6 mmHg, whereas the treatment level scarcely increased. Of the 39% of patients whose LDL cholesterol level was >or= 2.5 mmol/l, 49% did not use statins. In 2004 there was an increase in the percentage of patients using statins.

CONCLUSION

The decreasing population averages of HbA1c, systolic blood pressure and LDL cholesterol values suggest an improvement in the quality of care. However, the relatively few therapy modifications observed in insufficiently controlled patients indicates that there is still room for improvement.

Preventing weight gain: one-year results of a randomized lifestyle intervention

BACKGROUND

Lifestyle interventions targeting prevention of weight gain may have better long-term success than when aimed at weight loss. Limited evidence exists about such an approach in the primary care setting.

DESIGN

An RTC was conducted.

SETTING/PARTICIPANTS

Participants were 457 overweight or obese patients (BMI=25-40 kg/m(2), mean age 56 years, 52% women) with either hypertension or dyslipidemia, or both, from 11 general practice locations in The Netherlands.

INTERVENTION

In the intervention group, four individual visits to a nurse practitioner (NP) and one feedback session by telephone were scheduled for lifestyle counseling with guidance of the NP using a standardized computerized software program. The control group received usual care from their general practitioner (GP).

MAIN OUTCOME MEASURES

Changes in body weight, waist circumference, blood pressure, and blood lipids after 1 year (dropout <10%). Data were collected in 2006 and 2007. Statistical analyses were conducted in 2007 and 2008.

RESULTS

There were more weight losers and stabilizers in the NP group than in the general practitioner usual care (GP-UC) group (77% vs 65%; p<0.05). In men, mean weight losses were 2.3% for the NP group and 0.1% for the GP-UC group (p<0.05). Significant reductions occurred also in waist circumference but not in blood pressure, blood lipids, and fasting glucose. In women, mean weight losses were in both groups 1.6%. In the NP group, obese people lost more weight (-3.0%) than the non-obese (-1.3%; p<0.05).

CONCLUSIONS

Standardized computer-guided counseling by NPs may be an effective strategy to support weight-gain prevention and weight loss in primary care, in the current trial, particularly among men.

TRIAL REGISTRATION

The study was registered with the Netherlands Trial Register (NTR), www.trialregister.nl, study no. TC 1365.

A survey of Dutch GPs' attitudes towards help seeking and follow-up care for relatives bereaved by suicide

BACKGROUND

Relatives who are bereaved by suicide likely consult their GP when they feel the need for professional help. GPs may play a key role in establishing who is at risk for adverse consequences of the loss as they are familiar with relatives' possible psychiatric vulnerabilities. The availability of evidence-based services for relatives of suicide victims is limited. Successful implementation of services needs analysis of key factors considered critical in the achievement of changes. We investigated GPs' management of help requests of relatives bereaved by suicide and examined determinants of GPs willingness to refer for evidence-based follow-up care.

METHODS

A cross-sectional survey among 488 GPs in the northern part of The Netherlands.

RESULTS

A 44% response was achieved (n = 214) during the last 3 years, 38 (18%) were exposed to suicide, 21 (10%) to help requests without being exposed to suicide and 52 (24%) to both suicide and help requests. Out of 106 requests, 69 (65%) were handled by the GP; 60 (57%) were either directly or additionally referred, principally for mental health care. Suicide exposure and female gender were associated with the doctor's perception that follow-up care following a loss through suicide is useful. The perception that help is useful increased the likelihood of GPs' referral for evidence-based follow-up care.

CONCLUSIONS

GPs support the availability of evidence-based follow-up care for relatives of suicide victims. To modify GPs' key role in referring relatives for it, GPs should be well informed of its usefulness and to whom.

Does burnout among doctors affect their involvement in patients' mental health problems? A study of videotaped consultations

Background

General practitioners' (GPs') feelings of burnout or dissatisfaction may affect their patient care negatively, but it is unknown if these negative feelings also affect their mental health care. GPs' available time, together with specific communication tools, are important conditions for providing mental health care. We investigated if GPs who feel burnt out or dissatisfied with the time available for their patients, are less inclined to encourage their patients to disclose their distress, and have shorter consultations, in order to gain time and energy. This may result in less psychological evaluations of patients' complaints.

Methods

We used 1890 videotaped consultations from a nationally representative sample of 126 Dutch GPs to analyse GPs' communication and the duration of their consultations. Burnout was subdivided into emotional exhaustion, depersonalisation and reduced accomplishment. Multilevel regression analyses were used to investigate which subgroups of GPs differed significantly.

