Patient-oriented intervention in addition to centrally organised checkups improves diabetic patient outcome in primary care.

BACKGROUND: Logistic support to general practitioners improves the care processes for patients with diabetes but is not sufficient to meet all criteria. AIM: To introduce patient-oriented interventions by a practice nurse in general practices which already use logistic support to improve the care processes for patients with diabetes. DESIGN OF STUDY: A controlled before-after study with delayed intervention in the control group. SETTING: 51 practices (n = 23 for the intervention and n = 28 for the control group) in the south of The Netherlands and 900 of their patients with type 2 diabetes. METHODS: Data were collected on the results of the checkups (fasting blood glucose, glycosylated haemoglobin (HbA1C), cholesterol, cholesterol/high-density lipoprotein ratio, triglycerides, creatinine, blood pressure, fundus photo, foot exam and body mass index), smoking status, physical activity and medication use. The effect of the patient-oriented intervention was analysed in a mixed model with repeated measurement covariance structure. RESULTS: The HbA1C improved in the intervention group (from 7.3 to 7.1), while that of the control group deteriorated (from 7.2 to 7.3). The percentage of patients with an HbA1C >or=8.5 was halved after the intervention (from 13 to 6). Patients in the intervention group started to exercise more besides their daily activities compared with the control group. The need for medication increased more in the control group than in the intervention group (more changes to insulin and more defined daily dose (DDD) oral medication). CONCLUSION: Patient-oriented interventions in addition to logistic support have a positive effect on diabetic patient outcomes.

Do patients matter? Contribution of patient and care provider characteristics to the adherence of general practitioners and midwives to the Dutch national guidelines on imminent miscarriage.

OBJECTIVE: To assess the relative contribution of patient and care provider characteristics to the adherence of general practitioners (GPs) and midwives to two specific recommendations in the Dutch national guidelines on imminent miscarriage. The study focused on performing physical examinations at the first contact and making a follow up appointment after 10 days because these are essential recommendations and there was much variation in adherence between different groups of providers. DESIGN: Prospective recording by GPs and midwives of care provided for patients with symptoms of imminent miscarriage. SETTING: General practices and midwifery practices in the Netherlands. SUBJECTS: 73 GPs and 38 midwives who agreed to adhere to the guidelines; 391 patients were recorded during a period of 12 months. MAIN MEASURES: Adherence to physical examinations and making a follow up appointment were measured as part of a larger prospective recording study on adherence to the guidelines on imminent miscarriage. Patient and care provider characteristics were obtained from case recordings and interviews, respectively. Multilevel analysis was performed to assess the contribution of several care provider and patient characteristics to adherence to two selected recommendations: the number of recommended physical examinations at the first contact and the number of days before a follow up appointment took place. RESULTS: In the multilevel model explaining variance in adherence to physical examinations, the care provider's acceptance of the recommendations was the most important factor. Severity of symptoms and referral to an obstetrician were significant factors at the patient level. In the model for follow up appointments the characteristics of the care provider were less important. Referral to an obstetrician and probability diagnosis were significant factors at the patient level. CONCLUSIONS: The study showed that characteristics of both the patient and care provider contribute to the variability in adherence. Furthermore, the contribution of the characteristics differed per recommendation. It is therefore advised that the contribution of both patient and care provider characteristics per recommendation should be carefully examined. If implementation is to be successful, strategies should be developed to address these specific contributions.

Reasons why patients bypass their GP to visit a hospital emergency department.

Knowledge about what motivates patients to visit the emergency department (ED) of a hospital for minor complaints, instead of visiting their general practitioner (GP), can help to reduce unnecessary utilization of expensive services. This paper reports on a study designed to investigate the reasons why patients visit the ED and to determine the influence of patient characteristics on specific motives. A multidimensional measurement instrument was designed to identify the motives of patients who bypass their GP and visit the ED. The instrument assessed 21 motives, all measured by means of three questions in Likert format. During a period of 1 week, all patients who visited the ED of two hospitals in Amsterdam were asked to complete a questionnaire when they were 'self-referred' with minor complaints. A total of 403 questionnaires were analysed, and the results show that motives relating to the GP play a minor role in the decision of patients to visit the ED. Profiles of two major patient groups could be identified. One group comprised patients with a high socio-economic status living in suburbs, whose motives for visiting the ED are mainly of a financial nature. Patients in the second group mainly lived in the inner-city, and preferred the expertise and facilities provided by the ED.

