Patients' views on student participation in general practice consultations: a comprehensive review.

BACKGROUND: Recruiting general practitioners (GPs) to host students for their clerkship is difficult. GPs often assume patients dislike consulting a student-doctor. AIM: To systematically review the evidence on patient satisfaction regarding the presence/participation of a student during a consultation in general practice. METHOD: Medline search (January 1990 to July 2010). One reviewer extracted data from the articles fulfilling the criteria which were set, and a second reviewer checked these for accuracy. Due to heterogeneity a quantitative synthesis could not be performed. RESULTS: Sixteen studies fulfilled the criteria. The majority of patients gave permission for the presence or participation of a student-doctor. Emotional problems and the need for an intimate examination were the main reasons for refusal. Satisfaction was high. Benefits the patients mentioned were: more time, a more thorough physical examination, better patient education and getting a second opinion. Altruism also played a role. CONCLUSION: In general, the attitude of patients towards student-doctors is positive. There is a general reluctance to see a student-doctor for emotional or intimate problems. Future research should focus on the effect of the preceptor's presence in the latter case. Another interesting topic would be the effect on consent and appreciation of the student-doctor when there are differences in cultural background between patient and student.

Intervention with educational outreach at large scale to reduce antibiotics for respiratory tract infections: a controlled before and after study.

BACKGROUND: A multiple intervention targeted to reduce antibiotic prescribing with an educational outreach programme had proven to be effective in a randomized controlled trial in 12 peer review groups, demonstrating 12% less prescriptions for respiratory tract infections. OBJECTIVE: To assess the effectiveness of a multiple intervention in primary care at a large scale. METHODS: A controlled before and after study in 2006 and 2007 was designed. Participants were from general practices within a geographically defined area in the middle region of The Netherlands. Participants were GPs in 141 practices in 25 peer review groups. A control group of GP practices from the same region, matched for type of practice and mean volume of antibiotic prescribing. The multiple intervention consisted of the following elements: (i) group education meeting and communication training; (ii) monitoring and feedback on prescribing behaviour; (iii) group education for GPs and pharmacists assistants and (iv) patient education material. The main outcome measures are as follows: (i) number of antibiotic prescriptions per 1000 patients per GP and (ii) number of second-choice antibiotics, obtained from claims data from the regional health insurance company. The associations between predictors and outcome measurements were assessed by means of a multiple regression analyses. RESULTS: At baseline, the number of antibiotic prescriptions per 1000 patients was slightly higher in the intervention group than in the control group (184 versus 176). In 2007, the number of prescriptions had increased to 232 and 227, respectively, and not differed between intervention and control group. CONCLUSIONS: The implementation of an already proven effective multiple intervention strategy at a larger scale showed no reduction of antibiotic prescription rates. The failure might be attributed to a less tight monitoring of intervention and audit. Inserting practical tools in the intervention might be more successful and should be studied.

Management of upper respiratory tract infection in Dutch general practice.

A questionnaire, sent to a 10% random sample of Dutch general practitioners (n = 635) included descriptions of four cases of upper respiratory tract infections (acute tonsillitis, recurrent tonsillitis, acute otitis media and sinusitis). This was used to study the general practitioners' management of upper respiratory tract infections. A total of 376 doctors responded (59%). The majority of general practitioners would prescribe antibiotics for sinusitis (80% of respondents) but only 29% would prescribe antibiotics for acute otitis media. For acute tonsillitis and recurrent tonsillitis the proportions were 52% and 59%, respectively. The low prescription rate for acute otitis media was in accordance with national standards, such as the standard of the Netherlands college of general practitioners. A penicillin (phenoxymethylpenicillin or phenethicillin) was most likely to be selected for the two types of tonsillitis, amoxycillin for acute otitis media and doxycycline for sinusitis. Other antibiotics such as erythromycin, other tetracyclines and ampicillin, were seldom selected. Most respondents would prescribe antibiotics for seven days, but there was considerable variation. The influence of the characteristics of the general practitioners and their practices on their antibiotic prescribing was small. Only type of practice correlated with antibiotic treatment, in that general practitioners in single-handed practices would prescribe antibiotics more often than their colleagues in health centres. Among those who would prescribe symptomatic treatment nearly all would prescribe nosedrops for acute otitis media and sinusitis. Eighty five per cent of the respondents would refer the patient with recurrent tonsillitis, while 10% would refer the patient with acute otitis media. The results suggest that some aspects of the prescribing behaviour of Dutch general practitioners might be improved.

Implementing the Dutch College of General Practitioner's guidelines for influenza vaccination: an intervention study.

