Managing diabetes mellitus with comorbidities in primary healthcare facilities in urban settings: a qualitative study among physicians in Odisha, India.

AIM: To explore the perceived barriers and facilitators in the management of the patients having diabetes with comorbidities by primary care physicians. METHODS: A qualitative In-Depth Interview study was conducted among the primary care physicians at seventeen urban primary health care centres at Bhubaneswar city of Odisha, India. The digitally recorded interviews were transcribed verbatim and translated into English. The data were analysed using thematic analysis. RESULTS: Barriers related to physicians, patients and health system were identified. Physicians felt lack of necessary knowledge and skills, communication skills and overburdening due to multiple responsibilities to be major barriers to quality care. Patients' attitude and beliefs along with socio-economic status played an important role in treatment adherence and in the management of their disease conditions. Poor infrastructure, irregular medicine supply, and shortage of skilled allied health professionals were also found to be barriers to optimal care delivery, as was the lack of electronic medical records and personal treatment records. CONCLUSION: Comprehensive guidelines with on the job training for capacity building of the physicians and creation of multidisciplinary teams at primary care level for a more holistic approach towards management of diabetes with comorbidities could be the way forward to optimal delivery of care.

Mismatch between self-perceived and calculated cardiometabolic disease risk among participants in a prevention program for cardiometabolic disease: a cross-sectional study.

BACKGROUND: The rising prevalence of cardiometabolic diseases (CMD) calls for effective prevention programs. Self-assessment of CMD risk, for example through an online risk score (ORS), might induce risk reducing behavior. However, the concept of disease risk is often difficult for people to understand. Therefore, the study objective was to assess the impact of communicating an individualized CMD risk score through an ORS on perceived risk and to identify risk factors and demographic characteristics associated with risk perception among high-risk participants of a prevention program for CMD. METHODS: A cross-sectional analysis of baseline data from a randomized controlled trial conducted in a primary care setting. Seven thousand five hundred forty-seven individuals aged 45-70 years without recorded CMD, hypertension or hypercholesterolemia participated. The main outcome measures were: 1) differences in cognitive and affective risk perception between the intervention group - who used an ORS and received an individualized CMD risk score- and the control group who answered questions about CMD risk, but did not receive an individualized CMD risk score; 2) risk factors and demographic characteristics associated with risk perception. RESULTS: No differences were found in cognitive and affective risk perception between the intervention and control group and risk perception was on average low, even among high-risk participants. A positive family history for diabetes type 2 (ß0.56, CI95% 0.39-0.73) and cardiovascular disease (ß0.28, CI95% 0.13-0.43), BMI ≥25 (ß0.27, CI95% 0.12-0.43), high waist circumference (ß0.25, CI95% 0.02-0.48) and physical inactivity (ß0.30, CI95% 0.16-0.45) were positively associated with cognitive CMD risk perception in high-risk participants. No other risk factors or demographic characteristics were associated with risk perception. CONCLUSIONS: Communicating an individualized CMD risk score did not affect risk perception. A mismatch was found between calculated risk and self-perceived risk in high-risk participants. Family history and BMI seem to affect the level of CMD risk perception more than risk factors such as sex, age and smoking. A dialogue about personal CMD risk between patients and health care professionals might optimize the effect of the provided risk information. TRIAL REGISTRATION: Dutch trial Register number NTR4277, registered 26th Nov 2013.

[Developments in mental health care in Dutch general practices: an overview of recent studies]. / Ontwikkelingen in de Nederlandse huisartsenzorg voor psychische problemen: een overzicht van recente studies.

BACKGROUND: Dutch policy aims to strengthen mental health care in general practices, to keep health care affordable. Recently, a new function (mental health nurses) and a new referral model for patients with mental health problems were introduced.
AIM: To explore to what extent the volume of mental health care in Dutch general practices has increased and to what extent the content changed in the period 2010-2015.
METHOD: This study employed: 1. analyses of medical records, and 2. a case study in a primary health care centre.
RESULTS: The number of general practices with at least one mental health nurse increased from 20% in 2010 to almost 90% in 2015. In the period 2010-2014, general practitioners (gps) and mental health nurses treated increasing numbers of patients with mental health problems. No task shifting from gps to mental health nurses was observed. In the period 2011-2015, the number of antidepressant prescriptions increased slightly. In 2014, gps in a well-prepared primary care centre allocated 87% of their patients with mental health problems to a treatment setting in line with the referral model.
CONCLUSION: Dutch general practices have recently provided more mental health care, thereby emphasising their important role in the mental health care system.

