Adverse events at the end of life of hospital patients with or without a condition relevant for palliative care: a nationwide retrospective record review study in the Netherlands.

BACKGROUND: Patient safety is crucial for quality of care. Preventable adverse events (AEs) occur in 1 of 20 patients in the hospital, but it is unknown whether this is different for patients with a condition relevant for palliative care. The majority of the limited available research on this topic is only focused on patients already receiving palliative care, and do not make comparisons with other patients at the end-of-life. We identified and compared the prevalence, preventability, nature and causes of AEs in patients with and without a condition relevant for palliative care. METHODS: A nationwide retrospective record review study was performed in 20 Dutch hospitals. A total of 2,998 records of patients who died in hospital in 2019 was included. Records were reviewed for AEs. We identified two subgroups: patients with (n = 2,370) or without (n = 248) a condition relevant for palliative care through the selection method of Etkind (2017). Descriptive analyses were performed to calculate prevalence, nature, causes and prevention strategies. T-tests were performed to calculate differences between subgroups. RESULTS: We found no significant differences between subgroups regarding AE prevalence, this was 15.3% in patients with a condition relevant for palliative care, versus 12.0% in patients without a condition relevant for palliative care (p = 0.148). Potentially preventable AE prevalence was 4.3% versus 4.4% (p = 0.975). Potentially preventable death prevalence in both groups was 3.2% (p = 0.938). There were differences in the nature of AEs: in patients with a condition relevant for palliative care this was mostly related to medication (33.1%), and in patients without a condition relevant for palliative care to surgery (50.8%). In both subgroups in the majority of AEs a patient related cause was identified. For the potentially preventable AEs in both subgroups the two most important prevention strategies as suggested by the medical reviewers were reflection and evaluation and quality assurance. DISCUSSION: Patient safety risks appeared to be equally prevalent in both subgroups. The nature of AEs does differ between subgroups: medication- versus surgery-related, indicating that tailored safety measures are needed. Recommendations for practice are to focus on reflecting on AEs, complemented with case evaluations.

Measurement and documentation of quality indicators for the end-of-life care of hospital patients a nationwide retrospective record review study.

BACKGROUND: Quality of care at the end of life in hospitals is often perceived to be lower compared to the care that is provided to people who die in their own home. Documenting and measuring indicators of common end-of-life symptoms could help improve end-of-life care in hospitals. This study provided insight into quality indicators for the end-of-life care of patients who died in a Dutch hospital, and assessed differences between deceased patients who were admitted for palliative/terminal care versus patients admitted for other reasons. METHODS: In a retrospective record review study, trained nurses reviewed electronic health records (EHRs) of patients who died in 2019 (n = 2998), in a stratified sample of 20 Dutch hospitals. The nurses registered whether data was found in de EHRs about quality indicators for end-of-life care. This concerned: symptoms (pain, shortness of breath, anxiety, depressive symptoms), spiritual and psychological support and advance care planning. Multilevel regression analyses were performed to assess differences between patients who had been admitted for palliative/terminal care and patients admitted for other reasons. RESULTS: Common end-of-life symptoms were rarely measured using a standardized method (e.g. Numeric Rating Scale, Visual Analogue Scale or Utrecht Symptom Diary). The symptom burden of pain was measured using a standardized method more often (63.3%) than the symptom burden of shortness of breath (2.2%), anxiety (0.5%) and depressive symptoms (0.3%). Similarly, little information was documented in the EHRs regarding wish to involve a spiritual counsellor, psychologist or social worker. Life expectancy was documented in 66%. The preferred place of death was documented less often (20%). The documentation of some quality indicators differed between patients who were admitted for palliative/terminal care compared to other patients. CONCLUSION: Except for the burden of pain, symptoms are rarely measured with standardized methods in patients who died in Dutch Hospitals. This study underlines the importance of documenting information about symptom burden and aspects related to advance care planning, and spiritual and psychological support to improve the quality of end-of-life care for patients in hospitals. Furthermore, uniformity in measuring methods improves the possibility to compare results between patient groups and settings.

Emergency department crowding and older patients: a nationwide retrospective cohort study.