BACKGROUND: Influenza is a major health problem in most Western countries. In September 1993, the Dutch College of General Practitioners (NHG) issued guidelines for influenza vaccination. Although most general practitioners (GPs) are well acquainted with NHG standards, knowledge does not invariably lead to application. AIM: To evaluate a regional intervention promoting the implementation of NHG's influenza vaccination guidelines. METHOD: In a non-equivalent control group design (pre-test 1992, post-test 1993), two general practice regions were studied. In the intervention region, Amersfoort, there were 82 practices (118 GPs, 250,000 patients) and in the control region, Arnhem, 97 practices (124 GPs, 300,000 patients). In the intervention region, all professionals involved in influenza vaccination were approached at educational meetings and by mail. Postcard material and vaccines were distributed. The main outcome measures were five organizational aspects measured by a questionnaire (registration of high-risk patients, mail prompt, vaccine in stock, special vaccination hours and vaccination by practice assistant), and the vaccination rate (number of vaccines delivered divided by the total number of regional health insurance patients). RESULTS: All practices in the intervention region were involved; 78% responded to the pre-test and post-test questionnaires compared with 76% in the control region. Three of the five organizational aspects improved more in the intervention region: mail prompt by 25% (95% CI 11-38%), vaccine in stock by 29% (95% CI 16-44%), and special vaccination hours by 16% (95% CI 2-27%). Multivariate analyses failed to reveal any modifying factors. The vaccination rate increased by 21% (from 7.7% to 9.3%) in the intervention region, and by 6% (from 8.5% to 9.0%) in the control region. The mean increase in the intervention region exceeded that in the control region by 1.1 per 100 patients (95% CI 0.6-1.6). Multiple regression analysis revealed that this was an independent effect. CONCLUSIONS: This complex intervention was considered to be effective. The same strategy might be appropriate for other regions and other guidelines.

Population-based prevention of influenza in Dutch general practice.

BACKGROUND: Although the effectiveness of influenza vaccination in high-risk groups has been proven, vaccine coverage continues to be less than 50% in The Netherlands. To improve vaccination rates, data on the organizational factors, which should be targeted in population-based prevention of influenza, is essential. AIM: To assess the organizational factors in Dutch general practice, which were associated with the influenza vaccination rate in 1994. METHOD: A retrospective questionnaire study was undertaken in 1586 of the 4758 Dutch general practices, which were randomly selected. A total of 1251 (79%) practices returned a questionnaire. The items verified were practice profile, urbanization, delegation index, use of computer-based patient records, influenza vaccination characteristics and influenza vaccination rate. RESULTS: No differences were found with regard to the percentage of single-handed practices (65%), practices situated in urban area (38%), practices with a pharmacy (12%), patients insured by the National Health Service (59%) and use of computer-based patient records (57%) when compared with national statistics. The mean overall influenza vaccination rate was 9.0% (SD 4.0%). Using a logistic regression analysis, a high vaccination rate (> or = 9%) was associated with the use of personal reminders (odds ratio (OR) 1.7, 1.3-2.2), monitoring patient compliance (OR 1.8, 1.3-2.4), marking risk patients in computer-based patient records (OR 1.3, 1.0-1.6), a small number of patients per full-time practice assistant (OR 1.5, 1.1-1.9), urban areas (OR 1.6, 1.3-2.1) and single-handed practices (OR 1.5, 1.1-1.9). CONCLUSION: Improvement of vaccination rates in high-risk patients may be achievable by promoting the use of personal reminders and computer-based patient records, as well as monitoring patient compliance. In addition, the role of practice assistants with regard to preventive activities should be developed further. Practices situated in rural areas and group practices may need more support with a population-based approach for the prevention of influenza.

Antimicrobial agents in lower respiratory tract infections in Dutch general practice.

This study describes the prescription of antimicrobial agents in cases of lower respiratory tract infections in Dutch general practice. A secondary analysis of data from the National Study of Illness and Procedures of The Netherlands Institute of Primary Health Care (a nationwide group of 161 general practitioners with data from 334,449 patients) had been carried out. Antimicrobial agents were prescribed in 30% of all contacts: in about half of the first contacts and contacts for recurrences, and in one out of six repeat contacts. The prescription rates were associated with diagnosis and reason for encounter but rarely with older age or comorbidity. Amoxycillin and doxycycline were most frequently prescribed. While most lower respiratory tract infections are virus-induced and antibiotics are not effective in most cases, antimicrobial agents might still be overprescribed.

Intercultural training of medical students.

