Quality assessment of automatically extracted data from GPs' EPR.

There are many secondary benefits to collecting routine primary care data, but we first need to understand some of the properties of this data. In this paper we describe the method used to assess the PPV and sensitivity of data extracted from Belgian GPs' EPR (diagnoses, drug prescriptions, referrals, and certain parameters), using data collected through an electronic questionnaire as a gold standard. We describe the results of the ResoPrim phase 2 project, which involved 4 software systems and 43 practices (10,307 patients). This method of assessment could also be applied to other research networks.

Nation-wide primary healthcare research network: a privacy protection assessment.

Efficiency and privacy protection are essential when setting up nationwide research networks. This paper investigates the extent to which basic services developed to support the provision of care can be re-used, whilst preserving an acceptable privacy protection level, within a large Belgian primary care research network. The generic sustainable confidentiality management model used to assess the privacy protection level of the selected network architecture is described. A short analysis of the current architecture is provided. Our generic model could also be used in other countries.

Higher incidence of common diagnoses in patients with low back pain in primary care.

Most studies on comorbidity in low back pain (LBP) have been conducted in specialized settings with the use of self-reports. This study has an original design using data from family practices: the incidence of the most frequent diseases was compared in patients with and without LBP in 2004. The database includes data from 67 family physicians in 52 family practices in Flanders, Belgium. It contains data from 160,000 different patients with 1,500,000 diagnoses during the period 1994 to 2004. The incidence of the most frequent diagnoses is presented in patients with and without LBP in 2004. The diagnoses were coded according to the ICPC-2-classification. In 2004, the incidence of LBP was 51.4‰ (95% CI: 49.8 to 53.1) in patients aged 18 or older. The incidence was slightly higher in women than in men: 53.0‰ (95% CI: 50.7 to 55.4) vs. 49.9‰ (95% CI: 47.7 to 52.3). The highest incidence was recorded in the age group of 50 to 54 years. The most frequent "other" diagnoses in patients with and without LBP are comparable, but some were more frequent in patients with LBP. Respiratory infections and diseases of the locomotor apparatus (neck syndrome, bursitis) are more frequent in patients with LBP. Low back pain is one of the most frequent diagnoses in general practice. Striking is the relatively higher frequency of common self-limiting diseases in patients with a diagnosis of LBP during the same year. To the authors' knowledge, this is the first time that medical demands for non-LBP reasons in family practice have been reported in patients with LBP.

Incidence and outcome of first syncope in primary care: A retrospective cohort study.

ABSTRACT: BACKGROUND: Assessment of risk for serious cardiovascular outcome after syncope is difficult. OBJECTIVES: To determine the incidence of first syncope in primary care. To investigate the relation between syncope and serious cardiovascular (CV) outcome and serious injury. METHODS: Retrospective cohort study using data from the Intego general practice-based registration network, collecting data from 55 general practices (90 GP's). All patients with a first syncope from 1994 to 2008 were included; five participants without syncope were matched for age and gender for every patient with syncope. The main outcome measures were incidence of first syncope by age and gender and one year risk of serious CV outcome or injury after syncope. RESULTS: 2785 patients with syncope and 13909 matched patients without syncope were included. The overall incidence of a first syncope was 1.91 per 1000 person-years (95% CI 1.83-1.98). The incidence was higher in females (2.42 (95% CI 2.32-2.55) per 1000 person-years) compared to males (1.4 (95% CI 1.32-1.49) per 1000 person-years) and follows a biphasic pattern according to age: a first peak at the age of 15-24 years is followed by a sharp rise above the age of 45. One year serious outcome after syncope was recorded in 12.3% of patients. Increasing age (HR 1.04 (1.03-1.04)), CV comorbidity (HR 3.48 (95% CI 2.48-4.90) and CV risk factors (HR 1.65 (95% CI 1.24-2.18) are associated with serious outcome. Cox regression, adjusting for age, gender, CV comorbidity and risk factors, showed that syncope was an independent risk factor for serious CV outcome or injury (HR 3.99 (95% CI 3.44-4.63)). The other independent risk factors were CV comorbidity (HR 1.81 (95% CI 1.51-2.17)) and age (HR 1.03 (95% CI 1.03-1.04)). CONCLUSIONS: Incidence rate of first syncope in primary care was 1.91 per 1000 person-years. One year risk of serious outcome after syncope was 12.3%. Increasing age, CV comorbidity and risk factors are associated with serious outcome. Compared to a control group, syncope on itself is an independent risk factor for serious outcome (adjusted for age, gender, CV comorbidity and risk factors).