Does the care given by general practitioners and midwives to patients with (imminent) miscarriage meet the wishes and expectations of the patients?

OBJECTIVE: In 1989 a Dutch national guideline on (imminent) miscarriage was developed for use in general practice. A prospective recording study was carried out to determine how the patients evaluated the care they received from general practitioners (GPs) and midwives who agreed to adhere to this (imminent) miscarriage guideline and to determine the aspects that influence this evaluation. SETTING: GP practices and midwifery practices in The Netherlands. DESIGN: Prospective recording of appointments during 4 consecutive weeks in a diary by patients who contacted their GP or midwife with symptoms of (imminent) miscarriage. STUDY PARTICIPANTS: Over a period of 12 months, 75 GPs and 43 midwives recorded all patients (n = 407) showing symptoms of (imminent) miscarriage. In total 265 patients had completed at least the first contact in the diary; 200 patients actually recorded all contacts. RESULTS: Most patients gave their GP or midwife a high evaluation score (8.2 or 8.7 respectively). Yet, 20% thought that the care could be improved if the GP or midwife gave more information, was more empathetic and carried out an ultrasound scan. In determining the aspects that have most influence on the patients' evaluation, empathy and support came first, followed by involvement of the patient in decision making, putting her at ease, and the total duration of the contacts. Although patients who wanted a referral gave a lower score, this seems to be of less importance than the above mentioned aspects. Expecting and getting an ultrasound scan did not influence the patient's evaluation.

Well-being and symptoms in relation to insulin therapy in type 2 diabetes.

OBJECTIVE: To determine the influence of insulin therapy on physical symptoms, emotional and general well-being, and treatment satisfaction in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: A descriptive prospective 2-year cohort study was performed. The study population consisted of 272 eligible NIDDM patients of Dutch origin > or = 40 years of age who had a known diabetes duration > or = 3 months and who were treated with diet and/or oral hypoglycemic agents. Dependent variables in the logistic regression analysis were scores on the Type 2 Diabetes Symptom Checklist, the Profile of Mood States, and questions regarding general well-being and treatment satisfaction. Potential determinants under study were age, sex, known diabetes duration, insulin dose, duration of insulin therapy, comorbidity, baseline and change in metabolic parameters and cardiovascular risk factors. RESULTS: A baseline and 2-year questionnaire were available for 157 patients (58%). During follow-up, 39 of them (24.8%) were treated with insulin. Initiation of insulin therapy was significantly associated with improved glycemic control (mean HbA1c 8.2 +/- 1.4 [SD] to 7.4 +/- 0.9%, P = 0.001) and weight gain (BMI 27.1 +/- 3.9 to 28.6 +/- 4.3 kg/m2, P = 0.000). Of all symptom and well-being scores, only feelings of emotional fatigue worsened significantly, although modestly (0.4-1.7 on a scale of 0.0-10.0, P = 0.02). Although diabetes management with insulin was experienced as more demanding (P = 0.04), treatment satisfaction scores were not adversely influenced (2.5-1.9, P = 0.39). High insulin doses were significantly and independently associated with high symptom scores (total score, hypoglycemic score) and with low mood (displeasure score, anger, tension, emotional fatigue) and perceived state of health. CONCLUSIONS: Initiation of insulin therapy in type 2 diabetes improves glycemic control effectively, has little influence on physical and psychological well-being dimensions, and does not affect treatment satisfaction.

Sustained good glycaemic control in NIDDM patients by implementation of structured care in general practice: 2-year follow-up study.

