Duration of hormonal replacement therapy in general practice; a follow-up study.

OBJECTIVES: To assess the mean duration of use of HRT in general practice and to identify determinants of the duration of HRT use. METHODS: A general population of 1689 women aged 45-60 years and enlisted in five group practices of general practitioners were followed for 9 months to trace first HRT prescriptions. All 103 women who were prescribed HRT were followed for a period of 2.25 years. Duration of HRT was assessed by using the data provided on the dispensing of HRT. Possible determinants of duration of use, such as attitude towards menopause, menopausal status and another six variables were measured by means of a questionnaire. RESULTS: None of the 103 women received HRT for a preventive purpose; the main indication was menopausal complaints. More than 60% of the women stopped their HRT within 6 months and only 8% of the women remained on HRT for more than 2 years. The mean duration of use was 7 months. Determinants that significantly predicted the duration of HRT use were age, attitude towards treatment of the menopause and the group practice. CONCLUSIONS: The mean duration of HRT use is very short, despite the fact that the most prevalent indication is the alleviation of menopausal symptoms. Apparently, Dutch women are presently unwilling to take HRT for longer periods.

Children referred for specialist care: a nationwide study in Dutch general practice.

BACKGROUND: Insight into referral patterns provides general practitioners (GPs) and specialists with a frame of reference for their own work and enables assessment of the need for secondary care. Only approximate information is available. AIM: To determine how often, to which specialties and for what conditions children in different age groups are referred, as well as how often a condition is referred given the incidence in general practice. METHOD: From data of the Dutch National Survey of Morbidity and Interventions in General Practice, 63,753 new referrals (acute and non-acute) were analysed for children (0-14 years) from 103 participating practices (161 GPs) who registered. Practices were divided into four groups. Each group of practices participated for three consecutive months covering a whole year altogether. We calculated referral rates per 1000 children per year and referability rates per 100 episodes, which quantifies the a priori chance of a condition being referred for specialist care. RESULTS: The referral rate varied by age from 231 for children under 1 year old to 119 for those aged 10-14 years (mean 159). The specialties mainly involved were ENT, paediatrics, surgery, ophthalmology, dermatology and orthopaedics. Referrals in the first year of life were most frequently to paediatricians (123); among older children the referral rate to paediatricians decreased (mean 36). Referrals to ENT specialists were seen particularly in the age groups 1-4 (71) and 5-9 (53). For surgery, the referral rate increased by age from 19 to 34. Differences between boys and girls were small, except for surgery. The highest referral rates were for problems in the International Classification of Primary Care (ICPC) chapters: respiratory (28); musculoskeletal (25); ear (24) and eye (21). Referability rates were, in general, low for conditions referred to paediatrics and dermatology and high for surgery and ophthalmology. The variation in problems presented to each specialty is indicated by the proportion of all referrals constituted by the 10 most frequently referred diagnoses: from 35% for paediatrics to 81% for ENT; for ophthalmology, five diagnoses accounted for 83% of all referrals. CONCLUSIONS: The need for specialist care in childhood is clarified with detailed information for different age categories, specialties involved and variation in morbidity presented to specialists, as well as the proneness of conditions to be referred.

Vasomotor symptoms and well-being in the climacteric years.

OBJECTIVES: To determine more closely the relationship between vasomotor symptoms, well-being and climacteric status according to the last menstrual bleeding and according to the women themselves. METHODS: A population-based cross-sectional study was executed using a postal questionnaire. Well-being of women with and without vasomotor symptoms was compared, for the different menopausal statuses. All 2729 women living in a commuter suburb of Rotterdam aged 45-60 years were approached of whom 1947 (71.3%) responded. Well-being was measured by the Inventory of Subjective Health (ISH) and three subscales of the Sickness Impact Profile (SIP). RESULTS: The results showed that the relationship between vasomotor symptoms and well-being was dependent on climacteric status. Pre- and (middle and late) postmenopausal women with vasomotor symptoms more often experienced a relatively lower level of well-being compared to women without these symptoms. However, when the prevalence of vasomotor symptoms is as its peak, i.e. in late perimenopause, a difference in the level of well-being between women with and without vasomotor symptoms was absent. CONCLUSIONS: It is concluded that well-being and vasomotor symptoms were inversely related in all menopausal statuses except for the (late) perimenopausal phase. For this no somatic explanation seems plausible. A more social scientific explanation is suggested.