Incident somatic comorbidity after psychosis: results from a retrospective cohort study based on Flemish general practice data.

BACKGROUND: Psychotic conditions and especially schizophrenia, have been associated with increased morbidity and mortality. Many studies are performed in specialized settings with a strong focus on schizophrenia. Somatic comorbidity after psychosis is studied, using a general practice comorbidity registration network. METHODS: Hazard ratios are presented resulting from frailty models to assess the risk of subsequent somatic disease after a diagnosis of psychosis compared to people without psychosis matched on practice, age and gender. Diseases studied are cancer, physical trauma, diabetes mellitus, gastrointestinal disorders, joint disorders, irritable bowel syndrome, general infections, metabolic disorders other than diabetes, hearing and vision problems, anemia, cardiovascular disease, alcohol abuse, lung disorders, mouth and teeth problems, sexually transmitted diseases. RESULTS: Significant higher risks after a diagnosis of psychosis were found for the emergence of diabetes, physical trauma, gastrointestinal disorders, alcohol abuse, chronic lung disease and teeth and mouth problems. With regard to diabetes, by including the type of antipsychotic medication it is clear that the significant overall effect was largely due to the use of atypical antipsychotic medication. No significant higher risk was seen for cancer, joint conditions, irritable bowel syndrome, general infections, other metabolic conditions, hearing/vision problems, anaemia, cardiovascular disease or diabetes, in case no atypical antipsychotic medication was used. CONCLUSION: Significantly higher morbidity rates for some somatic conditions in patients with psychosis are apparent. People with a diagnosis of psychosis benefit from regular assessments for the emergence of somatic disorders and risk factors, including diabetes in case of atypical antipsychotic medication.

Computerized general practice based networks yield comparable performance with sentinel data in monitoring epidemiological time-course of influenza-like illness and acute respiratory illness.

BACKGROUND: Computerized morbidity registration networks might serve as early warning systems in a time where natural epidemics such as the H1N1 flu can easily spread from one region to another. METHODS: In this contribution we examine whether general practice based broad-spectrum computerized morbidity registration networks have the potential to act as a valid surveillance instrument of frequently occurring diseases. We compare general practice based computerized data assessing the frequency of influenza-like illness (ILI) and acute respiratory infections (ARI) with data from a well established case-specific sentinel network, the European Influenza Surveillance Scheme (EISS). The overall frequency and trends of weekly ILI and ARI data are compared using both networks. RESULTS: Detection of influenza-like illness and acute respiratory illness occurs equally fast in EISS and the computerized network. The overall frequency data for ARI are the same for both networks, the overall trends are similar, but the increases and decreases in frequency do not occur in exactly the same weeks. For ILI, the overall rate was slightly higher for the computerized network population, especially before the increase of ILI, the overall trend was almost identical and the increases and decreases occur in the same weeks for both networks. CONCLUSIONS: Computerized morbidity registration networks are a valid tool for monitoring frequent occurring respiratory diseases and the detection of sudden outbreaks.

The use of human tissue in epidemiological research; ethical and legal considerations in two biobanks in Belgium.

This paper discusses the legal implications of setting up two new biobanks in Belgium. The first is hospital-based and will archive tissue from patients with haematologic cancer, whereas the second is linked to a general practice based morbidity registry and will involve storage of blood samples. To date, Belgium has no specific legislation that regulates storage of human tissue and related databases. Several issues concerning the protection of individuals with regard to the processing of personal medical data are discussed from the existing privacy legislation. We will address the principle of consent (broad versus specific) and the type of data recorded (anonymous, encoded and identifiable) for both biobanks.

Trends in total cholesterol screening and in prescribing lipid-lowering drugs in general practice in the period 1994-2003.

BACKGROUND: General Practitioners (GPs) play a central role in controlling an important risk factor for cardiovascular diseases, i.e. cholesterol levels in serum. In the past few decades different studies have been published on the effect of treating hyperlipidemia with statins. Guidelines for treatment have been adopted. We investigated the consequences on the practice of GPs screening cholesterol levels and on the timing of starting statin prescription. METHODS: For this descriptive study, data from the Intego database were used, composed with data from the electronic medical records (EMR) of 47 general practices in Flanders. GPs had not received special instructions for testing specific patients. For each patient the mean cholesterol level per year was calculated. A patient belonged to the group with lipid-lowering drugs if there was at least one prescription of the drug in a year in his EMR. Mixed model linear regression models were used to quantify the effect of covariates on total cholesterol values. RESULTS: In the period 1994-2003 total cholesterol was tested in 47,254 out of 139,148 different patients. Twelve percent of those tested took lipid-lowering medication. The proportion of patients with at least one cholesterol test a year, increased over a period of ten years in all age groups, but primarily for those over the age of 65. The mean cholesterol level decreased in the treated as well as in the non-treated group. Of the patients with a cardiovascular antecedent who were on lipid-lowering drugs in 2003, 56% had a cholesterol level

Epidemiology and comorbidity of erysipelas in primary care.