Effectiveness of tailored support for people with Type 2 diabetes after a first acute coronary event: a multicentre randomized controlled trial (the Diacourse-ACE study).

AIMS: To evaluate the effectiveness of a tailored, supportive intervention strategy in influencing diabetes-related distress, health status, well-being and clinical outcomes in people with Type 2 diabetes shortly after a first acute coronary event. METHODS: People with Type 2 diabetes and a recent first acute coronary event (n = 201) were randomized to the intervention group (three home visits by a diabetes nurse) or the attention control group (one telephone consultation). Outcomes were measured after discharge (baseline) and at 5 months (follow-up) using validated questionnaires for diabetes-related distress (Problem Areas in Diabetes), well-being (WHO Well-Being Index) and health status (Euroqol 5 Dimensions; Euroqol Visual Analogue Scale). ancova was used to analyse change-over-time differences between groups. RESULTS: Follow-up data were available for 81 participants in the intervention group (66.0 ± 9.3 years, 76% male) and 80 in the control group (65.6 ± 9.4 years, 75% male) participants. Mean diabetes-related distress was low after hospital discharge (intervention group: 8.2 ± 10.1; control group: 9.2 ± 12.4) and did not change after 5 months (intervention group: 9.2 ± 12.4; control group: 9.0 ± 11.2). Baseline well-being was less favourable but improved significantly in the intervention group (baseline: 58.5 ± 28.0; follow-up: 65.5 ± 23.7; P = 0.005), but not in the control group (baseline: 57.5 ± 25.2; follow-up: 59.6 ± 24.4; P = 0.481). Health status also improved in the intervention group (baseline: 69.9 ± 17.3; follow-up: 76.8 ± 15.6; P < 0.001) but not in the control group (baseline: 68.6 ± 15.9; follow-up: 69.9 ± 16.7; P = 0.470). A significant group effect was found for health status (F = 7.9; P = 0.006). CONCLUSIONS: Although the intervention had no effect on diabetes-related distress, this might be at least partially attributable to very low levels of diabetes-related distress at baseline. Interestingly, health status scores and well-being, which were less favourable at baseline, both improved after the tailored support intervention.

Effect of the partner's health and support on cancer patients' use of general practitioner care.

OBJECTIVE: Cancer and its treatment often have a profound impact on patients, leading to increased health care use in the years after diagnosis. Social support is an important determinant of health care use. Partners of cancer patients may not always be able to provide all support patients need and patients may then revert to professional health care. We examined whether partners' health and the support they provide affect the use of general practitioner (GP) care in cancer patients. METHODS: Cancer patients aged ≥18, diagnosed <20 years ago with a cancer type with a 5-year survival rate >20% and no distant metastases were sent a questionnaire, along with their partners. Patients' self-reported recent use of GP care, i.e. whether they had discussed health problems with the GP in the past year, was assessed. Partner support as perceived by the patient was measured on three scales: Active engagement, protective buffering and overprotection. RESULTS: We included 219 patients and partners. Many patients discussed physical and emotional problems with their GP (60% and 28% of patients, respectively). Patients were less likely to discuss physical problems when they experienced active engagement and protective buffering, the latter only for females. CONCLUSION: Partner support affects use of GP care in cancer patients. GPs should therefore pay attention to the support style of the partner. GPs could ask about the support provided by the partner and inform both patients and partners about support groups where they can share experiences.

Expanding access to pain care for frail, older people in primary care: a cross-sectional study.

