Optimal timing of near-term delivery in different ethnicities: a national cohort study.

OBJECTIVE: To study possible ethnic disparities in perinatal mortality and morbidity independent of the occurrence of pregnancy complications. In addition, to study the probabilities of adverse neonatal outcome for delivery, compared with 1 week of expectant management for each week of gestational age in the range of 36-42 weeks of gestation. DESIGN: National cohort study. SETTING: The Netherlands. POPULATION: All women who were recorded as being of white European (982,318), Mediterranean (94,130), or African-Caribbean (25,253) descent with singleton cephalic births delivered between 36(+0) and 42(+6) weeks of gestation. Women with hypertension, pre-eclampsia, or diabetes, or with fetuses that were small for gestational age (below the tenth percentile) or with congenital abnormalities, were excluded. Data were obtained from the Netherlands Perinatal Registry (1999-2007). METHODS: Numbers of antepartum and intrapartum/neonatal death, and neonatal morbidity, were expressed using the fetus/neonate-at-risk approach. For each week of gestation, we compared the probability of adverse neonatal outcome (intrapartum/neonatal death in that week) for delivery with the probability of adverse neonatal outcome for expectant management (antepartum death in that week plus intrapartum/neonatal death and morbidity in the subsequent week). RESULTS: Women of Mediterranean and African-Caribbean descent who were near term were at increased risk of antepartum and intrapartum/neonatal death, and neonatal morbidity, compared with white European women. Expectant management from 40 weeks of gestation onwards was associated with an increased probability of adverse neonatal outcome in white European women and in women of Mediterranean descent, compared with delivery (risk ratio, RR 1.45, 95% confidence interval, 95% CI 1.25-1.68, versus RR 1.69, 95% CI 1.11-2.60, and with number needed to deliver to prevent one adverse neonatal outcome being 563 and 364, respectively). This was not observed for women of African-Caribbean descent. CONCLUSIONS: Ethnic disparities in perinatal outcomes were observed, with higher risks for women of Mediterranean descent. Expectant management in white European and Mediterranean women after 39 weeks of gestation is associated with an increased risk of adverse neonatal outcome.

Increasing maternal age at first pregnancy planning: health outcomes and associated costs.

OBJECTIVES: To describe the consequences in terms of health outcomes, care and associated healthcare costs for three hypothetical cohorts of women planning their first pregnancy at a fixed, different age. DESIGN: Decision model based on data from perinatal registries and the literature. SETTING: The Netherlands. POPULATION: 3 hypothetical cohorts of 100, 000 women aged 23, 29 and 36 years, planning a first pregnancy. MAIN OUTCOME MEASURES: Live birth, pregnancy complications for mother and child and associated healthcare costs. Results For the three cohorts of 23-, 29- and 36-year-old women, 1.6%, 4.6% and 14% of women would not succeed in an ongoing pregnancy (spontaneous or after assisted reproductive technology). The cohort aged 36 gave 9% more miscarriages, 8% more fertility treatment and 1.4% more multiple births than the cohort aged 29. The proportion of caesarean sections among low risk women was 4.9% and 11% higher respectively for the cohorts aged 29 and 36, compared with the cohort aged 23 at start. Eventually, 98%, 95% and 85% of the women in each of the three cohorts gave live birth. The costs for the two older cohorts were €415 and €1662 higher per ongoing pregnancy than the cohort aged 23 years. CONCLUSIONS: Spontaneous conception and mode of delivery are most susceptible to increasing maternal age leading to involuntary childlessness and non-spontaneous labour. The increase in assisted reproduction technology, twin pregnancies and delivery complications results in higher costs along with fewer ongoing pregnancies at higher age.

Does removal of aids/devices and help make a difference in the Childhood Health Assessment Questionnaire disability index?

OBJECTIVE: To assess whether the removal of aids/devices and/or help from another person in the Childhood Health Assessment Questionnaire (C-HAQ) leads to a significant change in the disability index (DI) score and responsiveness in juvenile idiopathic arthritis (JIA). METHODS: Changes in the C-HAQ DI score in a cross-sectional sample of 2663 children with JIA and in 530 active patients with JIA in a trial of methotrexate (MTX) were compared. RESULTS: Patients in the MTX trial had higher disease activity and disability than the cross-sectional sample. The frequency of aids/devices (range 1.2-10.2%) was similar between the two samples, while help (range 5.3-38.1%) was more frequently used in the MTX group. Correlation between disease severity variables and the two different C-HAQ DI scoring methods did not change substantially. There was a decrease in the C-HAQ DI score for both the cross-sectional (mean score from 0.64 with the original method to 0.54 without aids/devices and help, p<0.0001) and the MTX sample (mean score from 1.23 to 1.07, p<0.0001). A linear regression analysis of the original C-HAQ DI score versus the score without aids/devices and help demonstrated the substantial overlap of the different scoring methods. Responsiveness in the responders to MTX treatment did not change with the different C-HAQ DI scoring methods (range 0.86-0.82). CONCLUSION: The removal of aids/devices and help from the C-HAQ does not alter the interpretation of disability at a group level. The simplified C-HAQ is a more feasible and valid alternative for the evaluation of disability in patients with JIA.

Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births.

OBJECTIVE: To compare perinatal mortality and severe perinatal morbidity between planned home and planned hospital births, among low-risk women who started their labour in primary care. DESIGN: A nationwide cohort study. SETTING: The entire Netherlands. POPULATION: A total of 529,688 low-risk women who were in primary midwife-led care at the onset of labour. Of these, 321,307 (60.7%) intended to give birth at home, 163,261 (30.8%) planned to give birth in hospital and for 45,120 (8.5%), the intended place of birth was unknown. METHODS: Analysis of national perinatal and neonatal registration data, over a period of 7 years. Logistic regression analysis was used to control for differences in baseline characteristics. MAIN OUTCOME MEASURES: Intrapartum death, intrapartum and neonatal death within 24 hours after birth, intrapartum and neonatal death within 7 days and neonatal admission to an intensive care unit. RESULTS: No significant differences were found between planned home and planned hospital birth (adjusted relative risks and 95% confidence intervals: intrapartum death 0.97 (0.69 to 1.37), intrapartum death and neonatal death during the first 24 hours 1.02 (0.77 to 1.36), intrapartum death and neonatal death up to 7 days 1.00 (0.78 to 1.27), admission to neonatal intensive care unit 1.00 (0.86 to 1.16). CONCLUSIONS: This study shows that planning a home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low-risk women, provided the maternity care system facilitates this choice through the availability of well-trained midwives and through a good transportation and referral system.

Inter-observer agreement of the physician's global assessment of disease activity in children with juvenile idiopathic arthritis.

OBJECTIVE: To assess the inter-observer agreement in the physician's global assessment of overall disease activity (MD global) in a cohort of patients with juvenile idiopathic arthritis (JIA). METHODS: Forty consecutive patients with JIA, who were representative of a wide spectrum of disease activity and severity, were examined simultaneously by 4 observers. Observer 1 (who was the most experienced rheumatologist) carried out a routine rheumatologic examination of each patient including a complete articular assessment, and subsequently calculated in secrecy the MD global score on an anchored horizontal 10-cm VAS. Observers 2, 3 and 4 were present during the examination; afterwards they also scored in secrecy the MD global score for the patient. Agreement was measured by the intra-class correlation coefficient (ICC), using the score of Observer 1 as the gold standard. An ICC below 0.75 was considered unsatisfactory. RESULTS: The mean (SD) MD global scores for Observers 1, 2, 3, and 4 were 5.2 (3.4), 6.7 (3.9), 5.9 (3.5), and 5.6 (3.7), respectively. The level of agreement with Observer 1 in scoring was 0.83 for Observer 2, 0.88 for Observer 3, and 0.90 for Observer 4, indicating good agreement for all observers. CONCLUSIONS: Our study shows a good inter-observer agreement in the physician's global assessment of overall disease activity in patients with JIA. Analyses involving investigators from different countries are needed to determine whether these results can be generalized.

Relative responsiveness of condition specific and generic health status measures in juvenile idiopathic arthritis.

OBJECTIVES: To compare the relative responsiveness of condition specific measures with that of a generic health status instrument for outcome assessment of intra-articular corticosteroid (IAC) injection in patients with juvenile idiopathic arthritis (JIA). METHODS: We examined 44 consecutive patients with oligoarticular JIA before an IAC injection and after 6 months. Condition specific measures included physician's and parent's global assessments, the Childhood Health Assessment Questionnaire (CHAQ), the articular indices, and laboratory indicators of systemic inflammation. The generic health status instrument was the Child Health Questionnaire (CHQ), which was divided into two parts: the physical score (PhS) and the psychosocial score (PsS). Responsiveness statistics were the standardised response mean, the effect size, and Guyatt's method. The discriminative ability of the clinical measures in distinguishing improved from non-improved patients was evaluated with the correlation and the receiver operating characteristic methods, using the physician's and the parent's judgements of the treatment outcome as external criteria. RESULTS: All responsiveness statistics and discriminative ability assessments consistently ranked the physician's global assessment of the disease activity as the most responsive measure. The CHQ-PhS revealed superior ability in detecting baseline versus 6 month change compared with the CHAQ and the CHQ-PsS; both summary scales of the CHQ revealed better discriminative ability than the CHAQ. CONCLUSIONS: The physician's global assessment of the disease activity proved the most responsive outcome measure in our patients with JIA. The relative evaluative properties of the generic health status instrument and the CHAQ should be further investigated.

