[Prevalence of and health care consumption for asthma and COPD in relation to ethnicity]. / Prevalentie en zorgconsumptie bij astma en COPD in relatie tot etniciteit.

OBJECTIVE: To determine whether there are differences in prevalence of and health care consumption for asthma and COPD between Dutch people of Turkish, Moroccan and Surinamese origin and indigenous Dutch people. DESIGN: Retrospective. METHOD: Based on data from the 'Second Dutch national study into morbidity and interventions in general practice', we compared the prevalence of asthma and COPD in the different ethnic groups. In addition, we compared the use of various airway medications and the number of general practice contacts between these ethnic groups. RESULTS: We analysed data of 240,067 indigenous Dutch, 2,942 Turkish, 2,416 Moroccan and 3,320 Surinamese subjects. Asthma is more prevalent among Surinamese and seems less prevalent among Moroccans. COPD seems less prevalent among immigrants than among the indigenous Dutch population. Immigrants tend to have less prescriptions of prophylactic maintenance airway medication and they also tend to have less airway-related general practice contacts than indigenous Dutch patients. CONCLUSION: Differences exist in the prevalence of and health care consumption for asthma and COPD between the different ethnic groups in the Netherlands. There seems to be underdiagnosis of COPD in immigrants. Moreover, immigrant asthma and COPD patients are probably undertreated.

Are asymptomatic airway hyperresponsiveness and allergy risk factors for asthma? A longitudinal study.

Airway hyperresponsiveness (AHR) is a characteristic feature of asthma, but it is unclear whether asymptomatic AHR is associated with a higher risk of asthma. The present study assessed whether there is an association between asymptomatic AHR in adolescence and asthma in adulthood. The association between allergy and development of asthma was also investigated. A follow-up study of a general population cohort of adolescents was performed 14 yrs after baseline. Respiratory status was assessed at baseline in 1989 and at follow-up in 2003-2004 by a respiratory symptoms questionnaire, spirometry and histamine challenge. Allergy status was also assessed. The respiratory status of 199 subjects was assessed twice. In total, 91 (46%) subjects had the same AHR status in combination with respiratory symptoms at follow-up as at baseline. Adjusted for age, sex, allergy, family history of asthma and smoking history, having asymptomatic AHR was not significantly related to having asthma 14 yrs later (odds ratio (OR) 2.15, 95% confidence interval (CI) 0.67-6.83). For subjects with allergy at baseline, the OR for developing asthma was 4.45 (95% CI 1.46-13.54). Screening for asymptomatic airway hyperresponsiveness in adolescence does not identify subjects at risk of developing asthma. Conversely, the presence of allergy in adolescence does seem to be a risk factor for asthma development.

Impact of a spirometry expert system on general practitioners' decision making.

The present study assessed the impact of computerised spirometry interpretation expert support on the diagnostic achievements of general practitioners (GPs), and on GPs' decision making in diagnosing chronic respiratory disease. A cluster-randomised controlled trial was performed in 78 GPs who each completed 10 standardised paper case descriptions. Intervention consisted of support for GPs' spirometry interpretation either by an expert system (expert support group) or by sham information (control group). Agreement of GPs' diagnoses was compared with an expert panel judgement, which served as the primary outcome. Secondary outcomes were: additional diagnostic test rates; width of differential diagnosis; certainty of diagnosis; estimated severity of disease; referral rate; and medication or nonmedication changes. Effects were expressed as odds ratios (ORs) with 95% confidence intervals (CIs). There were no differences between the expert support and control groups in the agreement between GPs and expert panel diagnosis of chronic obstructive pulmonary disease (OR (95% CI) 1.08 (0.70-1.66)), asthma (1.13 (0.70-1.80)), and absence of respiratory disease (1.32 (0.61-2.86)). A higher rate of additional diagnostic tests was observed in the expert support group (2.5 (1.17-5.35)). Computerised spirometry expert support had no detectable benefit on general practitioners' diagnostic achievements and the decision-making process when diagnosing chronic respiratory disease.