OBJECTIVE: Emergency department (ED) crowding is a worldwide problem and one of the main causes internationally is an increase in presentations by older patients with complex and chronic care needs. Although there has been a 4,3% reduction in total ED visits from 2016-2019 in the Netherlands, the EDs still experience crowding. National crowding research has not focused on the older group in detail, hence their possible role remains ill defined. The primary aim of this study was to map the trend in ED visits by older patients in the Netherlands. The secondary aim was to identify healthcare utilization 30 days before/after ED visit. METHODS: We conducted a nationwide retrospective cohort study, using longitudinal health insurance claims data (2016-2019). The data encompasses all Dutch patients of 70 years or older who visited the ED. RESULTS: The number of older patients who visited the ED followed by admission, increased from 231,223 patients (2016), to 234,817 (2019). The number without admission also increased from 244,814 patients, to 274,984. There were 696,005 total visits by older patients (2016) increasing to 730,358 visits (2019). CONCLUSION: The slight rise in older patients at the ED is consistent with overall population growth of older people in the Netherlands. These results indicate that Dutch ED crowding cannot be explained by mere numbers of older patients. More research is needed with data on patient level, to study other contributing factors, such as complexity of care needs within the ageing population.

Pseudotumor in metal-on-metal hip arthroplasty: a comparison study of three grading systems with MRI.

OBJECTIVE: Pseudotumors, a well-known complication of metal-on-metal total hip arthroplasty (MoM THA), are well identified on metal artifact-reducing sequences magnetic resonance imaging (MARS-MRI). Several MRI grading systems are described in the orthopedic literature, but their validity is unknown in large clinical studies. Our study was undertaken to describe the classification of pseudotumors in a preselected cohort divided into high- and low-risk patients, using three pseudotumor grading systems applied on MARS-MRI, and to determine the interobserver reliability of the grading systems. PATIENTS AND METHODS: A retrospective study was performed on 377 consecutive patients (240 MRI scans) treated with an M2a-38 and Taperloc stem combination (Biomet, Warsaw, IN, USA). Patients were divided into a high-risk and a low-risk group based on previous published risk factors. Two observers determined the presence of pseudotumors using three different pseudotumor grading systems for classifying MARS-MRI results. RESULTS: The prevalence of pseudotumors as determined with MARS-MRI was 59% in our high-risk group, 0% in the low-risk group and 43% in the control group. Serum cobalt values were increased in the high-risk group. The kappa values of the Anderson, Hauptfleisch and Matthies grading system scores were 0.43, 0.44, and 0.49 respectively. CONCLUSIONS: High-risk patients are at a high risk for pseudotumor development. No pseudotumor development was found in low-risk patients. Interobserver reliability scored best with the Matthies system, but all three grading systems showed only a moderate agreement.

Galectin-9 induced by dietary synbiotics is involved in suppression of allergic symptoms in mice and humans.

BACKGROUND: Prebiotic galacto- and fructo-oligosaccharides (scGOS/lcFOS) resembling non-digestible oligosaccharides in human milk reduce the development of atopic disorders. However, the underlying mechanisms are still unclear. Galectins are soluble-type lectins recognizing ß-galactoside containing glycans. Galectin-9 has been shown to regulate mast cell degranulation and T-cell differentiation. In this study, the involvement of galectin-9 as a mechanism by which scGOS/lcFOS in combination with Bifidobacterium breve M-16V protects against acute allergic symptoms was investigated. METHODS: Mice were sensitized orally to whey, while being fed with a diet containing scGOS/lcFOS and Bifidobacterium breve M-16V (GF/Bb) or a control diet. Galectin-9 expression was determined by immunohistochemistry in the intestine and measured in the serum by ELISA. T-cell differentiation was investigated in the mesenteric lymph nodes (MLN) as well as in galectin-9-exposed peripheral blood mononuclear cells (PBMC) cultures. Sera of the mice were evaluated for the capacity to suppress mast cell degranulation using a RBL-2H3 degranulation assay. In addition, in a double-blind, placebo-controlled multicenter trial, galectin-9 levels were measured in the sera of 90 infants with atopic dermatitis who received hydrolyzed formulae with or without GF/Bb. RESULTS: Galectin-9 expression by intestinal epithelial cells and serum galectin-9 levels were increased in mice and humans following dietary intervention with GF/Bb and correlated with reduced acute allergic skin reaction and mast cell degranulation. In addition, GF/Bb enhanced T(h)1- and T(reg)-cell differentiation in MLN and in PBMC cultures exposed to galectin-9. CONCLUSIONS: Dietary supplementation with GF/Bb enhances serum galectin-9 levels, which associates with the prevention of allergic symptoms.

Depletion of CD4+CD25+ T cells switches the whey-allergic response from immunoglobulin E- to immunoglobulin free light chain-dependent.