BACKGROUND/AIMS: Most studies on the epidemiology of erysipelas are done in hospitals, resulting in patient selection. The aim of this study is to determine epidemiological characteristics and comorbidity of erysipelas based on primary care data. METHODS: Incidence rate study and nested case-control study. A database containing data from 52 general practices in Flanders, Belgium, with morbidity data on 160,000 different patients in the period 1994-2004. Excess comorbidity was determined in patients with erysipelas in 2004. RESULTS: In the period 1994-2004, the age-standardized incidence of erysipelas increased significantly from 1.88 (95% confidence interval, CI, 1.62-2.13) per 1,000 patients to 2.49 (95% CI 2.24-2.74). Of patients with erysipelas, 16% had one or more recurrences. Local factors such as dermatophytosis, chronic ulcer of the skin, varicose veins of the leg and phlebitis and general disorders such as obesity, non-insulin-dependent diabetes and heart failure increased the risk of erysipelas. CONCLUSION: The incidence of erysipelas increased from 1994 to 2004. More attention should be paid to local factors such as dermatophytosis to prevent erysipelas.

Time trends in the incidence of peptic ulcers and oesophagitis between 1994 and 2003.

This study examined time trends in the incidence of peptic ulcers and oesophagitis, and the prescription of acid-inhibiting drugs in the period 1994-2003. Data were retrieved from records in general practices in Flanders, Belgium. The incidence of duodenal ulcers decreased by two-thirds and the incidence of gastric ulcers halved, the incidence of oesophagitis initially increased and decreased slowly later on. In 10 years the proportion of patients taking proton-pump inhibitors rose sixfold while the proportion taking H(2) antagonists remained stable.

Implementation of a general practitioner cooperative adjacent to the emergency department of a hospital increases the caseload for the GPC but not for the emergency department.

BACKGROUND: The implementation of general practitioner cooperatives (GPC) for out-of-hours (OOH) primary care, raises the question if the location of a GPC adjacent to a hospital reduces the OOH caseload of the emergency department (ED). METHODS: Two natural experiments were used in this before-after study, the effect of the implementation of two GPCs in two different regions on the out-of-hours caseload of the local EDs was compared. One GPC was located adjacent to the ED of a general hospital, the other was not. GPCs (or rota systems) and EDs in comparable regions were selected as control groups during the same study period. The study was performed in Flanders (Belgium) with no gatekeeping function for general practitioners (GPs). RESULTS: After implementation of the GPC there was a significantly increase in caseload at the GPC in the two regions, mainly due to an increase of consultations with small children. There were no significant changes in caseload at the ED services. Self-referrals' to the ED did not change significantly. For the GPs the number of home visits decreased during out-of-hours in one region. CONCLUSION: In a country with no gatekeeping role for GPs, implementing a GPC increased the out-of-hours caseload of the GPCs. The caseload of the EDs stabilised during the study period.

Serious infections in children: an incidence study in family practice.

BACKGROUND: Information on the incidence of serious infections in children in general practice is scarce. However, estimates on the incidence of disease are important for several reasons, for example to assess the burden of disease or as a basis of diagnostic research. We therefore estimated the incidence of serious infections in general practice in Belgium. METHODS: Intego is a morbidity registration network, in which 51 general practitioners continuously register all diagnoses and additional data in their electronic medical records. Serious infections were defined as pneumonia, sepsis, meningitis, pyelonephritis and osteomyelitis. Incidences are calculated for the period of 1998 to 2002, per 1000 patients in the yearly contact group, which is the group of patients that consulted their GP at least once that year, and in the practice population, which is the estimated true population of that practice. RESULTS: The incidence of all infectious diseases peaks in children between 0 and 4 years, with 1731 infections per 1000 children per year in the yearly contact group. Incidence drops with increasing age: 972 infections per 1000 children per year in children between 5 and 9 years old, and 732 in children between 10 and 14 years old. The same decline in incidence is observed in the subgroup of serious infections: 21 infections per 1000 children per year in children between 0 and 4 years, 12 in children between 5 and 9 years and 5 in children between 10 and 14 years. The results for the estimated practice population are respectively 17, 9 and 4 serious infections per 1000 children per year. CONCLUSION: In contrast to the total incidence of acute infections, serious infections are rare, around 1% per year. Children younger than 4 years old have the highest risk for serious infections, and incidences of some infections are different for boys and girls.

