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.

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.

Variation in diagnosis and management of common foot problems by GPs.

BACKGROUND: There are indications that the diagnosis and management of common foot problems vary widely in general practice. OBJECTIVES: Our aim was to explore the variation of GPs' diagnosis and management of common foot problems and the possible correlation between GPs' characteristics and their competence to diagnose correctly. METHODS: In a cross-sectional design, 90 GPs in The Netherlands were invited to complete a questionnaire regarding seven vignettes with common foot problems (hallux valgus, hallux rigidus, fasciitis plantaris, tarsal tunnel syndrome, metatarsalgia, corns and calluses, and rheumatoid arthritis), combined with questions covering diagnoses, management options and some GP characteristics. RESULTS: A total of 72 GPs responded (80%). They most often diagnosed hallux valgus (79%) and rheumatoid arthritis (86%) correctly, and most often hallux rigidus (37%) and tarsal tunnel syndrome (74%) incorrectly. GP characteristics did not correlate with their competence in diagnosing. The most frequently suggested management was referral to a podiatrist. The referral rate to medical specialists was low, except in the case of rheumatoid arthritis (79%). CONCLUSIONS: More than half of the GPs were competent in diagnosing vignettes of common foot problems. This diagnostic competence showed great variation and was not associated independently with GP characteristics. Educational programmes are recommended. Management showed less variation and often included referral to podiatrists. Further research into the effectiveness of specific treatments for different foot problems is recommended.

Health care utilisation by older people with non-traumatic foot complaints. What makes the difference?

OBJECTIVES: To determine the factors associated with the type of health care chosen by elderly people suffering from non-traumatic foot complaints. DESIGN: Cross-sectional mailed survey. SETTING: Population-based random sample of 7200 people aged > or = 65 years in The Netherlands. SUBJECTS: 1130 people > or = 65 years with non-traumatic foot complaints for 4 weeks or more. MAIN OUTCOME MEASURES: Use of non-(para)medical care (i.e. no care at all, self-care and chiropodial care) versus (para)medical care (i.e. care given by paramedical personnel, general practitioners and medical specialists). RESULTS: Six of every 10 respondents sought (para)medical care, half of these visited the GP. Factors associated with the use of (para)medical care were foot-related limitations (adj OR 3.18; 95% CI 2.26-4.46), painful feet (adj OR 1.55; 1.09-2.23), and foot osteoarthritis (adj OR 1.88; 1.32-2.68). (Para)medical care was sought less often than non-(para)medical care for forefoot complaints (adj OR 0.56; 0.41-0.76). CONCLUSIONS: Elderly people with non-traumatic foot complaints did not seem to underreport their problems to (para)medical care providers. Furthermore, they appeared to select the appropriate type of care. Future studies will have to assess the effectiveness of the care provided.

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.

Sex differences in the medication choice for hypertension in general practice. A study with written case simulations.

The objective of this study was to explore explanations for the preference of physicians to prescribe beta-blockers to hypertensive men and diuretics to hypertensive women. A qualitative study among 12 family physicians was conducted with a combination of written case simulations, semi-structured interviews and statements on attitudes of physicians towards antihypertensive drug choice. Among the male hypertensive cases the most frequently prescribed drugs were beta-blockers, whereas among the female hypertensive cases diuretics were more often prescribed. Physician characteristics associated with a preferred prescribing of beta-blockers to hypertensive men and diuretics to hypertensive women were: older age (no residency in family medicine), the believe that beta-blockers are more effective in men with regard to lowering blood pressure and that diuretics are more effective in women, a non-evidence based attitude and a sex-related attitude towards the choice of beta-blockers and diuretics in general, and in particular towards the prescribing of beta-blockers to hypertensive men because men have a higher absolute risk of coronary heart disease than women. An additional explanation for these findings may be the higher prevalence of ankle oedema among women. Patient characteristics associated with more prescribing of beta-blockers to hypertensive men and diuretics to hypertensive women were: current employment and a "high-risk" profile in terms of blood pressure level and additional cardiovascular risk factors. Although, most considerations underlying a preferred prescribing of beta-blockers to hypertensive men and diuretics to hypertensive women were not evidence-based, the actual choice of antihypertensive drug (diuretic or beta-blocker) was evidence-based. These considerations may also play a role in the sex difference in the choice of calcium antagonists and angiotensin converting enzyme inhibitors and require further investigation.