BACKGROUND: Symptoms of allergy are largely attributed to an IgE-mediated hypersensitivity response. However, a considerable number of patients also exhibit clinical features of allergy without detectable systemic IgE. Previous work showed that Ig-free light chains (IgLC) may act as an alternate mechanism to induce allergic responses. CD4+CD25+ T cells are crucial in the initiation and regulation of allergic responses and compromised function might affect the response to allergens. OBJECTIVE: To examine the contribution of CD4+CD25+ T cells and IgLC towards the whey-allergic response. METHODS: Mice were sensitized orally with whey using cholera toxin as an adjuvant. CD25+ T cells were depleted in vivo using a CD25 mAb. The acute allergic skin response to whey and ex vivo colon reactivity was measured in the presence or absence of F991, a specific inhibitor of IgLC. Serum whey-specific antibodies and IgLC in serum and mesenteric lymph node (MLN) supernatants were measured. Depletion of CD4+CD25+ T cells was confirmed in the spleen. RESULTS: Anti-CD25 treatment strongly reduced whey-specific antibody levels and resulted in a partial depletion of effector T cells and a major depletion of Foxp3(+) regulatory T cells. Surprisingly, despite the abolished specific IgE response, the acute allergic skin response to whey was not affected. IgLC levels were enhanced in the serum and MLN supernatants of CD25-depleted sensitized mice. F991 inhibited the acute skin response and colon hyperreactivity in anti-CD25-treated mice, indicating that these responses were mainly IgLC dependent. CONCLUSIONS: Depletion of CD4+CD25+ T cells resulted in a switch from an IgE- to an IgLC-dependent acute skin response and functional hyperresponsiveness of the colon. Our data suggest that CD25+ T cells play a crucial role in balancing cow's milk allergy between IgE and IgE-independent responses and both mechanisms might play a role in allergic responses to the same allergen.

Dental check-up frequency: preferences of Dutch patients.

OBJECTIVE: In 1995, the requirement to visit the dentist for a check-up every six months in The Netherlands was replaced by the obligation to get a routine examination no more than once a year. The aim of this study was to determine patients' opinions about this change in policy, and to assess their preferences regarding frequency and content of regular dental check-up visits. Possible associations between patients' preferences for regular dental check-ups and a number of antecedent variables, such as dental attitudes, were examined as well. BASIC RESEARCH DESIGN: Patients' preferences for regular dental check-ups were assessed by means of a questionnaire, containing a 19-item Likert-type scale, twelve visual analogue scales and seven forced choice items. Items assessing various background variables and a selection of items of the Dental Attitude Questionnaire were also added. This questionnaire was administered to patients of seven dental practices. A total of 428 patients completed the questionnaire. RESULTS: Results indicated that patients prefer to have regular dental check-ups. Patients' evaluation of six-monthly dental check-up visits was significantly more positive than their evaluation of flexible, individualized, check-up frequencies. Factors positively associated with a higher preference for regular dental check-up visits were female gender, being more satisfied with one's teeth, less cynicism toward dental health care professionals and more intrinsic motivation to maintain one's oral health. CONCLUSIONS: Patients seem to prefer to attend their dentist regularly, at fixed intervals of about six months. This fact should be taken into account when deciding about the most appropriate interval between dental examinations.

Incidence rates of erectile dysfunction in the Dutch general population. Effects of definition, clinical relevance and duration of follow-up in the Krimpen Study.

This study aims to describe the incidence rate of erectile dysfunction (ED) in older men in the Netherlands according to three definitions. The influence of the duration of follow-up on the incidence rate is also explored. In a large community-based follow-up study, 1661 men aged 50-75 y completed the International Continence Society sex questionnaire and a question on sexual activity, at baseline and at a mean of 2.1 and 4.2 y of follow-up. We defined 'ED' as a report of erections with 'reduced rigidity' or worse; 'Significant_ED' as 'severely reduced rigidity' or 'no erections'; and 'Clinically_Relevant_ED' as either 'ED' reported as 'quite a problem' or 'a serious problem', or 'Significant_ED' reported as at least 'a bit of a problem'. Incidence rates of ED status were calculated in those men who completed at least one period of follow-up and were not diagnosed with prostate cancer (n = 1604). For 'ED' the incidence rate (cases per 1000 person-years) is 99 and ranges over the 10-y age groups from 77 (50-59 y) to 205 (70-78 y); for 'Significant_ED' these rates were 33, 21, and 97, respectively and for 'Clinically_Relevant_ED' 28, 25, and 39, respectively. In general, incidence rates should not vary with the duration of follow-up. However, for 'ED' the 4.2 y incidence rate is about 69% of the 2.1 y incidence rate. This study presents incidence rates, for the general population, as well as based on a definition of ED that takes concern/bother into account. 'Clinically_Relevant_ED' has a lower increase in incidence with increasing age than other definitions that do not take concern/bother into account. The phenomenon of lower incidence rates with longer duration of follow-up may account for the differences in reported incidence rates between different studies. The effects of differences related to the duration of follow-up should be taken into consideration in future incidence reports.