BACKGROUND: Although untreated pain has a negative impact on quality of life and health outcomes, research has shown that older people do not always have access to adequate pain care. Practice nurse-led, comprehensive geriatric assessments (CGAs) may increase access to tailored pain care for frail, older people who live at home. To explore this, we investigated whether new pain cases were identified by practice nurses during CGAs administered as part of an intervention with the Geriatric Care Model, a comprehensive care model based on the Chronic Care Model, and whether the intervention led to tailored pain action plans in care plans of frail, older people. METHODS: We used cross-sectional data from the older Adults: Care in Transition (ACT) study, a 2-year clinical trial carried out in two regions of the Netherlands. Practice nurses proactively visited older people at home and administered an in-home CGA that included an assessment of pain. Pain care-related agreements and actions (pain action plans) based on CGA results were described in a tailored care plan. We analyzed care plans of 781 older people who received a first-time CGA by a practice nurse for the presence of pain, pain location and cause, new pain cases, and pain action plans. We used descriptive statistics to analyze our data. RESULTS: We found that 315 (40.3 %) older people experienced any type of pain. Practice nurses identified 20 (10.6 %) new pain cases, and 188 (59.7 %) older people with pain formulated at least one therapeutic or non-therapeutic pain action plan together with a practice nurse. More than half of the older people whose pain had already been identified by a primary care physician wanted a pain action plan. Most pain action plans consisted of actions or agreements related to continuity of care. DISCUSSION AND CONCLUSION: Practice nurses in primary care can contribute to expanding older people's access to tailored pain care. Future researchers should continue to direct their focus at ways to overcome the barriers that restrict older people's access to pain care.

Diabetes-related distress over the course of illness: results from the Diacourse study.

AIMS: To investigate the relationship between diabetes duration and diabetes-related distress and to examine the impact of micro- and macrovascular complications and blood glucose-lowering treatment on this relationship. METHODS: We conducted a cross-sectional study in people with Type 2 diabetes who participated in the Dutch Diacourse study (n = 590) and completed the Problem Areas in Diabetes questionnaire. Data on diabetes duration, micro- and macrovascular complications and blood glucose-lowering treatment were collected. Multiple linear regression analysis was used to investigate the association between diabetes duration and diabetes-related distress, and to examine whether complications and treatment could explain this association. RESULTS: A significant linear and quadratic association between diabetes duration and diabetes-related distress was found (duration: ß = 0.27, P = 0.005; duration(2): ß = -0.21, P = 0.030). The association between duration and distress could be explained by microvascular complications and insulin treatment, which were both more often present in people with a longer diabetes duration, and were associated with higher levels of diabetes-related distress (ß = 0.20, P < 0.001 and ß = 0.16, P = 0.006 respectively). Duration, age, gender, complications and treatment together explained 13.1% of the variance in distress. CONCLUSIONS: Diabetes duration was associated with diabetes-related distress. This association can be explained largely by the presence of diabetes-related microvascular complications and insulin treatment. Healthcare providers should focus on distress in people with Type 2 diabetes in different stages over the course of illness, especially when complications are present or when people are on insulin treatment. As well as diabetes duration, complications and blood glucose-lowering treatment, diabetes-related distress is likely to be influenced by many other factors.

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

BACKGROUND: General practice based registration networks (GPRNs) provide information on population health derived from electronic health records (EHR). Morbidity estimates from different GPRNs reveal considerable, unexplained differences. Previous research showed that population characteristics could not explain this variation. In this study we investigate the influence of practice characteristics on the variation in incidence and prevalence figures between general practices and between GPRNs. METHODS: We analyzed the influence of eight practice characteristics, such as type of practice, percentage female general practitioners, and employment of a practice nurse, on the variation in morbidity estimates of twelve diseases between six Dutch GPRNs. We used multilevel logistic regression analysis and expressed the variation between practices and GPRNs in median odds ratios (MOR). Furthermore, we analyzed the influence of type of EHR software package and province within one large national GPRN. RESULTS: Hardly any practice characteristic showed an effect on morbidity estimates. Adjusting for the practice characteristics did also not alter the variation between practices or between GPRNs, as MORs remained stable. The EHR software package 'Medicom' and the province 'Groningen' showed significant effects on the prevalence figures of several diseases, but this hardly diminished the variation between practices. CONCLUSION: Practice characteristics do not explain the differences in morbidity estimates between GPRNs.