Improving Care And Research Electronic Data Trust Antwerp (iCAREdata): a research database of linked data on out-of-hours primary care.

BACKGROUND: Primary out-of-hours care is developing throughout Europe. High-quality databases with linked data from primary health services can help to improve research and future health services. METHODS: In 2014, a central clinical research database infrastructure was established (iCAREdata: Improving Care And Research Electronic Data Trust Antwerp, www.icaredata.eu ) for primary and interdisciplinary health care at the University of Antwerp, linking data from General Practice Cooperatives, Emergency Departments and Pharmacies during out-of-hours care. Medical data are pseudonymised using the services of a Trusted Third Party, which encodes private information about patients and physicians before data is sent to iCAREdata. RESULTS: iCAREdata provides many new research opportunities in the fields of clinical epidemiology, health care management and quality of care. A key aspect will be to ensure the quality of data registration by all health care providers. CONCLUSIONS: This article describes the establishment of a research database and the possibilities of linking data from different primary out-of-hours care providers, with the potential to help to improve research and the quality of health care services.

Is herpes zoster a marker for occult or subsequent malignancy?

BACKGROUND: It has been suggested that herpes zoster may be a marker for occult malignancy. AIM: To examine the emergence of a subsequent cancer diagnosis in patients with and without herpes zoster. DESIGN OF STUDY: Retrospective cohort study. SETTING: Results were based on the database of Intego, an ongoing Belgian general practice-based morbidity registry, covering 37 general practitioners and including about 311 000 patient years between the years 1994 and 2000. METHOD: Survival analysis comparing the emergence of malignancy in patients with and without herpes zoster. RESULTS: The number of patients below the age of 65 years with herpes zoster, cancer or both was too low to draw any sensible conclusions. Above the age of 65 years we identified a significant increase of cancer emergence in the whole group and in females (hazard ratio = 2.65, 95% confidence interval = 1.43 to 4.90), but not in males. No difference could be identified in the first year after the herpes zoster infection. CONCLUSION: Our results do not justify extensive testing for cancer in herpes zoster patients. The association we identified, however, leaves open a number of questions with respect to the physiopathology behind it.

Staphylococcus aureus, Including Meticillin-Resistant Staphylococcus aureus, among General Practitioners and Their Patients: A Cross-Sectional Study.

BACKGROUND: The role of general practitioners (GPs) as reservoir and potential source for Staphylococcus aureus (SA) transmission is unknown. Our primary objective was to evaluate the prevalence of SA and community-acquired methicillin resistant SA (CA-MRSA) carrier status (including spa typing) among GPs and their patients in Belgium. The secondary objective was to determine the association between SA/CA-MRSA carriage in patients and their characteristics, SA carriage in GPs, GP and practice characteristics. METHODS: The Belgian GPs, who swabbed their patients in the APRES study (which assessed the prevalence of SA nasal carriage in nine European countries; November 2010 -June 2011), were asked to swab themselves as well (May-June 2011). GPs and their patients had to complete a questionnaire on factors related to SA carriage and transmission. SA isolation including CA-MRSA and spa typing was performed on the swabs. RESULTS: In eighteen practices 34 GPs swabbed patients of which 25 GPs provided personal swabs. The analysis was performed on 3008 patient records. Among GPs SA carriage (28%) was more prevalent than among their patients (19.2%), but CA-MRSA carriage was not present. SA was more prevalent among younger patients and those living with cattle. Spa typing SA and MRSA strains did not suggest correlation within practices or between patients and GPs, but chronic skin conditions of GPs and always handshaking patients by SA positive GPs were associated with more SA among patients, and hand washing after every patient contact with less SA among patients in practices with high antibiotic prescribing rates. CONCLUSION: No MRSA was found among GPs, although their SA carriership was higher compared to their patients'. Spa types did not cluster within practices, possibly due to difference in timing of swabbing. To minimise SA transmission to their patients GPs should consider taking appropriate care of their chronic skin diseases, antibiotic prescribing behaviour, handshaking and hand washing habits.

Quality of antibiotic prescription during office hours and out-of-hours in Flemish primary care, using European quality indicators.