Results

GPs with feelings of exhaustion or dissatisfaction with the available time have longer consultations compared to GPs without these feelings. Exhausted GPs, and GPs with feelings of depersonalisation, talk more about psychological or social topics in their consultations. GPs with feelings of reduced accomplishment are an exception: they communicate less affectively, are less patient-centred and have less eye contact with their patients compared to GPs without reduced accomplishment.

We found no relationship between GPs' feelings of burnout or dissatisfaction with the available time and their psychological evaluations of patients' problems.

Conclusion

GPs' feelings of burnout or dissatisfaction with the time available for their patients do not obstruct their diagnosis and awareness of patients' psychological problems. On the contrary, GPs with high levels of exhaustion or depersonalisation, and GPs who are dissatisfied with the available time, sometimes provide more opportunities to discuss mental health problems. This increases the chance that appropriate care will be found for patients with mental health problems. On the other hand, these GPs are themselves more likely to retire, or risk burnout, because of their dissatisfaction. Therefore these GPs may benefit from training or personal coaching to decrease the chance that the process of burnout will get out of hand.

Conservative or surgical treatment for subacromial impingement syndrome? A systematic review

BACKGROUND

Patients with subacromial impingement syndrome are often operated on when conservative treatments fail. But does surgery really lead to better results than nonoperative measures? This systematic review compared effects of conservative and surgical treatment for subacromial impingement syndrome in terms of improvement of shoulder function and reduction of pain.

METHODS

A literature search for randomized controlled trials (RCTs) in PubMed, EMBASE, PEDro, and the Cochrane Central Register of Controlled Trials was conducted. Two reviewers assessed the methodological quality of the selected studies. A best-evidence synthesis was used to summarize the results.

RESULTS

Four RCTs were included in this review. Two RCTs had a medium methodological quality, and 2 RCTS had a low methodological quality. No differences in outcome between the treatment groups were reported for any of the studies, irrespective of quality.

CONCLUSION

No high-quality RCTs are available so far to provide possible evidence for differences in outcome; therefore, no confident conclusion can be made. According to the best-evidence synthesis, however, there is no evidence from the available RCTs for differences in outcome in pain and shoulder function between conservatively and surgically treated patients with SIS.

LEVEL OF EVIDENCE

Review.

The effects of exercise and weight loss in overweight patients with hip osteoarthritis: design of a prospective cohort study

Background

Hip osteoarthritis (OA) is recognised as a substantial source of disability, with pain and loss of function as principal symptoms. An aging society and a growing number of overweight people, which is considered a risk factor for OA, contribute to the growing number of cases of hip OA. In knee OA patients, exercise as a single treatment is proven to be very effective towards counteracting pain and physical functionality, but the combination of weight loss and exercise is demonstrated to be even more effective. Exercise as a treatment for hip OA patients is also effective, however evidence is lacking for the combination of weight loss and exercise. Consequently, the aim of this study is to get a first impression of the potential effectiveness of exercise and weight loss in overweight patients suffering from hip OA.

Methods/Design

This is a prospective cohort study. Patients aged 25 or older, overweight (BMI > 25) or obese (BMI > 30), with clinical and radiographic evidence of OA of the hip and able to attend exercise sessions will be included. The intervention is an 8-month exercise and weight-loss lifestyle program. Main goal is to increase aerobic capacity, lose weight and stimulate a low-calorie and active lifestyle. Primary outcome is self-reported physical functioning. Secondary outcomes include pain, stiffness, health-related quality of life and habitual activity level. Weight loss in kilograms and percentage of fat-free mass will also be measured.

Discussion

The results of this study will give a first impression of potential effectiveness of exercise and weight loss as a combination program for patients with OA of the hip. Once this program is proven to be effective it may lead to postponing the moment of total hip replacement.

Trial Registration number

NTR1053

Receiving treatment for common mental disorders

OBJECTIVE

Anxiety and depressive disorders are widely prevalent, but patients are only treated in a minority of cases. In this study, the explanation of receiving mental health treatment is sought in predisposing and enabling characteristics and indicators for objective and self-perceived need.

METHODS

Cross-sectional analysis of data collected in the Netherlands Study of Depression and Anxiety (NESDA) among 743 persons with an anxiety and/or depression diagnosis as assessed by the CIDI. Receipt of mental health treatment was assessed in the face-to-face interview, as well as indicators of predisposing and enabling factors and variables evaluating need for care.