[Postgraduate training for general practitioners in the Netherlands--a model for Germany? Description of postgraduate training and critical comparison]. / Facharztweiterbildung Allgemeinmedizin in den Niederlanden--ein Modell für Deutschland? Beschreibung der Weiterbildung und kritischer Vergleich.

Unlike in other countries, postgraduate training in Germany is not attached to academic centres. Content and duration of postgraduate training are stipulated by the federal medical boards, with the process being unstructured and solely at the responsibility of the trainee. As a model for a structured postgraduate training programme, the Dutch training system for general practitioners is described in detail. The most important difference is the funding of trainees and training facilities within the frame of structured training programmes by the Dutch Ministry of Health. Acquisition of qualifications thus becomes more important than the work performance of the trainee. After reforming graduate medical training, it is now time to rethink postgraduate training in Germany.

Validity of spirometric testing in a general practice population of patients with chronic obstructive pulmonary disease (COPD).

OBJECTIVE: To investigate the validity of spirometric tests performed in general practice. METHOD: A repeated within subject comparison of spirometric tests with a "gold standard" (spirometric tests performed in a pulmonary function laboratory) was performed in 388 subjects with chronic obstructive pulmonary disease (COPD) from 61 general practices and four laboratories. General practitioners and practice assistants undertook a spirometry training programme. Within subject differences in forced expiratory volume in 1 second and forced vital capacity (DeltaFEV1 and DeltaFVC) between laboratory and general practice tests were measured (practice minus laboratory value). The proportion of tests with FEV1 reproducibility <5% or <200 ml served as a quality marker. RESULTS: Mean DeltaFEV1 was 0.069 l (95% CI 0.054 to 0.084) and DeltaFVC 0.081 l (95% CI 0.053 to 0.109) in the first year evaluation, indicating consistently higher values for general practice measurements. Second year results were similar. Laboratory and general practice FEV1 values differed by up to 0.5 l, FVC values by up to 1.0 l. The proportion of non-reproducible tests was 16% for laboratory tests and 18% for general practice tests (p=0.302) in the first year, and 18% for both in the second year evaluation (p=1.000). CONCLUSIONS: Relevant spirometric indices measured by trained general practice staff were marginally but statistically significantly higher than those measured in pulmonary function laboratories. Because of the limited agreement between laboratory and general practice values, use of these measurements interchangeably should probably be avoided. With sufficient training of practice staff the current practice of performing spirometric tests in the primary care setting seems justifiable.

Do levels of immunoglobulin G antibodies to foods predict the development of immunoglobulin E antibodies to cat, dog and/or mite?

BACKGROUND: In children at high risk of inhalation allergy, food sensitization is associated with an increased risk for sensitization to inhalant allergens. Furthermore, this association was also found in a cross-sectional study. OBJECTIVE: To examine in a prospective study, whether levels of IgG to foods (i.e. mixture of wheat and rice, mixture of soy bean and peanut, egg white, cow's milk, meat, orange and potato) indicate an increased risk for the future development of IgE antibodies to inhalant allergens in a low-risk population and whether they can be used as predictors of the subsequent development of IgE antibodies in young, initially IgE-negative children. METHODS: Coughing children, aged 1-5, visiting their GPs, were tested for IgE antibodies to mite, dog and cat (RAST) and IgG (ELISA) to foods. All IgE-negative children were retested for IgE antibodies after two years. The IgG results (66 percentiles) of the first blood sample were compared to the RAST-scores of the second blood sample. RESULTS: After two years, 51 out of 397 (12.8%) originally IgE-negative children, had become IgE-positive for cat, dog and/or mite. An increased IgG antibody level to wheat-rice (OR = 2.2) and to orange (OR = 2.0) indicated an increased risk of developing IgE to cat, dog or mite allergens. In addition to IgG to a mixture of wheat-rice and orange; total IgE, breastfeeding, eczema as a baby and age were the most important predictors for the subsequent development of IgE to inhalant allergens. DISCUSSION: An increased IgG antibody level to a mixture of wheat-rice or orange, indicates an increased risk of developing IgE to cat, dog or mite allergens. This indicates that excessive activity of the mucosal immune system is present before IgE antibodies to airborne allergens can be demonstrated. Nevertheless, IgG to foods is not very helpful (with a positive predictive value of 16.5%, and negative predictive value of 90.6%) in identifying individual children at risk in clinical practice. However, besides other risk factors, IgG to wheat-rice and to orange could be useful as a screening test for studies in the early identification, i.e. before IgE antibodies can be detected, of children with an increased risk of developing IgE antibodies in the future.