[For which health problems in children is the family physician consulted and how often?]. / Voor welke gezondheidsproblemen bij kinderen wordt de huisarts geconsulteerd en hoe vaak?

OBJECTIVE: To determine how often and for what health problems in children general practitioners (GPs) are consulted, and whether this is affected by age, gender, season, socioeconomic status and degree of urbanisation. DESIGN: Descriptive. SETTING: 103 general practices (161 GPs) in the Netherlands. METHOD: Data from 63,753 children (0-14 years of age) collected in the framework of the Dutch National Survey were used. A random sample of 161 GPs registered all contacts between patient and practice during 3 months. Sociodemographic characteristics of all practice populations were gathered. Health problems were coded according to the International Classification of Primary Care (ICPC). Consultation frequency, morbidity presented, age and gender specific incidence rates were determined, as well as relative risks of presented morbidity relative to sociodemographic characteristics and season. RESULTS: Children consulted a GP on average 2.8 times per year. Problems from the respiratory tract (upper respiratory tract infection, acute bronchitis, coughing and acute tonsillitis) and acute otitis media were presented most. The morbidity varied strongly with age. Children from low socioeconomic strata and children living in larger cities presented more problems (in particular respiratory and ear problems). CONCLUSION: The GP is confronted with a great diversity of health problems in children. The variation in consultation frequency and morbidity according to selected sociodemographic characteristics showed that presentation of information in more detail by age is necessary in order to obtain optimal insight.

Determinants of first prescription of hormone replacement therapy. A follow-up study among 1689 women aged 45-60 years.

The aim of the present study was to ascertain the cumulative incidence of first hormone replacement therapy (HRT) and the factors that predict its prescription. In a general population 1689 women were followed for 9 months in order to trace first HRT prescriptions. Determinants (well-being, attitude towards menopause, menopausal status and another 9 variables) were measured by means of a questionnaire. Data analyses were performed for all women and for women with or without typical climacteric complaints. The cumulative 9 month incidence of HRT was 6.2%. For women without typical complaints a lower level of well-being (odds ratio 5.5; 95% CI 1.9-15.5) and the former use of the contraceptive pill (odds ratio 4.6%; 95% CI 1.0-20.5) were independently associated with HRT prescription. For women with typical complaints a positive attitude towards 'menopause should be treated' (odds ratio 3.8; 95% CI 1.8-8.0) was a determinant of HRT prescription. The cumulative incidence of HRT prescription is high, but from additional data it is apparent that within a period of 1 year and 9 months the majority of women stop taking HRT. For women without typical complaints, physicians prescribe HRT five times more often to those with a lower level of well-being. For women with typical complaints the physician's prescription is primarily related to the woman's attitude towards (medical) treatment of the menopause.

Women's opinion on withdrawal bleeding with hormone replacement therapy.

The objective of the study was to assess the opinion of women about the use of hormone replacement therapy (HRT) in relation to continuation or re-induction of bleeding periods after menopause. The design was a population-based cross-sectional study using a postnatal questionnaire in Krimpen aan den IJssel, a commuter suburb of Rotterdam. The participants were all 2729 women living in Krimpen aan den IJssel aged 45-60 years, of whom 1947 (71.3%) responded. The main outcome measure was an opinion on monthly or trimonthly withdrawal bleedings with HRT. The results showed 16.9% of all women have no or little objection to use of HRT with monthly withdrawal bleedings. There is a marked difference between premenopausal women (32.4% have no or little objection) and postmenopausal women (only 9.2% have no or little objection). Trimonthly cycles during HRT tend to be perceived as more acceptable (41.4% of premenopausal women and 11.8% of postmenopausal women have no or little objection). It is concluded that a reasonable proportion of premenopausal women accept continuation of periodic bleeding with HRT. There is a preference for trimonthly cycles rather than monthly withdrawal bleedings. Most postmenopausal women object to having withdrawal bleedings with HRT, irrespective of a monthly or trimonthly cycle. Research should continue on schedules without withdrawal bleedings.

Relationships between attitude towards menopause, well-being and medical attention among women aged 45-60 years.