RESULTS

Of the total sample, 57% received treatment in the past 6 months in the general practice setting (50%) or the mental health care setting (14%). Younger patients, patients who evaluated their providers better on communicative abilities and patients who perceived mental health problems themselves had greater odds of having professional mental health contacts in the primary care setting. Confidence in professional help and higher severity of mental problems were associated with greater odds of having specialized mental health care.

CONCLUSION

Receiving help for common mental disorders depends not only on the objective need of the patient but also at least as much on the patients' own recognition that their problems have a mental health origin. Furthermore, in primary care especially, the patients' judgment of their providers' affective abilities may be decisive for being treated. For receiving specialized care, patients are also directed by their confidence in professional help.

The workload of general practitioners does not affect their awareness of patients' psychological problems

OBJECTIVE

To investigate if general practitioners (GPs) with a higher workload are less inclined to encourage their patients to disclose psychological problems, and are less aware of their patients' psychological problems.

METHODS

Data from 2095 videotaped consultations from a representative selection of 142 Dutch GPs were used. Multilevel regression analyses were performed with the GPs' awareness of the patient's psychological problems and their communication as outcome measures, the GPs' workload as a predictor, and GP and patient characteristics as confounders.

RESULTS

GPs' workload is not related to their awareness of psychological problems and hardly related to their communication, except for the finding that a GP with a subjective experience of a lack of time is less patient-centred. Showing eye contact or empathy and asking questions about psychological or social topics are associated with more awareness of patients' psychological problems.

CONCLUSION

Patients' feelings of distress are more important for GPs' communication and their awareness of patients' psychological problems than a long patient list or busy moment of the day. GPs who encourage the patient to disclose their psychological problems are more aware of psychological problems.

PRACTICE IMPLICATIONS

We recommend that attention is given to all the communication skills required to discuss psychological problems, both in the consulting room and in GPs' training. Additionally, attention for gender differences and stress management is recommended in GPs' training.

Enhanced treatment for depression in primary care: long-term outcomes of a psycho-educational prevention program alone and enriched with psychiatric consultation or cognitive behavioral therapy

BACKGROUND

The long-term outcome of major depression is often unfavorable, and because most cases of depression are managed by general practitioners (GPs), this places stress on the need to improve treatment in primary care. This study evaluated the long-term effects of enhancing the GP's usual care (UC) with three experimental interventions.

METHOD

A randomized controlled trial was conducted from 1998 to 2003. The main inclusion criterion was receiving GP treatment for a depressive episode. We compared: (1) UC (n=72) with UC enhanced with: (2) a psycho-educational prevention (PEP) program (n=112); (3) psychiatrist-enhanced PEP (n=37); and (4) brief cognitive behavioral therapy followed by PEP (CBT-enhanced PEP) (n=44). We assessed depression status quarterly during a 3-year follow-up.

RESULTS

Pooled across groups, depressive disorder-free and symptom-free times during follow-up were 83% and 17% respectively. Almost 64% of the patients had a relapse or recurrence, the median time to recurrence was 96 weeks, and the mean Beck Depression Inventory (BDI) score over 12 follow-up assessments was 9.6. Unexpectedly, PEP patients had no better outcomes than UC patients. However, psychiatrist-enhanced PEP and CBT-enhanced PEP patients reported lower BDI severity during follow-up than UC patients [mean difference 2.07 (95% confidence interval (CI) 1.13-3.00) and 1.62 (95% CI 0.70-2.55) respectively] and PEP patients [2.37 (95% CI 1.35-3.39) and 1.93 (95% CI 0.92-2.94) respectively].

CONCLUSIONS

The PEP program had no extra benefit compared to UC and may even worsen outcome in severely depressed patients. Enhancing treatment of depression in primary care with psychiatric consultation or brief CBT seems to improve the long-term outcome, but findings need replication as the interventions were combined with the ineffective PEP program.

A new interdisciplinary treatment strategy versus usual medical care for the treatment of subacromial impingement syndrome: a randomized controlled trial

Background

Subacromial impingement syndrome (SIS) is the most frequently recorded shoulder disorder. When conservative treatment of SIS fails, a subacromial decompression is warranted. However, the best moment of referral for surgery is not well defined. Both early and late referrals have disadvantages – unnecessary operations and smaller improvements in shoulder function, respectively. This paper describes the design of a new interdisciplinary treatment strategy for SIS (TRANSIT), which comprises rules to treat SIS in primary care and a well-defined moment of referral for surgery.