Until recently the Utrecht Medical School had a traditional curriculum with a predominantly biomedical orientation and strong emphasis on curative medicine. In 1997 an experimental 'Multi-cultural Family Attachment Course' started at the Utrecht Medical School with 20 second-year medical students. Each student was attached to a native Dutch and an ethnic minority family with a newborn or chronically ill child. In a period of 1.5 years students had to visit each family at home four times. The students monitored growth and development of the child and discussed several aspects of health and disease with the parents according to a structured schedule. In regular group sessions students reported back their experiences. In this way, the influence of socioeconomic circumstances, culture and environment on health becomes a real-life experience. This paper aims to describe some aspects of this pilot-course and the reactions of the students.

Nontraumatic foot complaints in older people. A population-based survey of risk factors, mobility, and well-being.

In a population-based cross-sectional survey conducted in the Netherlands of 7,200 people aged 65 years and older (with a response rate of 79%), 20% of the respondents were found to have nontraumatic foot complaints of more than 4 weeks' duration, often involving the forefoot. Female sex, joint disease, and multimorbidity were found to be risk factors for the presence of foot complaints; older age and obesity were not. Respondents with these complaints had limited mobility and poor perceived well-being.

Management of upper respiratory tract infections in Dutch family practice.

BACKGROUND: Family physicians vary in their management of upper respiratory tract infections (URTIs), especially regarding prescription of antimicrobial drugs and patient referral. This study was designed to provide insight into this variation in the management of URTI. METHODS: A secondary data analysis of a nationwide study of morbidity and interventions regarding the management of cases of acute otitis media, otitis media with effusion, acute upper respiratory tract infections (acute URTIs), sinusitis, and acute tonsillitis was performed. One hundred sixty-one Dutch family physicians and 335,000 patients were included in the study. RESULTS: About 10% of all first contacts in this study were house calls, which are most often made to patients in the youngest and oldest age categories. In one third of all first contacts, an antimicrobial drug was prescribed, most frequently for sinusitis (72%) and acute tonsillitis (74%), much less frequently for otitis media and acute URTI. Doxycycline and amoxicillin were prescribed most frequently; two thirds of all antimicrobial prescriptions for the first contact were for one of these two drugs. In 1% of all first contacts and 6% of repeat contacts, patients with URTI were referred to a specialist. CONCLUSIONS: Compared with physicians in other countries, Dutch family physicians show a relatively restrictive and selective prescription behavior in dealing with URTI. This may be why the Netherlands has one of the lowest reported levels of antibiotic resistance. House calls are still important in Dutch family practice.

[Deaths due to abuse for the age group 0-18 years; an estimate of 40 cases in 1996 based on a survey of family practitioners and pediatricians]. / Overlijdensgevallen onder 0-18-jarigen door vermoede mishandeling: naar schatting 40 gevallen in 1996 gebaseerd op een enquête onder huisartsen en kinderartsen.

OBJECTIVE: To determine the number of cases of death of children and youths (0-18 years) in 1996 in which the doctor suspected maltreatment as a possible cause of death and whether the death was declared the result of natural causes. DESIGN: Questionnaire. SETTING: Department of General Practice Medicine, University of Utrecht, the Netherlands. METHOD: In co-ordination with the Dutch College of General Practitioners and in consultation with the Dutch Society of Pediatricians a questionnaire was sent to all general practitioners (n = 6957) and pediatricians (n = 971) in the Netherlands. The definition of maltreatment was left to the respondents. The questionnaire included questions regarding some characteristics of the children and the motivation of the doctor to notify or not to notify the municipal coroner. It referred to 1996 but it also asked for cases in 1992-1995 to determine whether the earlier data supported the 1996 ones. RESULTS: The overall response was 83% (6583/7928). The doctors mentioned a total of 33 cases in which they suspected that the death was the result of some kind of maltreatment. 'Death from natural causes' was noted on the death certificates of 6 of these cases and the coroner was not notified. The estimated number of deaths due to mistreatment in the age group 0-18 years for 1996 was 40 (1.14 per 100,000; 95% confidence interval (95%-CI): 0.79-1.50) and 24 in the age group 0-2 years (4.13 per 100,000; 95%-CI: 2.48-5.79), with an estimate of 7 certificates stating death from natural causes. CONCLUSION: The Dutch figures are rather similar to the minimum estimate for the United States in the youngest age groups: 4-11 cases per 100,000 and lower than for other European countries.

[The Dutch version of 'Functional Status II(R)': a questionnaire measuring the functional health status of children]. / De Nederlandse 'Functional status II(R)': een vragenlijst voor het meten van de functionele gezondheidstoestand van kinderen.