In primary care it is difficult to treat the growing number of non-insulin-dependent diabetic (NIDDM) patients according to (inter)national guidelines. A prospective, controlled cohort study was designed to assess the intermediate term (2 years) effect of structured NIDDM care in general practice with and without 'diabetes service' support on glycaemic control, cardiovascular risk factors, general well-being and treatment satisfaction. The 'diabetes service', supervised by a diabetologist, included a patient registration system, consultation facilities of a dietitian and diabetes nurse educator, and protocolized blood glucose lowering therapy advice which included home blood glucose monitoring and insulin therapy. In the study group (SG; 22 general practices), 350 known NIDDM patients over 40 years of age (206 women; mean age 65.3 +/- SD 11.9; diabetes duration 5.9 +/- 5.4 years) were followed for 2 years. The control group (CG; 6 general practices) consisted of 68 patients (28 women; age 64.6 +/- 10.3; diabetes duration 6.3 +/- 6.4 years). Mean HbA1c (reference 4.3-6.1%) fell from 7.4 to 7.0% in SG and rose from 7.4 to 7.6% in CG during follow-up (p = 0.004). The percentage of patients with poor control (HbA1c > 8.5%) shifted from 21.4 to 11.7% in SG, but from 23.5 to 27.9% in CG (p = 0.008). Good control (HbA1c < 7.0%) was achieved in 54.3% (SG; at entry 43.4%) and 44.1% (CG; at entry 54.4%) (p = 0.013). Insulin therapy was started in 29.7% (SG) and 8.8% (CG) of the patients (p = 0.000) with low risk of severe hypoglycaemia (0.019/patient year). Mean levels of total and HDL-cholesterol (SG), triglycerides (SG) and diastolic blood pressure (SG + CG) and the percentage of smokers (SG) declined significantly, but the prevalence of these risk factors remained high. General well-being (SG) did not change during intensified therapy. Treatment satisfaction (SG) tended to improve. Implementation of structured care, including education and therapeutic advice, results in sustained good glycaemic control in the majority of NIDDM patients in primary care, with low risk of hypoglycaemia. Lowering cardiovascular risk requires more than reporting results and referral to guidelines.

The quality of the discharge planning process: the effect of a liaison nurse.

A project employing a liaison nurse has been started in the Dutch Zaandam region. The liaison project will focus on the experience of problems in preparing for hospital discharge and on continuity between hospital and home care. This article discusses the effect of the liaison nurse on the quality of the discharge planning process. The investigation included a pre-test and a main test for which data were collected using questionnaires. These were sent to patients who had received after-care on being discharged from hospital. To measure the quality of the discharge process and after-care continuity, use was made of explicit quality criteria, targeting discharge planning. The results show that discharge planning in hospitals has improved. No significant improvement was detected with respect to continuity of care. It may be concluded that the discharge process requires more attention. The quality criteria used here could function as points of departure.

The problems of elderly people at home one week after discharge from an acute care setting.

The problems of elderly people following discharge from hospital is a worldwide focus of nursing attention. Actual and local insight into the nature and extent of post-discharge problems is needed as a base for improving and evaluating discharge planning. Problems following discharge were investigated as the first part of a larger study. Over a 3-month period, 251 elderly people who had been discharged after a hospital stay of more than 3 days, were asked to participate in the study. Half received a postal questionnaire and half were interviewed at home, one week after discharge. There were 145 respondents. The need for information was mentioned by 80% of the patients. Housekeeping tasks also caused most patients some difficulty. Almost 40% of those discharged reported some kind of unmet need.

Adherence by midwives to the Dutch national guidelines on threatened miscarriage in general practice: a prospective study.