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

BACKGROUND: General practice based registration networks (GPRNs) provide information on morbidity rates in the population. Morbidity rate estimates from different GPRNs, however, reveal considerable, unexplained differences. We studied the range and variation in morbidity estimates, as well as the extent to which the differences in morbidity rates between general practices and networks change if socio-demographic characteristics of the listed patient populations are taken into account. METHODS: The variation in incidence and prevalence rates of thirteen diseases among six Dutch GPRNs and the influence of age, gender, socio economic status (SES), urbanization level, and ethnicity are analyzed using multilevel logistic regression analysis. Results are expressed in median odds ratios (MOR). RESULTS: We observed large differences in morbidity rate estimates both on the level of general practices as on the level of networks. The differences in SES, urbanization level and ethnicity distribution among the networks' practice populations are substantial. The variation in morbidity rate estimates among networks did not decrease after adjusting for these socio-demographic characteristics. CONCLUSION: Socio-demographic characteristics of populations do not explain the differences in morbidity estimations among GPRNs.

Long-term effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a randomized controlled trial comparing two different physical therapy interventions.

OBJECTIVE: To determine if behavioral graded activity (BGA) results in better long-term effectiveness (5 years after inclusion) than usual exercise therapy (UC; usual care) in patients with osteoarthritis (OA) of the hip or knee. METHOD: Long-term follow-up study of a single blind cluster randomized trial comparing BGA and UC. One hundred and forty-nine patients out of the 200 included were followed until 60 months' follow-up. Primary outcome measures were pain, physical function, and patient global assessment. Furthermore, patient-oriented physical function, physical performance, health care utilization and the number of joint replacement surgeries were assessed. Assessments took place at 3, 9, 15 and 60 months' follow-up. Data were analyzed according to intent-to-treat principle. RESULTS: Both treatments showed beneficial within-groups effects in the long-term. In patients with knee OA no differences between treatments were found on the short-, mid-long and long-term. In patients with hip OA significant differences in favor of BGA were found at 3 months' (pain and physical performance) and 9 months' follow-up (pain, physical function, patients global assessment and patient-oriented physical function). Furthermore, UC resulted in patients with hip OA in more joint replacement surgeries compared to BGA (hazard ratio [HR], 2.87; 95% confidence interval [CI], 1.1; 7.3). CONCLUSION: No differences between treatment groups were found in the long-term on the primary outcome measures. Although more research is needed to confirm the study findings, the results indicate that BGA reduces the risk for joint replacement surgeries compared to UC in patients with hip OA, which probably can be explained by better outcome in favor of BGA in the short- and mid-long-term.

The Application of the Concept of Resilience in Aging Research and Older Adult Care: A Focus Group Study.

Introduction: Research incorporating resilience, a concept featuring a positive outcome despite some type of stressor, has the potential to identify possibilities for promotion of the well-being of older people. This study aims to gain insight into the value and potential applications of resilience in both research and care practice from the perspective of researchers and care professionals. Specifically, the value of two scientific approaches, the a priori (i.e., based on a priori definition of a stressor and outcome) and dynamical systems approaches (i.e., based on mathematically modeled patterns in the real-time response to perturbations), was explored. Methods: Focus groups were performed to explore the thoughts of academic researchers from different disciplines in the fields of aging and care and care professionals on the application of the concept of resilience, including the a priori and dynamical systems approaches. Analysis of these focus groups was based on the framework method. Results: Five focus groups were held with a total of nine researchers from different disciplines (e.g., epidemiology, sociology) and 15 older adult care professionals from different professions (e.g., elderly care physician, physiotherapist). The participants described resilience as a concept with value for both aging research and care through its positive connotation and comprehensiveness. Continued research was thought to play an important role in clearing up some of the existing ambiguity surrounding resilience. The importance of resilience in the context of both high- and low-intensity stressors was underscored. The a priori and dynamical systems approaches were considered to have their specific advantages and disadvantages on both conceptual and feasibility levels. Therefore, the use of both approaches, side by side and in combination, was suggested. Conclusion: This qualitative exploration among researchers and care professionals confirms that the concept of resilience, including the a priori and dynamical systems approaches, is valuable. However, more work is necessary before can be delivered on the potential of resilience in aging research and older adult care practice. Greater conceptual and operational clarity can be achieved through more qualitative studies on the concept that take the perspective of older people into account and through empirical studies that work with both approaches simultaneously and/or in combination.