A Delphi technique as a method for selecting the content of an electronic patient record for asthma.

INTRODUCTION: An electronic patient record (EPR) with disease-specific data may support improvement of the quality of care for patients with chronic diseases. The structure and content of such a record can only be assessed by clinicians in co-operation with IT-specialists, because, the result has to be clinically relevant, easily accessible and adjusted to the information needs of different workers in primary care. METHODS: We applied a modified Delphi-procedure--a method characterized by anonymous written comments by an expert panel. The panel had to agree about the question whether or not an item should be included in the EPR. The questions for the written comments were prepared by a steering committee (general practitioners (GP) and health scientists, either expert in asthma and disease management or IT-specialist) based on the guidelines for diagnosing and treating asthma of the Dutch College of General Practitioners (DCGP). When agreement within the panel was < or = 70%, we sent a modified format to the expert panel for reassessment. RESULTS: Three written commentary rounds were necessary, in which 95 potential items were discussed with the expert panel. In the first round they selected 50 items relating to diagnosing asthma and 22 concerning the treatment of asthma. During the second round 17 items were still under discussion and six were rejected. In subsequent rounds, the expert-panel assessed the best registration format (operationalisation). The written rounds failed to create a full consensus. Therefore the study ended with a consensus meeting of the expert panel. Due to the presence and contribution of nearly all experts, consensus could be reached about the structure and contents of the EPR on asthma. DISCUSSION: The modified Delphi procedure, proved to be a feasible method for selecting the optimal content of an electronic registration protocol. Both, written and verbal commentary rounds were necessary. The existence of a set of guidelines was essential.

Development of specific immunoglobulin E in coughing toddlers: a medical records review of symptoms in general practice.

The aim of this study was to study whether young children, originally immunoglobulin E (IgE) negative and who became sensitized to specific inhalation allergens, presented more frequently to their general practitioner (GP) with other allergy- and asthma-related symptoms than children who remained IgE negative. It was also investigated whether asthma was diagnosed more often in children who developed IgE to inhalant allergens. Coughing children, 1-5 years of age, visiting the participating GPs, were tested for IgE antibodies to mites, dogs, and cats by using radioallergosorbent testing (RAST). All IgE-negative (RAST < 0.2 IU/ml) children were re-tested after 2 years. The medical records of 162 children were reviewed on asthma- and allergy-related symptoms and on prescribed medication. After 30 months, 27 of the 162 children (17%) had become IgE positive for one or more allergens. Most children (93%) had visited their GP for treatment of respiratory symptoms during this period. However, the children who had become IgE positive had visited their GP more often than the children who remained IgE negative. Differences in visits were seen for: shortness of breath (52% IgE-positive vs. 19% IgE-negative children, respectively), wheeze (37% vs. 17%), allergic rhinitis (33% vs. 16%), and pneumonia (22% vs. 8%), but not for coughing (89% vs. 88%). The IgE-positive children were more frequently diagnosed by their GP as having asthma (48%) than were the IgE-negative children (23%). In a multivariate analysis, indicators of becoming IgE positive were: a visit for shortness of breath (odds ratio [OR] = 6.9; 95% confidence interval [CI] = 2.1-23.1) and two or more visits for wheeze (OR = 6.0; 95% CI = 1.9-19.2), adjusted for breast-feeding, age, and asthma or allergy in the family. The positive predictive value (PPV) of being IgE positive with a diagnosis of asthma was 90% (whereas the negative predictive value was 48.0%) for a child attending their GP for treatment of wheeze. For recurrent coughing (six or more visits) and shortness of breath, the PPVs were 73% and 71%, respectively. The development of sensitization to common inhalant allergens is associated with specific allergy and asthma-related symptoms in young children. IgE-positive children were more frequently diagnosed as having asthma by their GP. This implies that in general practice it is possible to detect children at high risk for developing allergic asthma early in life by their respiratory symptoms and by subsequent testing for specific IgE to inhalant allergens.