OBJECTIVE: To determine the feasibility for midwives to adhere to Dutch national guidelines on threatened miscarriage in general practice. DESIGN: Prospective recording of appointments by midwives who agreed to adhere to the guidelines on threatened miscarriage. Interviews with the midwives after they had recorded appointments for one year. SETTING: Midwifery practices in The Netherlands. SUBJECTS: 56 midwives who agreed to adhere to the guidelines; 43 midwives actually made records from 156 clients during a period of 12 months. MAIN OUTCOME MEASURES: Adherence to each recommendation and reasons for non-adherence. RESULTS: The recommendation that a physical examination should take place on the first and also on the follow up appointment was not always adhered to. Reasons for non-adherence were the midwives' criticism of this recommendation, their lack of knowledge or skills, and the specific client situation. Adherence to a follow up appointment after 10 days, a counselling consultation after six weeks, and not performing an ultrasound scan was low. Reasons for non-adherence were mainly based on the midwives' criticism of these recommendations and reluctance on the part of the client. Furthermore, many midwives did not give information and instructions to the client. It is noteworthy that in 13% of the cases the midwife's policy was overridden by the obstetrician taking control of the situation after the midwife had requested an ultrasound scan. CONCLUSIONS: Those recommendations in the guidelines on threatened miscarriage that are most often not adhered to should be reviewed. To reduce conflicts about ultrasound scans and referrals, agreement on the policy on threatened miscarriage should be mutually established between midwives and obstetricians.

The prevalence and determinants of foot ulceration in type II diabetic patients in a primary health care setting.

The purpose of the study was to assess the prevalence of foot (pre-)ulcers and their determinants in type II diabetic patients in a primary health care setting. Six hundred and nine patients (246 men, mean age 64.8 (range, 40-94) years, diabetes duration, 4.3 (0-44.9) years) from 22 general practices attended a regional shared care project in Amsterdam. At first visit all patients were examined by a podiatrist. Amputations, active fool ulcers (Wagner stage 1 or 2) and pre-ulcers (Wagner stage 0, hard skin with or without macerating changes) were recorded in 0 (0%), 11 (1.8%) and 79 (12.9%) patients, respectively. In multivariate logistic regression analysis, after adjustment for age and gender, diabetes duration, cigarette smoking, peripheral vascular disease (assessed by calculating ankle/brachial index), sensory neuropathy (by Semmes-Weinstein monofilament 5.07), dry feet and severe hammer toes were independently and significantly associated (pre-)ulceration. In conclusion, one of every seven type II diabetic patients in primary health care has a foot (pre-)ulcer. Patients at risk for foot ulceration can be identified by inspection and the use of simple instruments.

The effects of involvement of the general practitioner and guidance of the hearing impaired on hearing-aid use.

A number of international and national publications report that hearing aids are sometimes under used. In this paper, results are reported of a project to increase the effective use of hearing aids. The first intervention was aimed at a more effective exchange of information between the general practitioner (GP) and the ENT specialist. This was achieved by the introduction of a structured referral form. In addition, a simple hearing aid was placed at the GP's disposal for demonstration purposes. As a second, independent intervention, 50% of the patients were visited at home by a trained volunteer. A measure of effective use that combines the effectiveness and actual use had been developed. After the first intervention the non-effective use of hearing aids decreased from 38% to 30%, this being just below statistical significance (p = 0.12). The protocol approach by the GP in combination with the demonstration hearing aid proved to be especially useful. Patients with a counselling visit at home had a significantly lower level of non-effective use (27% versus 37%; p < 0.05) than patients who had not been visited.

[Cause for referral by family physicians and obstetricians in Amsterdam in (threatened) miscarriage as reflected in the guideline '(Threatened) abortion' of the Dutch Society for Family Physicians]. / Verwijsredenen van huisartsen en verloskundigen in Amsterdam bij (dreigende) miskraam gespiegeld aan de standaard '(Dreigende) miskraam' van het Nederlands Huisartsen Genootschap.