Serious adverse events attributed to remifentanil patient-controlled analgesia during labour in The Netherlands.

BACKGROUND: During labour, remifentanil patient-controlled analgesia is used as an alternative to neuraxial analgesia. Remifentanil is associated with hypoventilation and respiratory depression but the frequency of serious maternal and neonatal adverse events is unknown. The aim of this study was to estimate the number of serious adverse events attributed to the use of remifentanil patient-controlled analgesia during labour in The Netherlands and to investigate the circumstances (e.g. monitoring, practice deviations) of these events and the subsequent management. METHODS: In a nationwide survey among obstetricians, anaesthetists and clinical midwives the frequency of serious adverse events was assessed. A questionnaire was sent by email to all 61 Dutch hospitals in which remifentanil patient-controlled analgesia is, or has been, available for labour analgesia. All reported cases were assessed independently by two expert teams. RESULTS: We received information from all hospitals. After independent assessments, 17 cases of single maternal desaturation; 10 maternal cases of apnoea, bradycardia and/or cardiac arrest; and two neonatal cases of respiratory depression, over a period of more than 10 years of remifentanil patient-controlled analgesia use, were identified as a serious adverse event. All serious adverse events were resolved without irreversible damage. CONCLUSIONS: The risk of a potentially life-threatening serious adverse event attributed to remifentanil patient-controlled analgesia seems to be low. All patients recovered without deficit. Adherence to strict monitoring and the attendance of trained healthcare providers is required to safely use remifentanil for labour analgesia.

Morbidity severity classifying routine consultations from English and Dutch general practice indicated physical health status.

OBJECTIVE: To investigate the construct validity of morbidity severity scales based on routine consultation data by studying their associations with sociodemographic factors and physical health. STUDY DESIGN AND SETTING: Study participants were 11,232 English adults aged 50 years and over and 9,664 Dutch adults aged 18 years and over, and their consulting morbidity data in a 12-month period were linked to their physical health data. Consulters with any of 115 morbidities classified on four ordinal scales of severity ("chronicity," "time course," "health care use," and "patient impact") were compared to all other consulters. RESULTS: As hypothesized, in both countries, morbidity severity was associated with older age, female gender, more deprivation (all comparisons P< or =0.05), and poor physical health (all trends P<0.001). The estimated strengths of association of poor physical health with the highest severity category expressed as odds ratios, for each of the four scales, were 5.4 for life-threatening on the "chronicity" scale, 1.8 for time course, 2.8 for high health care use, and 3.7 for high patient impact. CONCLUSIONS: Four scales of morbidity severity have been validated in English and Dutch settings, and they offer the potential to use simple routine consultation data as an indicator of physical health status in populations from general practice.

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

BACKGROUND: most studies of older populations in developed countries show a decrease in the prevalence of disabilities, and an increase in chronic diseases over the past decades. Data in the Netherlands, however, mostly show an increase in the prevalence of chronic diseases and mixed results with regard to the prevalence of disability. This study aims at comparing changes in the prevalence, as well as the association between chronic diseases and disability between 1987 and 2001 in the older Dutch population using data representative of the general population. Most studies, so far, have only dealt with self-reported diseases, but in this study, we will use both self-reported and GP-registered diseases. STUDY DESIGN: data from the first (1987) and second (2001) Dutch National Survey of General Practice were used. In 1987, 103 general practices, compared to 104 in 2001, participated. Approximately 5% of the listed persons aged 18 years and over was asked to participate in an extensive health interview survey. An all-age random sample was drawn by the researchers from the patients listed in the participating practices (in 1987 n = 2, 708; in 2001 n = 3, 474). Both surveys are community based, with an age range between 55 and 97 years. Data on chronic diseases were based on GP registries and self-report. RESULTS: the prevalence of disability and of asthma/COPD, cardiac disease, stroke, and osteoarthritis decreased between 1987 and 2001, while the prevalence of diabetes increased. Changes were largely similar for GP-registered and self-reported diseases. Cardiac disease, asthma/COPD, and depression led to less disability, whereas low back pain and osteoarthritis led to more disability. CONCLUSIONS: in general, there were reductions in GP-registered chronic diseases as well as in self-reported diseases and disability. Results suggest that the disabling impact of fatal diseases decreased, while the impact of non-fatal diseases increased.