Deferoxamine induces hypotension in experimental gram-negative septicemia.

Multiple organ system failure may result from tissue damage caused by activated neutrophils or endotoxin. A significant part of this tissue damage is due to peroxidation induced by oxygen-free radicals and requires iron as a co-factor. Iron chelation has been shown to prevent tissue damage in some models. This experiment was carried out to determine whether iron chelation with deferoxamine (DFO) would prevent lung damage in a swine model of Gram-negative septicemia. Fifteen animals were randomized to control, Pseudomonas aeruginosa infusion at a rate of 2 x 10(7) colony forming units/20 kg/min (septic group), or Pseudomonas infusion combined with DFO pretreatment at a dose of 80 mg/kg/h (septic-treated group). Three of six septic-treated animals became severely hypotensive and died during the course of the experiment as opposed to none of six septic animals. Surviving septic-treated animals were significantly hypotensive (60 +/- 24 mmHg mean arterial pressure) compared to septic (122 +/- 9 mmHg) and control (109 +/- 8 mmHg) animals. DFO did not improve respiratory function (e.g., pO2) or morphology in septic animals. We conclude that iron-chelation therapy with DFO at the above dosage results in a significant deterioration in cardiovascular function in septic swine. Lung damage was not prevented.

No relevant seasonal influences on office and ambulatory blood pressure: data from a study in borderline hypertensive primary care patients.

Our objective was to study seasonal influences on office and ambulatory blood pressure. We therefore designed a prospective 7-month study of 47 borderline hypertensive patients in a primary care setting. We used no interventions. Our main outcome measures were the differences between summer and winter office and ambulatory blood pressures and 95% confidence intervals. Results showed that winter minus summer differences ranged from 0 to 3 mm Hg. Only one significant difference was found: ambulatory systolic daytime pressure was significantly higher (3 mm Hg) in winter than in summer. Our results do not confirm the data of earlier studies in hypertensives. In view of the small and clinically irrelevant winter-summer differences, it seems unnecessary to modify antihypertensive treatment of borderline hypertensives according to the season.

Pneumonia complicating abdominal sepsis. An independent risk factor for mortality.

Nosocomial pneumonia (NP) is associated with a significant mortality, 66% in a previous retrospective study of NP complicating intra-abdominal sepsis (IAS). We prospectively compared the outcome of NP complicating IAS with that of recurrent IAS (R-IAS) in the absence of NP. Data were collected prospectively on 300 patients with IAS; 34 patients who presented with pneumonia were excluded from the analysis (44% mortality). One hundred seventy-one patients with no NP and no R-IAS (group 1) had a hospital mortality of 20% (34 patients); 36 without NP in whom R-IAS developed (group 2) had a 17% mortality (six patients); and 47 with NP but no R-IAS (group 3) had a 53% mortality (25 patients). Finally, 12 patients who had both NP and R-IAS suffered a 75% mortality (nine patients). We examined the relationships among the following putative risk factors and mortality: APACHE (acute physiology and chronic health evaluation) II score (at initial presentation with IAS), the need for mechanical ventilatory assistance following initial treatment for peritonitis, steroid requirement, generalized peritonitis vs abscess, and the need for surgical as opposed to percutaneous treatment. Using mortality as the dependent variable, group 2 vs 3 as the explanatory variable, and the risk factors as confounders, logistic regression analysis indicated that the group difference was significant after controlling for confounders. We conclude that NP complicating IAS is an independent risk factor associated with a significant mortality compared with R-IAS. These data challenge the notion that death in IAS is usually due to recurrent or persistent intra-abdominal infection.

Steroids, APACHE II score, and the outcome of abdominal infection.