OBJECTIVE: Clinimetric evaluation of the Dutch version of the Functional Status II(R) (FS II), measuring children's behaviour and the effect of disease on it. DESIGN: Descriptive. SETTING: University of Utrecht, department of General Practice Medicine, and Julius Centre for Patient-linked Research. METHODS: Parents of children (6 months-11 years of age) with or without asthma were questioned using the Dutch translation of the FS II. Parents of children with asthma and of control children were questioned again using the FS II after 24 hours and after one month. A child version of the FS II, developed by our group, was used for children between 8 and 12 years of age. We tested internal consistency, test-retest reliability, discriminant validity, sensitivity to parents' opinion on presence or absence of health complaints and agreement between the parent and the child version. RESULTS: The group included 124 parents of asthmatic children and 224 parents of control children, 111 of whom were aged 8-12 years. The parent version of the FS II showed good reliability and validity. Cronbach's alpha, measuring internal consistency, was between 0.66 and 0.90, and the 24-hour test-retest reliability was between 0.83 and 0.92. FS II-scores of children with asthma were significantly lower than those of children in the control group, and scores of children with health complaints were significantly lower than those of children without any health complaints, cross-sectionally as well as longitudinally. Reliability and validity figures of the child version of the FS II were far behind those of the parent version. Scores on the child version were only weakly related to those on the parent version. CONCLUSION: The parent version of the Dutch FS II is recommended as a generic measure of functional health status of children for medical research. The child version should be improved first.

[The Dutch 'Rand General Health Rating Index for Children': a questionnaire measuring the general health status of children]. / De Nederlandse 'RAND general health rating index for children': een meetinstrument voor de algemene gezondheid van kinderen.

OBJECTIVE: Clinimetric evaluation of the Dutch version of the RAND general health rating index for children (child RAND), measuring the general health of children. DESIGN: Descriptive. METHOD: The child RAND, containing 7 questions, was administered to parents of 124 children with asthma and of an unselected control group of 224 children, all between 6 months and 12 years of age. The parents also answered a question about the existence of complaints about health. Measurements were repeated after 24 hours and after one month. We tested internal consistency, test-retest reliability, discriminant validity and sensitivity to change. Results were compared with those of the Functional status II (FS II). RESULTS: The child RAND showed good reliability and validity. Cronbach's alpha was between 0.87 and 0.88 in the asthma group and between 0.71 and 0.80 in the control group. Test-retest reliability was 0.93 in the asthma group and 0.83 in the control group. Scores on the child RAND of children with asthma were significantly lower than those of children in the control group, and scores of children with health complaints were significantly lower than those of children without any health complaints in both groups. The sensitivity to change was lower than that of the FS II. The figures of the child RAND on the other measures of reliability and validity were comparable with those of the FS II. CONCLUSION: The Dutch child RAND is recommended as a generic measure of perceived health of children for medical research and may serve as a valuable addition to the measurement of functional health status by the FS II.

Incidence of GP-diagnosed respiratory tract infections according to age, gender and high-risk co-morbidity: the Second Dutch National Survey of General Practice.

BACKGROUND: Figures on GP-diagnosed respiratory tract infections (RTI) are outdated because of demographic changes and increase in co-morbid conditions, respiratory vaccination programmes and change in illness behaviour. OBJECTIVE: To determine the incidence of RTI in patients presenting to the GP according to age, gender and common high-risk co-morbidity in primary care. METHODS: In the Second Dutch National Survey of General Practice 90 computerized general practices with 358,008 patients recorded all consecutive patient contact by use of the ICPC coding system in a year. Incidences were calculated using the mid-year population in the denominator and RTI episodes as the nominator. RESULTS: In all, 4.2% of the patient population were diagnosed with RTI with an incidence rate of 144 per 1000 person-years. Upper RTI were more common in children of 0-4 years than in other year-cohorts [392 versus 80 per 1000; relative risk 4.9, 95% confidence interval (95% CI) 4.8-5.0]. An U-shape association was observed between age and lower RTI (78 and 70 per 1000 in children and persons aged 75 years or over, respectively, versus 23 per 1000 in other age-categories). Females had slightly higher incidence rates of URTI (relative risk 1.4, 95% CI 1.35-1.45) and similar rates for LRTI. Patients with chronic medical conditions as pulmonary and cardiac disease, and diabetes. DISCUSSION: A small proportion of the patient population present themselves to the GP with a RTI. RTI are more common among children, elderly persons and patients with pulmonary and cardiac disease, and diabetes of the ICPC coding system.

Students' conceptions of the medical profession; an interview study.