Implementation fidelity of a clinical medication review intervention: process evaluation.

Background Implementation of clinical medication reviews in daily practice is scarcely evaluated. The Opti-Med intervention applied a structured approach with external expert teams (pharmacist and physician) to conduct medication reviews. The intervention was effective with respect to resolving drug related problems, but did not improve quality of life. Objective The objective of this process evaluation was to gain more insight into the implementation fidelity of the intervention. Setting Process evaluation alongside a cluster randomized trial in 22 general practices and 518 patients of 65 years and over. Method A mixed methods design using quantitative and qualitative data and the conceptual framework for implementation fidelity was used. Implementation fidelity is defined as the degree to which the various components of an intervention are delivered as intended. Main outcome measure Implementation fidelity for key components of the Opti-Med intervention. Results Patient selection and preparation of the medication analyses were carried out as planned, although mostly by the Opti-Med researchers instead of practice nurses. Medication analyses by expert teams were performed as planned, as well as patient consultations and patient involvement. 48% of the proposed changes in the medication regime were implemented. Cooperation between expert teams members and the use of an online decision-support medication evaluation facilitated implementation. Barriers for implementation were time constraints in daily practice, software difficulties with patient selection and incompleteness of medical files. The degree of embedding of the intervention was found to influence implementation fidelity. The total time investment for healthcare professionals was 94 min per patient. Conclusion Overall, the implementation fidelity was moderate to high for all key components of the Opti-Med intervention. The absence of its effectiveness with respect to quality of life could not be explained by insufficient implementation fidelity.

Prevalence and pattern of co morbidity among type2 diabetics attending urban primary healthcare centers at Bhubaneswar (India).

OBJECTIVE: India has the second largest diabetic population in the world. The chronic nature of the disease and high prevalence of co-existing chronic medical conditions or "co morbidities" makes diabetes management complex for the patient and for health care providers. Hence a strong need was felt to explore the problem of co morbidity among diabetics and its dimensions in primary health care practices. METHOD: This cross sectional survey was carried out on 912 type 2 diabetes patients attending different urban primary health care facilities at Bhubaneswar. Data regarding existence of co morbidity and demographical details were elicited by a predesigned, pretested questionnaire"Diabetes Co morbidity Evaluation Tool in Primary Care (DCET- PC)". Statistical analyses were done using STATA. RESULTS: Overall 84% had one ormore than one comorbid condition. The most frequent co morbid conditions were hypertension [62%], acid peptic disease [28%], chronic back ache [22%] and osteoarthritis [21%]. The median number of co morbid conditions among both males and females is 2[IQR = 2]. The range of the number of co morbid conditions was wider among males [0-14] than females [0-6]. The number of co morbidities was highest in the age group > = 60 across both sexes. Most of the male patients below 40 years of age had either single [53%] or three co morbidities [11%] whereas among female patients of the same age group single [40%] or two co morbidities [22%] were more predominantly present. Age was found to be a strong independent predictor for diabetes co morbidity. The odds of having co morbidity among people above poverty line and schedule caste were found to be[OR = 3.50; 95%CI 1.85-6.62]and [OR = 2.46; CI 95%1.16-5.25] respectively. Odds were increased for retired status [OR = 1.21; 95% CI 1.01-3.91] and obesity [OR = 3.96; 95%CI 1.01-15.76]. CONCLUSION: The results show a high prevalence of co morbidities in patients with type 2 diabetes attending urban primary health care facilities. Hypertension, acid peptic disease, chronic back ache and arthritis being the most common, strategies need to be designed taking into account the multiple demands of co morbidities.

[Inter-practice variation in polypharmacy prevalence amongst older patients in primary care]. / Bij iedere huisarts evenveel pillen?