OBJECTIVE: To determine the reasons general practitioners (GPs) and midwives have for referring patients with symptoms of imminent miscarriage to hospital and the management in hospital. DESIGN: Prospective and descriptive. SETTING: Research Centre Primary/Secondary Health Care, University Hospital Free University, the "Onze Lieve Vrouwe Gasthuis' hospital, both in Amsterdam, the Netherlands. METHOD: During the period August 1994-February 1995 anamnesis, diagnostics, diagnosis and further management were recorded for all patients who visited the "Onze Lieve Vrouwe Gasthuis' hospital with blood loss and/or pain in the first 16 weeks of gestation. Patients revealed their wishes concerning referral by filling in questionnaires. Their GPs/midwives were asked about the referral motives in a telephone interview. RESULTS: In the hospital 105 patients were recorded; 34% came on their own initiative. In hospital none of the patients with the diagnosis "imminent miscarriage' was referred back to the GP/midwife. Only 59% of the GPs/midwives performed the physical examinations the (imminent) miscarriage guideline of the Dutch College of General Practitioners advises. In 56% of the 32 patients referred there was no reason for referral according to the (imminent) miscarriage guideline. CONCLUSION: The (imminent) miscarriage guideline issued by the Dutch College of General Practitioners was not always followed because patients went to the hospital on their own account, GPs/midwives did not agree with the guideline, patients wanted another policy and obstetricians kept patients in their own care.

Primary health care replacing hospital care--the effect on quality of care.

In order to change current practice concerning hospital stays, a project was initiated in which shortening hospital stay was combined with shifting care to primary health care. Research was aimed at assessing quality of care of shortened hospital stays with home care by the community nurse and/or the general practitioner (GP). A randomized clinical trial was conducted with three subgroups: 1. traditional hospital stay; 2. hospital admission on the day of surgery, discharge the day after; two consultations at the outpatient department; one visit by the community nurse before surgery, two visits after; 3. mostly as for 2. with two GP visits replacing the two consultations at the outpatient department. The selected surgical procedures were: laparoscopic cholecystectomy, varicose veins, removal of osteosynthesis material, hernia surgery and other minor surgery (normal hospital stay 4-6 days). Every motivated patient meeting the inclusion criteria entered the study. During one year 120 patients were thus selected. Only minor differences were found between the three subgroups in the resulting quality of care. It is concluded that late admission and early discharge even without after discharge care is feasible in most cases for healthy patients.

Retinopathy screening in type 2 diabetes: reliability of wide angle fundus photography.

The purpose of the study was to assess the reliability of mydriatic 60 degrees fundus photography in a retinopathy screening programme for Type 2 diabetic patients in a primary health care setting. In 323 eligible consecutive Type 2 diabetic patients above 40 years of age, attending a regional shared care diabetes project, mydriatic wide angle fundus photography was compared with standardized fundoscopy in dilated pupils as the recommended test for the detection of diabetic retinopathy. Fundus photography included two black and white transparencies per eye visualizing the central and nasal retinal field. Fundoscopy findings and pictures were scored according to modified Wisconsin criteria. Fundoscopy revealed in 95/646 eyes (14.7%) some degree of diabetic retinopathy. Sensitivity and specificity of fundus photography (omitting ungradable transparencies) were 97% for the diagnosis of any diabetic retinopathy (DRP). All patients with moderate and severe DRP (Wisconsin grade 3 and worse) according to fundoscopy were detected by fundus photography. In conclusion, mydriatic wide angle 60 degrees fundus photography, making two pictures per eye, can be applied effectively and reliably in the detection of diabetic retinopathy in patients with Type 2 diabetes.

Psychiatric consultation for somatizing patients in the family practice setting: a feasibility study.

OBJECTIVE: The purpose of the study was to assess the feasibility of a psychiatric consultation intervention for somatizing patients in the family practice setting in terms of 1) patient compliance, 2) patient satisfaction, and 3) compliance and satisfaction of general practitioners (GPs). METHOD: In a period of nine months, forty-six patients were selected for psychiatric consultation in six solo family practices in a semi-urban area in the Netherlands. The consultation included an interview with the consulting psychiatrist, the patient, and the GP. A written summary of the consultation was provided to the GP and the patient. A booster session with a GP and psychiatrist was included to evaluate and reinforce the recommendations. RESULTS: The majority of the selected patients agreed to participate after informed consent. An intervention was implemented containing interpersonal techniques, reattribution, clarification, and structuring. GP compliance with recommendations was 100 percent, patient compliance 75 percent. CONCLUSION: A standardized psychiatric consultation for somatizing patients in a family practice setting can be implemented. Several levels of implementation can be distinguished.