Students' beliefs and attitudes towards the medical profession have been studied in relation to career choices, but most research has been restricted to either predetermined aspects or to a limited number of specialties. This study aimed at getting unprompted insight in the students' perceptions of their future profession in dimensions that may be determinants of study success and career choice. Undergraduate and graduated medical students were interviewed and asked to characterize the medical profession in general and four contrasting specialties in particular. Grounded Theory methodology was used to analyse the data. Participants were medical students at the start of their training (n = 16), during clerkships (n = 10) and after graduation (n = 37). Beginning students perceive the medical profession in limited dimensions: the activities of a physician, their relationship to patients and the physician's knowledge, skills and personality. They do not see many differences between specialties, in contrast with students with clinical experience and graduate students. Undergraduate students' perception is focussed more on social aspects of the profession compared to graduates.

Referrals to specialists. An exploratory investigation of referrals by 13 General Practitioners to medical and surgical departments.

Several aspects of referrals to medicine and surgery of National Health Service (NHS) patients in thirteen Dutch General Practices were investigated. In The Netherlands active and passive referrals have to be separated. Only one out of three referrals to medicine was an active referral on the initiative of the GP. With regard to surgical referrals about half were active referrals. About half the passive referrals were referrals in retrospect. The thirteen GPs differed in the percentages of active and passive referrals. There was a strong positive correlation between the percentages of passive referrals to medicine and surgery (Spearman Rs = .81). The correlation between the percentages of repeat cards for both groups of specialists was almost as strong (Spearman Rs = .73). In four out of five active referrals the GPs informed the specialist about some aspects of the referral, usually by letter and rarely by telephone. GPs who sent information along with a referral to medicine often did the same with a referral to surgery (Rs = .60). The legibility of the written information was, in general, moderate to poor. Only occasionally the GPs formulated clearly what they expected from the specialist. Suggestions are formulated to improve the referral process between primary and secondary care.

Diagnostic styles of general practitioners confronted with ambiguous symptoms. An exploratory study.

This study explores the diagnostic process of general practitioners confronted with ill-defined and ambiguous complaints, which eventually appeared to be caused by a malignancy. Three aspects were rated: (a) the adequacy of the initial problem definition; (b) the carefulness of further diagnostic methods; and (c) how the suspicion of malignancy originated. These three aspects, which were strongly connected, seem to be parts of a diagnostic approach with two polar extrems: a critical style and a biased style. Characteristic of a critical style is full awareness of detail, careful observations, consideration of ambiguous symptoms, and consciousness that the correct diagnosis is often other than the one initially judged most likely. The opposite, the biased style, is characterized by little alertness for detail, less careful observations, and overinterpretation of facts supporting the initial hypotheses.

Compliance with influenza vaccination. Its relation with epidemiologic and sociopsychological factors.

OBJECTIVE: To identify patient characteristics that are associated with compliance with influenza vaccination reminders in high-risk patients. DESIGN: Registration of the vaccination of high-risk patients invited by their family physicians. Factors that might be associated with compliance were evaluated, eg, sex, age, insurance, diagnosis, seriousness, and multiple indications. A questionnaire about sociopsychological factors was sent to all noncompliant patients and a random sample of 25% of compliant patients. SETTING: Four single and 3 partnership practices with 2142 high-risk patients in a total of 26,000 patients in the Netherlands. MAIN OUTCOME MEASURES: (1) Compliance by at-risk group; odds ratios (ORs) for epidemiologic and diagnosis-based factors, adjusted by multiple logistic regression analysis; (2) adjusted ORs (adj ORs) for sociopsychological factors; and (3) decisive reason whether to comply. RESULTS: Compliance was 86% (95% confidence interval [CI], 85%-88%), with little difference between at-risk groups. The epidemiologic factors age older than 50 years (adj OR, 1.9; 95% CI, 1.5-2.5) and multiple indication (adj OR, 2.2; 95% CI, 1.3-3.6) were related to compliance, independent of at-risk group. Belief in the absence of side effects (adj OR, 10.5; 95% CI, 5.5-20.2) and in the efficacy of the vaccine (adj OR, 5.6; 95% CI, 3.0-10.2) were most positively associated with compliance. Perceived susceptibility to influenza also was associated (adj OR, 2.9; 95% CI, 1.5-5.8), but perception of one's health was not. There was a negative association of compliance in the interaction of age younger than 50 years and disbelief in the possible complications of influenza (adj OR, 0.2; 95% CI, 0.0-0.5). These factors and the family physician's invitation were decisive. CONCLUSIONS: Information about the protection and the side effects of vaccination and the complications of influenza should be directed to patients younger than 50 years; no specific high-risk groups require special information.