PURPOSE: Complex medication management in older people with multiple chronic conditions can introduce practice variation in polypharmacy prevalence. This study aimed to determine the inter-practice variation in polypharmacy prevalence and examine how this variation was influenced by patient and practice characteristics. METHODS: This cohort study included 45,731 patients aged 55 years and older with at least one prescribed medication from 126 general practices that participated in NIVEL Primary Care Database in the Netherlands. Medication dispensing data of the year 2012 were used to determine polypharmacy. Polypharmacy was defined as the chronic and simultaneous use of at least five different medications. Multilevel logistic regression models were constructed to quantify the polypharmacy prevalence variation between practices. Patient characteristics (age, gender, socioeconomic status, number, and type of chronic conditions) and practice characteristics (practice location and practice population) were added to the models. RESULTS: After accounting for differences in patient and practice characteristics, polypharmacy rates varied with a factor of 2.4 between practices (from 12.4% to 30.1%) and an overall mean of 19.8%. Age and type of conditions were highly positively associated with polypharmacy, and to a lesser extent a lower socioeconomic status. CONCLUSIONS: Considerable variation in polypharmacy rates existed between general practices, even after accounting for patient and practice characteristics, which suggests that there is not much agreement concerning medication management in this complex patient group. Initiatives that could reduce inappropriate heterogeneity in medication management can add value to the care delivered to these patients.

[Time trends in prevalence of chronic diseases and multimorbidity not only due to aging: data from general practices and health surveys]. / Toename in chronische ziekten en multimorbiditeit.

INTRODUCTION: Chronic diseases and multimorbidity are common and expected to rise over the coming years. The objective of this study is to examine the time trend in the prevalence of chronic diseases and multimorbidity over the period 2001 till 2011 in the Netherlands, and the extent to which this can be ascribed to the aging of the population. METHODS: Monitoring study, using two data sources: 1) medical records of patients listed in a nationally representative network of general practices over the period 2002-2011, and 2) national health interview surveys over the period 2001-2011. Regression models were used to study trends in the prevalence-rates over time, with and without standardization for age. RESULTS: An increase from 34.9% to 41.8% (p<0.01) in the prevalence of chronic diseases was observed in the general practice registration over the period 2004-2011 and from 41.0% to 46.6% (p<0.01) based on self-reported diseases over the period 2001-2011. Multimorbidity increased from 12.7% to 16.2% (p<0.01) and from 14.3% to 17.5% (p<0.01), respectively. Aging of the population explained part of these trends: about one-fifth based on general practice data, and one-third for chronic diseases and half of the trend for multimorbidity based on health surveys. CONCLUSIONS: The prevalence of chronic diseases and multimorbidity increased over the period 2001-2011. Aging of the population only explained part of the increase, implying that other factors such as health care and society-related developments are responsible for a substantial part of this rise.

Disparities in stroke preventive care in general practice did not explain socioeconomic disparities in stroke.

OBJECTIVE: To assess socioeconomic disparities in stroke incidence and in the quality of preventive care for stroke in the Netherlands. STUDY DESIGN AND SETTINGS: A total of 190,664 patients who registered in 96 general practices were followed up for 12 months. Data were collected on diagnoses, referrals, prescriptions, and diagnostic procedures. Hazard ratios (HR) were calculated to assess the association between educational level and stroke incidence. Multilevel logistic regression was used to assess socioeconomic disparities in the quality of preventive care for stroke precursors. RESULTS: Lower educational level was associated with higher incidence of stroke in men (HR=1.36, 95% CI=1.06-1.74) but not in women. Among both men and women, there were socioeconomic disparities in the prevalence of hypertension, hypercholesterolemia, diabetes, angina pectoris, heart failure, and peripheral artery disease. Lower educated hypercholesterolemia patients under medication were less likely to be prescribed statins (odds ratio=0.62, 95% CI=0.42-0.91). However, for other precursors of stroke, there were no major disparities in the quality of preventive care. CONCLUSION: There are socioeconomic disparities in stroke incidence among men but not among women. Socioeconomic differences in factors such as hypertension and diabetes are likely to contribute to stroke disparities. However, general practitioners (GPs) provide care of a similar quality to patients from different socioeconomic groups.