This study aims to answer the following questions: (i) what is the attitude of women in the climacteric years towards menopause, (ii) what is the association between attitude towards menopause and well-being and (iii) to what extent is medical attention determined by both well-being and attitude towards menopause. All 2729 women aged 45-60 years living in a suburb of Rotterdam were sent a questionnaire, of these 1947 (71.3%) were returned. Attitude was measured on a 5-point rating scale using 28 items that have been used in other studies. Well-being was measured by the Inventory of Subjective Health and three subscales of the Sickness Impact Profile. Medical attention was measured by asking the women whether they were currently being treated by a general practitioner or specialist. Results show that three clusters of attitudes towards menopause exist: two clusters encompasses items reflecting attitudes towards disadvantages and advantages of the menopause, one cluster encompasses items reflecting attitudes towards (medical) treatment of the menopause. On the whole, women answer neutrally to items relating menopause with the disadvantages and tend to agree with items relating menopause with the advantages. The women slightly agree, premenopausal women more than others, with items that are in favour of treatment of menopausal complaints. Agreement with items on the disadvantage cluster is moderately associated with a low level of well-being, whereas agreement with items on the advantage cluster is slightly associated with a high level of well-being; the treatment cluster is not associated with well-being. Both well-being and agreement with items on the treatment cluster are statistically significantly associated with medical attention. Apart from these variables, the woman's ideas about treatment are also related to medical attention.

Dissatisfied patients: improving general practitioners' initial reactions.

General practitioners often have difficulty in dealing with dissatisfied patients. One underlying reason could be the disturbed relationship between the doctor and the dissatisfied patient. A training course has been developed taking the relationship as a starting-point. Based on Watzlawick et al.'s theory on communication GPs have been trained to react to a dissatisfied patient on a relational level ('Are you dissatisfied with my treatment?') rather than on a contents level ('How long have you been suffering from this?'). This method seeks to improve the relationship and the satisfaction of both doctor and patient. Three types of initial reaction to dissatisfied patients were offered to four groups of GPs (19 trainees in general practice and 19 trainers in general practice). Pre- and post-measurement were executed by means of registering the initial reactions on videorecorded vignettes of re-enacted dissatisfied patients. Subsequently the reactions were categorized blind by two judges. The 12 possible categories can be subdivided into categories primarily aimed at the contents or primarily aimed at the relationship. The results show that, as compared to the pre-measurements, GPs more frequently use empathic reactions and reactions in which they bring their own actions up for discussion. The number of responses in which doctors ask a further clinical question or in which GPs expect a solution whether from themselves or from others, decrease. It is concluded that the course appears to change for the better the GPs' initial reaction to dissatisfied patients.

The climacteric and well-being.

The climacteric is accompanied by many changes in life, which may give cause to a variety of complaints. Thus, it may be difficult to discern to what extent the climacteric is related to well-being. The association between menopausal status and well-being was determined in a population of 2729 women aged 45-60 years. A self-administered questionnaire was filled out and returned by 1947 women (response 71.3%). Well-being was measured by the Inventory of Subjective Health (ISH) and the three subscales of the Sickness Impact Profile (SIP): social functioning; emotions, feelings and sensations; and intellectual functioning. The relationship between menopausal status and well-being was estimated using linear regression analysis, while adjusting for age and other potential confounding variables, including body mass index, smoking behavior, education, work outside the home, parity, way of cohabitation, difference in age with the partner and partner's employment. The results show that early perimenopausal women report a lower level of well-being as compared to premenopausal women on all three SIP scales. Early postmenopausal women report a lower level of well-being on the SIP emotions, feelings and sensations. Intermediate postmenopausal women have a lower level of well-being on the ISH only. Finally, late postmenopausal women have a lower level of well-being on the SIP social functioning and SIP emotions, feelings and sensations. We tentatively conclude that the influence of the climacteric on well-being independent of confounders is primarily found in behavioral functioning in the daily life of a woman.

Possibilities of continuous care. Part I.

The continuity of health care in the Netherlands is hampered by its structure. There exists a sharp border between the first echelon in which the primary general care is given and the higher echelons in which the out-patient and hospital care is delivered. The policy of the Government is directed to substitution of out-patient and hospital functions, executed in primary care. The possibilities and difficulties for patients and pharmacists are discussed.