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.

Do doctors pay attention to the religious beliefs of their patients? A survey amongst Dutch GPs.

BACKGROUND: Patients' religious beliefs can offer support at times of illness and disease. Therefore religious beliefs of patients are important in doctor-patient interaction. OBJECTIVE: To assess to what extent GPs pay attention to religious beliefs of patients in their daily work. METHODS: A postal questionnaire was sent to 120 GPs. The questionnaire consisted of five clusters of items with precoded Likert-scale answer categories related to several clinical situations. RESULTS: Response rate was 72% (n = 87). Upon registration in the practice, 16% of the GPs paid attention to the religious beliefs of patients, while in situations concerning end-of-life decisions like terminal illness or requests for euthanasia most GPs pay attention to religious beliefs of patients (79%). In general GPs brought up in Protestant families tend to pay more attention to religious beliefs of patients than GPs with a Catholic background (65% vs 36%; 95% CI 5-51) and Protestant GPs pay more attention to these aspects than Catholic GPs (81% vs 47%; 95% CI 5-63). CONCLUSIONS: Most GPs tend to pay attention to religion when their medical possibilities in patient care come to an end. GPs and trainees might be conscious of these aspects in patient management. Since most GPs are familiar just with Western religions, the increasing number of non-Western religious denominations might have consequences for patient care in general practitioners' work.

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.

Effectiveness of a co-ordinated nation-wide programme to improve influenza immunisation rates in The Netherlands.

OBJECTIVE: To assess t he effectiveness of a nation-widemultifaceted intervention programme involving general practitioners (GPs) on influenza immunisation practice. DESIGN: Pragmatic before-after trial using pre- and post-measurement questionnaires. SETTING AND SUBJECTS: Random sample of Dutch general practices. INTERVENTION: During a 2.5-year period (1995-1997) a variety of methods was implemented to enhance physician adoption of the immunisation guideline, including employment of facilitators, information-based methods, small-group consensus meetings, individual instructions and introduction of supportive computer software. MAIN OUTCOME MEASURES: Influenza immunisation practice and influenza vaccine uptake. RESULTS: In 988 practices all influenza vaccination characteristics markedly improved from 1995 to 1997. The most significant changes were found in computerised marking of high-risk patients (from 54% to 82% of practices), computerised selection (41% to 77%) and sending personal reminders (40% to 77%). Vaccine uptake increased from 9% to 16% of the practice population (78% increase, p < 0.001). Uptake was most prominent in urban and single-handed practices and in those with more patients insured through the National Health Service, low GP workload and low baseline uptake. CONCLUSION: Our data suggest that a co-ordinated approach involving primary care physicians can succeed in enlarging the public health impact of a population-based preventive measure.

[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.

Why do healthy elderly people fail to comply with influenza vaccination?

OBJECTIVE: to assess motivating factors of healthy elderly people to comply with influenza vaccination. DESIGN: survey of healthy elderly people invited by mail by their general practitioner to come for influenza vaccination. Compliance and the personal characteristics of gender, age and medical insurance were recorded by the general practitioner. A postal questionnaire assessing socio-psychological factors was sent to all non-compliant patients and to a random sample of 30% of the compliant patients. SETTING: seven family practices with a total of 26,000 patients in The Netherlands. PATIENTS: 505 healthy elderly people over 65. MAIN OUTCOME MEASURES: odds ratios (ORs) for non-compliance by personal characteristics and socio-psychological factors, adjusted by multiple logistic regression analysis; decisive reason whether to comply. RESULTS: non-compliance was 16%. Correlations between personal characteristics and non-compliance were low, except for age: those under 75 were less compliant than those over 75. Elderly people endorsing the statement about the vaccine's serious side-effects displayed the highest non-compliance [adjusted OR 216; 95% confidence interval (CI) 16.2 to 2883]; patients judging their own health to be good were also less compliant (adjusted OR 57.9; 95% CI 4.4 to 770). The belief of not being susceptible to influenza was the most frequently mentioned reason for not complying, while the general practitioner's mail cue was the most common reason for complying. CONCLUSIONS: in healthy elderly people, fear of the side-effects of influenza vaccination and perceived good health seem to be the main factors leading to non-compliance. Better and more specific information about the paucity of systemic side-effects should accompany the invitations.

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.

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.