Care for the imminent miscarriage by midwives and GPs.

A postal questionnaire was sent to a random sample of 495 Dutch general practitioners (GPs) and 278 midwives to evaluate the use of the 'imminent miscarriage' standard used by the Dutch College of General Practitioners. The response rates were 63 and 87% respectively. The first questions asked related to the respondents' routine management of an imminent miscarriage. The second part of the questionnaire addressed the respondents' attitude to the 17 most important guidelines in the standard. Finally, the respondents were invited to describe problems arising in adhering to the standard. Midwives and GPs differed in their management of an imminent miscarriage. Midwives used more 'technology' such as ultrasound scans or a doptone to trace complications or see if the fetus was still viable, whereas the GPs more often carried out vaginal and speculum examinations. Midwives also paid more attention to care following a miscarriage. The guidelines that many respondents did not adhere to involved the period of 10 days for the follow-up appointment and counselling after 6 weeks. Guidelines restricting ultrasound scans and the decision only to refer the patients to an obstetrician after three consecutive miscarriages were also not accepted by all respondents. Respondents mentioned several practical problems or obstacles in adhering to the standard, including women's requests for ultrasound scans or referrals and also the attitude of obstetricians who sometimes simply assumed control. The results will serve as a starting point for updating the standard.

Acute bronchitis: general practitioners' views regarding diagnosis and treatment.

A survey was conducted among 800 Dutch general practitioners to establish their views on the diagnosis and treatment of bronchitis and related disorders with reference to 12 theoretical patients. The answers of the 467 respondents (response rate 60%) showed no clear relationship between signs and symptoms of the patients and the diagnosis made. In the authors' opinion the diagnosis of pneumonia was made too often. The decision whether or not to prescribe an antibiotic for a coughing patient was based in part on the diagnosis made, but in part it was also made on the basis of the signs and symptoms, irrespective of the diagnosis. The authors have the impression that general practitioners tend to prescribe antibiotics too quickly to coughing patients. There is a need for guidelines for diagnosis and treatment of patients with acute bronchitis and related conditions.

Encouraging the development of integrated health centres: a critical analysis of lower referral rates.

Dutch government policy places considerable emphasis on the strengthening of the primary health care sector. In this connection, it has been shown that health centres tend to reduce costs. The referral rate for GPs in health centres is considerably lower than for GPs practising alone. The question this raises is whether the lower rates are due to the performance of the GPs or to intermediate variables. Three research projects which cast some light on this issue are examined. The first dealt with a possible explanation by means of structural variables, such as differences in the level of urbanization and the availability of hospital services. The second addressed itself to the question of 'patient mix' and asked whether this is responsible for differences in referral rates, which the third project put the same question in respect to the selection of physicians. All results supported rejection of the hypothesis that the statistical relation between the practice-setting and the referral rate was spurious. A clear result concerning the causality of the relation is not yet available.

Lower referral rates for integrated health centres in The Netherlands.

The strengthening of primary health care is an important issue in health policy in The netherlands. The stimulation of co-operation and cohesion within primary health care and, in particular, the stimulation of integrated health centres is supposed to be an important mean to reduce the expansive growth of expenditures in the so-called second line (mainly medical specialists and hospitals). This article first describes recent trends in co-operation within primary health care and referral rates. For a better understanding of the issue in the context of the Dutch health care system we will also describe some of the rationale of the government policy to strengthen primary health care. In the second part results are presented of a study carried out to test if differences in referral rates among GPs in different practice settings can be explained by structural factors.