OBJECTIVE: To compare the outcome of abdominal infection in patients with or without previous systemic glucocorticoid therapy and to determine the effect of steroid administration on the relationship between APACHE II (Acute Physiology and Chronic Health Evaluation) scores and mortality. HYPOTHESIS: Steroid therapy leads to greater mortality and relatively lower APACHE II scores. DESIGN: Prospective cohort study. SETTING: University hospital. PATIENTS: Two hundred ninety-seven consecutive adult patients with abdominal infection treated by surgical or percutaneous drainage. Treatment was at the clinician's discretion. Seventy-one patients received systemic steroid therapy. OUTCOME MEASURES: APACHE II score, clinical course, and death in hospital; relationship between APACHE II score and mortality in the steroid and no steroid groups. RESULTS: Thirty-three patients receiving steroid therapy (46%) died vs 55 (24%) of 226 patients not receiving steroid therapy. The APACHE II score (P < .0001) and steroid administration (P = .04) were each independently associated with death. Steroid-treated patients had the same probability of dying as "nonsteroid" patients with an APACHE II score a mean of 3.7 points higher (95% confidence limits, 0.03 and 7.7). The confidence that 2, 3, or 4 extra APACHE II points is the appropriate correction for steroid-treated patients is 80%, 60%, or 40%, respectively. CONCLUSIONS: Patients receiving steroid therapy appear to be at higher risk of dying of abdominal infection than predicted by APACHE II scores. The number of patients receiving cancer chemotherapy was too small to determine whether this was an additional risk factor. In the design of clinical trials stratified by APACHE II scores, steroid-treated patients should either be excluded or assigned two extra APACHE II points.

APACHE II score and abdominal sepsis. A prospective study.

Therapeutic trials for intra-abdominal sepsis require pretreatment stratification; physiologic scoring has been recently proposed for this purpose. We have prospectively tested the validity of one such scoring system, namely, the Acute Physiology and Chronic Health Evaluation (APACHE II). As part of a larger database, we correlated APACHE II scores with mortality in 100 patients hospitalized for generalized peritonitis or abdominal abscess. Use of steroids was recorded because of our suspicion that steroids increase mortality but blunt the physiologic response to sepsis. Thirty-one patients died, including 12 of 19 patients receiving steroids. Stepwise discriminant analysis revealed that the APACHE II score and steroid use were each independently associated with the rate of mortality. We report a prospective validation of pretreatment APACHE II scoring in abdominal sepsis. Steroid use is an independent risk factor.

Information and participation preferences of dental patients.

Dutch dentists have a moral and legal obligation to inform their patients and involve them in the decision-making process. It is unclear, though, to what extent patients prefer information and involvement in decision-making. Therefore, the aim of this study was to determine levels of preference for information and participation in decision-making among emergency patients (n = 96) and regular patients (n = 245). It was hypothesized that female gender, higher education, younger age, and a monitoring coping style are positively associated with higher preferences for information and participation. The results demonstrated that emergency and regular patients have high preferences for information, but that their preferences for actual involvement are significantly lower. Only weak associations were found between the antecedent variables and patients' preferences. It is concluded that, in the study of the etiology of patients' preferences for information and participation, future research should incorporate factors such as dental anxiety and seriousness of the dental condition.

Is outpatient surgery safe for the higher risk patient?

The trend toward outpatient surgery led to this study to determine the safety of elective outpatient laparoscopic surgery for the higher risk patient. One hundred consecutive higher risk patients from all patients scheduled for elective outpatient laparoscopic surgery were studied prospectively in a 256-bed community hospital. Seventeen percent of patients required admission. In each instance the need was readily evident in the perioperative observation period. Eighty-three percent of patients were stable and were successfully treated as outpatients. No patient who remained stable decompensated later, and none required readmission to treat complications resulting from outpatient status. The 2% readmission rate (for unrelated reasons) was comparable to the 2% readmission rate for low-risk patients. It was concluded that routine outpatient laparoscopic surgery is safe for elective higher risk patients. Problems requiring admission are readily evident during the period of observation and no patient who remains stable decompensates later.

Serum phospholipase A2 enzyme activity and immunoreactivity in a prospective analysis of patients with septic shock.