BACKGROUND: European disease-specific antibiotic prescribing quality indicators (APQI) were proposed for seven acute indications (bronchitis, upper respiratory infection, cystitis, tonsillitis, sinusitis, otitis media and pneumonia): (a) the percentage of patients prescribed an antibiotic; (b) the percentage of patients receiving the guideline recommended antibiotic; (c) the percentage of patients receiving quinolones. OBJECTIVES: To assess the feasibility of calculating values for these 21 APQI using primary care databases; and to assess the quality of antibiotic prescribing in office hours and out-of-hours general practice. METHODS: Data was extracted from a morbidity registration network ( http://www.intego.be ) and the out-of-hours service centre in Flanders. Within both databases diagnoses are labelled using the revised second edition of International Classification of Primary Care (ICPC-2-R) and antibiotic prescriptions using Anatomical Therapeutic Chemical (ATC) classification. RESULTS: Both databases allow calculation of APQI values and results are similar. Only for cystitis was the percentage of patients prescribed an antibiotic within the proposed acceptable range. For all indications, the percentage of recommended antibiotics was below the proposed acceptable range (80-100%). The percentage of quinolones was within the proposed acceptable range (0-5%) for otitis media, upper respiratory infection and tonsillitis. CONCLUSION: Primary care databases can produce APQI values. These values revealed huge opportunities to improve the quality of antibiotic prescribing in office hours and out-of-hours Flemish general practice, especially the prescription of recommended antibiotics.

Influence of chronic comorbidity and medication on the efficacy of treatment in patients with diabetes in general practice.

BACKGROUND: Evidence on the influence of comorbidity and comedication on clinical outcomes in patients with type 2 diabetes mellitus is scarce. AIM: To ascertain the effect of five chronic diseases (joint disorder, respiratory disease, anaemia, malignancy, depression) and three chronically used drugs (non-steroid anti-inflammatory drugs [NSAIDs], corticosteroids, antidepressants) on treatment for hypoglycaemia in patients with type 2 diabetes. DESIGN AND SETTING: Retrospective cohort study in a variety of practices across Flanders, Belgium. METHOD: A retrospective cohort study was conducted, based on data from Intego, a general practice-based continuous morbidity registry. Multiple logistic regression analysis was used to predict the change in glycosylated haemoglobin (HbA1c) levels related to comorbidity, comedication, and a combination of both in 3416 patients with type 2 diabetes. Adjustments were made for age, sex, and diabetes-treatment group (diet, oral antidiabetic drugs, combination treatment, insulin). RESULTS: Concomitant joint and respiratory disorders, as well as the chronic use of NSAIDs and corticosteroids, either separately or in combination, were significantly associated with the worsening of HbA1c levels. Anaemia, depression, malignancy, and antidepressants had no statistically significant influence on the efficacy of treatment for hypoglycaemia. CONCLUSION: The presence of some comorbid diseases or drug use can impede the efficacy of treatment for type 2 diabetes. This finding supports the need to develop treatment recommendations, taking into account the presence of both chronic comorbidity and comedication. Further research must be undertaken to ascertain the effect other combinations of chronic diseases have on the efficacy of treatment of this and other diseases.

The denominator in general practice, a new approach from the Intego database.

BACKGROUND: To determine the denominator or the 'population at risk' is a problem which has long been encountered in general practice-based epidemiological research. It is important for calculating epidemiological figures. OBJECTIVES: The aim of this article is to demonstrate how in the absence of a patient list, a reliable denominator can be calculated, starting from the number of patients who contacted their GP in the period of one year. Therefore a brief overview will be given from known approaches, then the new approach will be illustrated on a database named Intego, with data from 43 general practices in Belgium. METHODS: The Intego database contains information about patient contacts, diagnoses, laboratory results and drug prescriptions, extracted from the participants' structured electronic medical record system. The number of patients who contacted the practice in a year can be calculated from the Intego data. On the other hand, the percentage of the population that consults a GP during a particular period was obtained from the reimbursement claims data available from the sickness funds. By combining these two datasets, stratified by age, gender and district, a correction factor was calculated. An estimate of the real size of the Intego practice populations was obtained by extrapolating the yearly contact group by this factor. RESULTS: In 2003 according the Intego-register, 64,161 patients contacted their family practice and this correlated with an estimated practice population of 80,094 patients. The absence of the socio-economic status in the estimation is irrelevant in our model of estimating the practice population. CONCLUSION: The availability of a denominator in general practice-based research is essential to calculate epidemiological figures. This method using a correction factor makes it possible to calculate a reliable practice population. A similar approach will probably also be applicable in other European countries.