Added value of co-morbidity in predicting health-related quality of life in COPD patients.

The extent to which a chronic obstructive pulmonary disease (COPD) patient is impaired in health-related quality of life (HRQoL) is only to a small extent reflected in clinical and demographical measures. As the influence of comorbidity on HRQoL is less clear, we investigated the added value of 23 common diseases in predicting HRQoL in COPD patients with mild to severe airways obstruction. COPD patients from general practice who appeared to have an forced expiratory volume in 1 sec/inspiratory vital capacity (FEV1/IVC) < predicted -1.64 SD, FEV1 <80% predicted, FEV1 reversibility < 12% and a smoking history, were included (n=163). HRQoL was assessed with the short-form-36 (SF-36) and the presence of comorbidity was determined by a questionnaire, which asked for 23 common diseases. All domains of the SF-36 were best predicted by the presence of three or more co-morbid diseases. FEV1 % predicted, dyspnoea and the presence of one or two diseases were second-best predictors. Co-morbidity explained an additional part of the variance in HRQoL, particularly for emotional functioning (delta R2=0.11). When individual diseases were investigated, only insomnia appeared to be related to HRQoL. As HRQoL is still only partly explained, co-morbidity and other patient characteristics do not clearly distinguish between COPD patients with severe impairments in HRQoL and COPD patients with minor or no impairments in HRQoL. Therefore, it remains important to ask for problems in daily functioning and well-being, rather than to rely on patient characteristics alone.

Prevalence of comorbidity in patients with a chronic airway obstruction and controls over the age of 40.

The goal of this study is to determine the prevalence of 23 common diseases in subjects with a chronic airway obstruction and in controls. All subjects with a known diagnosis by their general practitioner of asthma or chronic obstructive pulmonary disease (COPD), and who were 40 years and older were selected (n = 1145). Subjects who were willing to participate (n = 591) and who appeared to have an irreversible airway obstruction (n = 290) were included. To recruit controls, a random sample was taken of 676 individuals who were 40 years and older and who were not diagnosed as having asthma or COPD by their general practitioner. Of these 676 individuals 421 were willing to participate. The presence of diseases was determined by using a questionnaire. One hundred and ninety-four subjects (73%) and 229 controls (63%) were shown to be suffering from one or more (other) diseases. In both groups, locomotive diseases, high blood pressure, insomnia and heart disease were most common. Locomotive diseases, insomnia, sinusitis, migraine, depression, stomach or duodenal ulcers and cancer were significantly more common in the subject group than in the control group. For both clinical and research purposes, it is important to consider the presence of diseases in patients with a chronic airway obstruction.

Quality assessment in general practice trainers.

INTRODUCTION: General practice trainers hold a key position in general practice training, especially through their provision of a role model. Their own competence in general practice care is important in this regard. The purpose of the study was to evaluate whether a quality assessment programme could identify the strengths and weaknesses of GP trainers in four main domains of general practice care. METHODS: The quality assessment programme comprised validated tests on four domains of general practice: general medical knowledge, knowledge of medical-technical skills, consultation skills and practice management. The criterion for the identification of relative strengths and weaknesses of GP trainers was a variation in the scores of trainers indicating higher and lower scores (strengths and weaknesses) within each domain. RESULTS: GP trainers (n=105) were invited to participate in the study and 90% (n=94) did so. The variation in scores allowed the indication of strengths and weaknesses. Main strengths were: general medical knowledge of the digestive system; knowledge of medical skills relating to the skin; consultation skills concerning empathy; practice management with regard to accessibility. Main weaknesses were: general medical knowledge of the neurological system; knowledge of the medical/technical skills relating to the endocrine metabolic and nutritional system; consultation skills regarding shared decision making; practice management involving cooperation with staff and other care providers. DISCUSSION: This first systematic evaluation of GP trainers identified their strengths and weaknesses. The weaknesses identified will be used in the improvement process as topics for collective improvement in the GP trainers' general curriculum and in individual learning plans.