Massive elevations of serum phospholipase A2 activity have been documented in patients with septic shock. Serum PLA2 activity correlated to the degree and duration of circulatory collapse, while purified native PLA2 reproduced hypotension in experimental animals. In a prospective study of patients with septic shock, we have determined the relationship of PLA2 enzyme activity to PLA2 immunoreactivity using radiolabelled E. coli phospholipid substrate and an ELISA specific for group II human nonpancreatic PLA2. In all patients, there was a clear concordance of the two assays. Maximal PLA2 concentration was increased a mean of 554-fold over normal levels. We found no evidence to support the presence of activating or inhibitory proteins. These data confirm that the observed increase in serum PLA2 activity in septic shock is due to intravascular release of group II nonpancreatic PLA2.

Informed consent in Dutch dental practice: knowledge, attitudes and self-efficacy of dentists.

The introduction of the 'Medical Treatment Contract Act' in the Netherlands 5 years ago, established some major rights and duties of both patients and members of the medical profession. The aim of this study was to assess Dutch dentists' knowledge, attitudes and self-efficacy with regard to several topics of this act. A questionnaire was sent to 806 dental practitioners; 41.6% of them responded. Results show that dentists are well informed about some of the most important topics of this law, such as the requirement to obtain the patient's consent to major dental treatments. The results concerning their attitude and self-efficacy, however, are less positive. A majority of the respondents believe that the principle of informed consent will lead to a commercialization of the dentist-patient relation. Also, fear for legal procedures and difficulty with what patients must be informed about appears present. It is concluded that improvement of the implementation of the requirements of this legislation in dental practice requires both a change in attitude and an enhancement of the communicative skills of dentists.

Comparison of appropriateness of cholesterol testing in general practice with the recommendations of national guidelines: an audit of patient records in 20 general practices.

OBJECTIVE: To compare the profiles of those patients selected by general practitioners for measurement of serum cholesterol with the recommended profiles for opportunistic cholesterol testing described in the national practice guidelines published by the Dutch College of General Practitioners. DESIGN: Retrospective audit of general practitioners' records. MATERIALS: Practice records of 3577 adult patients systematically sampled from 20 general practices. MAIN MEASURES: With criteria set by the national guidelines, the proportion of patients per practice (a) for whom cholesterol testing would be considered justified, and (b) for whom cholesterol testing would be considered unjustified, and the proportion of patients within each of these groups who had had a cholesterol measurement recorded. RESULTS: Cholesterol tests were performed on 415 (11.7%) of the 3577 patients. National guidelines on the management of hypercholesterolaemia state that a positive cardiovascular risk profile is an indication for cholesterol measurement. Just under one fifth (668) of the patients in this study were recorded as having a positive cardiovascular risk profile, but only 31% of these had had their cholesterol measured. Of the patients without recorded evidence of a positive cardiovascular risk profile cholesterol had been measured in 8%. Restricting the analyses to the age group 18-65 (n = 3060) of whom 12.5% had a positive risk profile, did not improve the results. In practices with a computerised information system 37% of patients with recorded evidence of a positive cardiovascular risk profile had had their cholesterol measured. CONCLUSIONS: Cholesterol testing was not targeted as selectively as recommended by the national guidelines. The major problem was failure to test those likely to benefit. Improving the targeting of cholesterol measurements would undoubtedly increase the workload of general practitioners. If the national guidelines are to have an effect on health promotion the first step must be to increase the proportion of patients with positive cardiovascular risk profiles who get their cholesterol tested. A major factor in successfully selecting cases seems to be that practices are equipped with a computerised medical information system.

Dentists' and patients' communicative behaviour and their satisfaction with the dental encounter.

OBJECTIVE: The aim of this study was to examine the relations between patients' and dentists' communicative behaviour and their satisfaction with the dental encounter. PARTICIPANT: The sample consisted of 90 patients receiving emergency care from 13 different dentists. BASIC RESEARCH DESIGN: Consultations were videotaped in order to assess dentists' and patients' communicative behaviour. Dentists' behaviour was coded by means of the Communication in Dental Setting Scale (CDSS), scores for patients' behaviour included among other things, the number of questions asked during the consultation. MAIN OUTCOME MEASURES: After treatment, patients filled out a questionnaire that assessed their satisfaction with their own and their dentist's communicative behaviour. Dentists also filled out a satisfaction questionnaire after each consultation. RESULTS: Results showed that dentists' satisfaction could not be explained by patients' or dentists' communicative behaviour. Patients' satisfaction was mainly influenced by the communicative behaviour of the dentist. CONCLUSION: Not only is patients' satisfaction positively related to the communicative behaviour of dentists, but the principle of informed consent requires dentists also to inform their patients adequately enough for them to reach a well-informed decision about the treatment. Therefore, it remains important to train dentists in communicative skills.