Immigrants in the Netherlands: equal access for equal needs?

OBJECTIVE: This paper examines whether equal utilisation of health care services for first generation immigrant groups has been achieved in the Netherlands. DESIGN: Survey data were linked to an insurance register concerning people aged 16-64. Ethnic differences in the use of a broad range of health care services were examined in this group, with and without adjustment for health status and socioeconomic status, using logistic regression. SETTING: Publicly insured population in Amsterdam, the Netherlands. PARTICIPANTS: 1422 people from the indigenous population, and 378 people from the four largest immigrant groups in the Netherlands-that is, the Surinamese, the Netherlands Antilleans, and the Turkish and Moroccan. MAIN OUTCOME MEASURES: General practitioner service use (past two months), prescription drug use (past three months), outpatient specialist contact (past two months), hospital admission (past year), physiotherapist contact (past two months) and contact with other paramedics (past year). MAIN RESULTS: Ethnicity was found to be associated with the use of health care after controlling for health status as an indicator for need. The use of general practitioner care and the use of prescribed drugs was increased among people from Surinam, Turkey and Morocco as compared with the indigenous population. Compared with the indigenous group with corresponding health status, the use of all other more specialised services was relatively low among Turkish and Moroccan people. Among the Surinamese population, the use of more specialised care was highly similar to that found in the Dutch population after differences in need were controlled for. Among people from the Netherlands Antilles, we observed a relatively high use of hospital services in combination with underuse of general practitioner services. The lower socioeconomic status of immigrant groups explained most of the increased use of the general practitioner and prescribed drugs, but could not account for the lower use of the more specialised services. CONCLUSIONS: The results indicate that the utilisation of more specialised health care is lower for immigrant groups in the Netherlands, particularly for Turkish and Moroccan people and to a lesser extent, people from the Netherlands Antilles. Although underuse of more specialised services is also present among the lower socioeconomic groups in the Netherlands, the analyses indicate that this only partly explains the lower utilisation of these services among immigrant groups. This suggests that ethnic background in itself may account for patterns of consumption, potentially because of limited access.

Discordance between proxy-reported and observed assessment of functional ability of children with juvenile idiopathic arthritis.

OBJECTIVE: To determine the level of agreement between parents and clinicians in rating dysfunction in children with juvenile idiopathic arthritis (JIA). METHODS: A parent of each patient completed the Italian version of the Childhood Health Assessment Questionnaire (CHAQ). Subsequently, an examiner assessed, in a specially equipped room, the child's performance of tasks as described by the CHAQ. Demographic and clinical variables were recorded for all patients. RESULTS: Seventy consecutive JIA patients and their parents were included. The mean proxy-reported and observed CHAQ score was 0.64+/-0.53 and 0.47+/-0.62 respectively, the difference ranging from -1.75 to 1.5. There were 30 cases (43%) of agreement (difference < or =0.25 CHAQ units) between the parent's and clinician's ratings, whereas in 40 cases (57%) there was discordance (difference >0.25 CHAQ units). In 30 cases the parent rated the child's functional ability as worse than that observed by the clinician (i.e. the parent underestimated the child's function), whereas in 10 cases the parent rated the child's functional ability as better than that observed by the clinician (i.e. overestimated the child's function). Multivariate regression analysis showed that children's functional ability was overestimated by parents with increasing erythrocyte sedimentation rate and global articular severity score and underestimated with increasing level of pain. Among the functional areas of the CHAQ, the level of agreement was poorest in the areas of eating and hygiene and was best for activities. CONCLUSIONS: Discordance between proxy-reported and observed functional ability was frequent in our patients with JIA. The children's functional ability was overestimated by parents as the severity of arthritis increased and underestimated as the level of pain increased.

Cross-cultural adaptation and psychometric evaluation of the Childhood Health Assessment Questionnaire (CHAQ) and the Child Health Questionnaire (CHQ) in 32 countries. Review of the general methodology.

The aim of this project was to cross-culturally adapt and validate the American English version of the Childhood Health Assessment Questionnaire (CHAQ) and of the Child Health Questionnaire (CHQ) in the 32 different member countries of the Paediatric Rheumatology International Trials Organisation (PRINTO). This effort forms part of an international study supported by the European Union to evaluate the health-related quality of life in children with juvenile idiopathic arthritis (JIA) as compared to their healthy peers. A total of 6,644 subjects were enrolled from 32 countries: Argentina, Austria, Belgium, Brazil, Bulgaria, Chile, Croatia, the Czech Republic, Denmark, Finland, France, Georgia, Germany, Greece, Hungary, Israel, Italy, Korea, Latvia, Mexico, the Netherlands, Norway, Poland, Portugal, Russia, Slovakia, Spain, Sweden, Switzerland, Turkey, the United Kingdom, and Yugoslavia. A total of 3,235 patients had JIA (20% systemic onset, 33% polyarticular onset, 17% extended oligoarticular subtype, and 30% persistent oligoarticular subtype) while 3,409 were healthy children. This introductory paper describes the methodology used by all the participants. The results and the translated version of both the CHAQ and the CHQ for each country are fully reported in the following papers. The results of the present study show that cross-cultural adaptation is a valid process to obtain reliable instruments for the different socio-economic and socio-demographic conditions of the countries participating in the project.