Methods/Design

The effectiveness of an arthroscopic subacromial decompression versus usual medical care will be evaluated in a randomized controlled trial (RCT). Patients are eligible for inclusion when experiencing a recurrence of SIS within one year after a first episode of SIS which was successfully treated with a subacromial corticosteroid injection. After inclusion they will receive injection treatment again by their general practitioner. When, after this treatment, there is a second recurrence within a year post-injection, the participants will be randomized to either an arthroscopic subacromial decompression (intervention group) or continuation of usual medical care (control group). The latter will be performed by a general practitioner according to the Dutch National Guidelines for Shoulder Problems. At inclusion, at randomization and three, six and 12 months post-randomization an outcome assessment will take place. The primary outcome measure is the patient-reported Shoulder Disability Questionnaire. The secondary outcome measures include both disease-specific and generic measures, and an economic evaluation. Treatment effects will be compared for all measurement points by using a GLM repeated measures analyses.

Discussion

The rationale and design of an RCT comparing arthroscopic subacromial decompression with usual medical care for subacromial impingement syndrome are presented. The results of this study will improve insight into the best moment of referral for surgery for SIS.

Does the attention General Practitioners pay to their patients' mental health problems add to their workload? A cross sectional national survey

Background

The extra workload induced by patients with mental health problems may sometimes cause GPs to be reluctant to become involved in mental health care. It is known that dealing with patients' mental health problems is more time consuming in specific situations such as in consultations. But it is unclear if GPs who are more often involved in patients' mental health problems, have a higher workload than other GPs. Therefore we investigated the following: Is the attention GPs pay to their patients' mental health problems related to their subjective and objective workload?

Methods

Secondary analyses were made using data from the Second Dutch National Survey of General Practice, a cross sectional study conducted in the Netherlands in 2000–2002. A nationally representative selection of 195 GPs from 104 general practices participated in this National Survey. Data from: 1) a GP questionnaire; 2) a detailed log of the GP's time use during a week and; 3) an electronic medical registration system, including all patients' contacts during a year, were used. Multiple regression analyses were conducted with the GP's workload as an outcome measure, and the GP's attention for mental health problems as a predictor. GP, patient, and practice characteristics were included in analyses as potential confounders.

Results

Results show that GPs with a broader perception of their role towards mental health care do not have more working hours or patient contacts than GPs with a more limited perception of their role. Neither are they more exhausted or dissatisfied with the available time. Also the number of patient contacts in which a psychological or social diagnosis is made is not related to the GP's objective or subjective workload.

Conclusion

The GP's attention for a patient's mental health problems is not related to their workload. The GP's extra workload when dealing in a consultation with patients' mental health problems, as is demonstrated in earlier research, is not automatically translated into a higher overall workload. This study does not confirm GPs' complaints that mental health care is one of the components of their job that consumes a lot of their time and energy. Several explanations for these results are discussed.

Communicative skills of general practitioners augment the effectiveness of guideline-based depression treatment

BACKGROUND

Although good physician communication is associated with positive patient outcomes, it does not figure in current depression treatment guidelines. We examined the effect of depression treatment, communicative skills and their interaction on patient outcomes for depression in primary care.

METHODS

In a cohort of 348 patients with ICD-10 depression in primary care, patient outcomes were studied over 3- and 12-month follow-ups. The association of these outcomes with both depression-specific process of care variables and a nonspecific variable-communicative skillfulness of GP-was examined. Patient outcomes consisted of change from baseline in symptomatology, disability, activity limitation days, and duration of the depressive episode.

RESULTS

In accordance with treatment guidelines, some main effects of depression treatment were found, in particular on symptomatology, but these remained small (effect size<0.50). A moderate effect was found for treatment with a sedative, which proved to be related to worse patient outcomes at 12 months. An accurate GP diagnosis of depression and adequate antidepressant treatment were associated with better patient outcomes, but only when provided by GPs with good communicative skills. In contrast to the main effects, these interactions were seen on disability and activity limitation days, not on symptomatology.

LIMITATIONS

The study is observational and does not permit firm conclusions about causal relationships. Communicative skillfulness of the GP was assessed by patient report only.

CONCLUSION

Neither depression-specific interventions nor good GP communication skills seem to be sufficient for optimal patient improvement. Only the combination of treatments according to guidelines and good communication skills results in an effective antidepressive treatment.