The Italian version of the Childhood Health Assessment Questionnaire (CHAQ) and the Child Health Questionnaire (CHQ).

We report herein the results of the cross-cultural adaptation and validation into the Italian language of the parent's version of two health related quality of life instruments. The Childhood Health Assessment Questionnaire (CHAQ) is a disease specific health instrument that measures functional ability in daily living activities in children with juvenile idiopathic arthritis (JIA). The Child Health Questionnaire (CHQ) is a generic health instrument designed to capture the physical and psychosocial well-being of children independently from the underlying disease. The Italian CHAQ was already published in the literature and was therefore revalidated while the Italian CHQ was fully cross culturally adapted with 3 forward and 3 backward translations, and than validated. A total of 1,192 subjects were enrolled: 404 patients with JIA (16% systemic onset, 31% polyarticular onset, 21% extended oligoarticular subtype, and 32% persistent oligoarticular subtype) and 788 healthy children. The CHAQ clinically discriminated between healthy subjects and JIA patients, with the systemic, polyarticular and extended oligoarticular subtypes having a higher degree of disability, pain, and a lower overall well-being when compared to their healthy peers. Also the CHQ clinically discriminated between healthy subjects and JIA patients, with the systemic onset, polyarticular onset and extended oligoarticular subtypes having a lower physical and psychosocial well-being when compared to their healthy peers. In conclusion the Italian version of the CHAQ-CHQ are reliable, and valid tools for the functional, physical and psychosocial assessment of children with JIA.

Psychiatric morbidity, service use, and need for care in the general population: results of The Netherlands Mental Health Survey and Incidence Study.

OBJECTIVES: This study examined the use of primary health care, mental health care, and informal care services, as well as unmet care needs, by individuals with different psychiatric diagnoses. METHODS: Data were derived from the Netherlands Mental Health Survey and Incidence Study and were based on a representative sample (n = 7147) of the general population (aged 18-64 years). RESULTS: In a 12-month period, 33.9% of those with a psychiatric disorder used some form of care; 27.2% used primary care, and 15.3% used mental health care. Patients with mood disorders were the most likely to enlist professional care; those with alcohol- and drug-related disorders were the least likely to do so. Higher educated persons who live alone, single parents, unemployed persons, and disabled persons were more likely to use mental health care. Unmet need for professional help was reported by 16.8% (men 9.9%, women 23.9%) of those with a disorder. CONCLUSIONS: Care use varies widely by diagnostic category. The role of general medical practitioners in treating persons with psychiatric disorders is more limited than was anticipated. Patients in categories associated with extensive use of professional care are more likely to have unmet care needs.

Health education in mental health services.

In the past few years, we have witnessed numerous efforts to develop health education in psychiatry. Many of them, however, were not successfully implemented. In the Netherlands, a health education method was developed in conjunction with seven mental health providers. The method promotes a more successful implementation.

Usefulness of multiplane transesophageal echocardiography to improve the assessment of severity of mitral regurgitation.

This study was designed to examine the accuracy of multiplane transesophageal echocardiography (TEE) color Doppler measurements in comparison to monoplane or biplane measurements in estimating the severity of mitral regurgitation (MR). Multiplane TEE potentially increases diagnostic accuracy of transesophageal examinations; it is unknown if multiplane is more accurate in assessing the severity of MR than monoplane or biplane TEE. Left ventricular cineangiograms of 91 patients with MR (40 no or mild, 30 moderate, and 21 severe) were compared with systolic pulmonary venous flow reversal and transesophageal color Doppler measurements: jet area and length in the transverse and longitudinal plane, maximal and average of those 2 planes (biplane), and maximal and average of 11 different planes (multiplane). Flow reversal (16 patients) identified severe MR with a specificity of 96% and a sensitivity of 62%; these were 96% and only 10% to 43%, respectively, for color Doppler measurements. In the absence of flow reversal, multiplane maximal jet area predicted severe MR with a sensitivity of 88% and a specificity of 75%, which were 85% and 76%, respectively, for no or mild MR; this did not differ significantly from results obtained by monoplane or biplane measurements. Color Doppler measurements of eccentric jets were not reliable for identification of severe MR. Systolic pulmonary venous flow reversal identifies 2 of 3 patients with severe MR with a high accuracy. In patients without flow reversal, multiplane color Doppler TEE is very capable of assessing MR severity, but biplane and monoplane TEE are equally accurate.