Comparison of prescribing habits of general practitioners in The Netherlands versus England and Wales.

The alleged prescribing habits of 44 randomly chosen Dutch family doctors were compared with those of 59 family doctors from England and Wales by inference from their prescribing responses to 10 hypothetical patients presented in a mail survey. The response options were: (a) neither prescribing nor advising over-the-counter (OTC) medication; (b) advising OTC medication; or (c) prescribing medication. Although sample numbers were small, the sample appeared to be broadly representative of GPs in each country. There were significant differences in stated treatment habits between doctors of the 2 countries, especially with regard to treatment of sore throat, temporal arteritis, epigastric pain, travellers' diarrhoea and polyarthralgia. The results suggest substantial differences in management of common general practice problems exist between England/Wales and The Netherlands, despite their similar healthcare systems. These differences point to the need for rationalisation of management through improved education and audit.

A study of communication between general practitioners and specialists.

A random sample of referral letters from general practitioners to outpatient departments of general medicine, dermatology, neurology, and gastroenterology at an Amsterdam teaching hospital were analysed together with the specialists' replies for 144 referrals. The pairs of letters were judged by a panel of four general practitioners and four specialists. Letters were assessed according to quality and content, clarity, request for return to general practitioner care, time intervals between referral and consultation and between consultation and the specialist's reply. The judges were also asked to assess whether in their opinion the letters were of value in teaching or were discourteous. Though in general intraobserver agreement on what constitutes a good letter was low, deficiencies were revealed in the quality of letters and there were delays in transmission and missed educational opportunities.

Screening for hypertension by volunteers in a middle-class community.

Screening for hypertension in citizens 30-69 years of age by trained volunteers was initiated by the community of a middle-class town in Holland. At the same time counselling on cardiovascular risk factors was offered to the public. The campaign ran smoothly and at low cost, resulting in 4% hypertensives detected. The population appeared to be well-informed about cardiovascular risk factors in general, but were ignorant of prevailing personal risk factors. Review of results after one and two years shows that a considerable number of identified patients are lost to follow-up in primary health care. It is concluded that an integrated approach for anticipatory care is required for both screening and patient management by primary health care teams.

Dietary treatment of patients with mild to moderate hypertension in a general practice: a pilot intervention study (1). The first three months.

Thirty-five patients with mild to moderate hypertension were randomised into a three months' dietary advised and a three months' control group. The diet was of a composition currently considered to be appropriate, and was monitored by a dietitian. Statistically significant decreases in diastolic blood pressure, mean arterial pressure, sodium excretion, and low density lipoprotein (LDL)-cholesterol occurred in the intervention group, although differences in change between the intervention and the control group were, except for LDL-cholesterol, not statistically significant. Thus, it did not become clear whether and to what extent change in diet was responsible for the lowering of the blood pressure in the intervention group.

Dietary treatment of patients with mild to moderate hypertension in a general practice: a pilot intervention study (2). Beyond three months.

In a general primary care practice the feasibility and the effects of dietary counselling in mild and moderate hypertension were studied for a period of 18 months. Significant decreases in blood pressure and sodium excretion compared to baseline occurred, while serum lipids showed transient improvement. Of the original 35 participants, 28 finished the study.

Morbidity at an Amsterdam inner city clinic in relation to drug use.

In a small clinic in a deprived area of Amsterdam, a city with a high incidence of recreational drug use, sexually transmitted diseases and social problems, the association between drug use and disease was notable. Frequent presentation with sexually transmitted diseases, repeated trauma, unexplained recurrence of infections of the skin and respiratory tract, or severe dental caries may alert the physician to the possibility of recreational drug use and with it an increased possibility of HIV related illness. The group of drug users staying permanently in the city appeared to be ageing, without being replenished by youngsters. Very young drug users were mainly 'drug tourists' from neighbouring countries who were without medical insurance or money.

ADAMO revisited: an interpretative review of a data management system.

In this paper the use for research purposes of an existing data management system, ADAMO (A Database Management system for Oncology), is described. The aim of this paper is to discuss the experiences, obtained with this 'home-made' system and to describe some of the extensions that were recently made. Reasons are presented why the system is still extensively used by clinicians although a number of commercial database management systems is now available on personal computers. These database systems are more flexible than the system described here. It is concluded that it is precisely this flexibility of current systems that prevents an optimal use by busy clinicians. Clinicians need a research system that contains just the functions that they need. These functions have to be available via simple commands, so that no additional programming--even at the high level of a query language--is necessary.

Effects of enalapril with and without hydrochlorothiazide in hypertensive patients with non-insulin-dependent diabetes mellitus.

The purpose of this study was to evaluate the effects of the ACE inhibitor enalapril (E) on blood pressure and metabolic control in 15 hypertensive patients with non-insulin-dependent diabetes mellitus. When the treatment goal was not reached with enalapril alone, hydrochlorothiazide (HCTZ) was added. A diastolic blood pressure (DBP) below 90 mmHg was achieved in seven patients with enalapril alone (47%), and in an additional four (27%) with concomitant hydrochlorothiazide. No significant adverse effects of enalapril occurred and all patients completed the study. Monotherapy with enalapril did not affect metabolic control or renal function. Addition of HCTZ to E did not consistently result in further lowering of blood pressure and caused deterioration of both the degree of metabolic control and renal function. We, therefore, conclude that monotherapy with enalapril can be a safe and satisfactory treatment for hypertensive patients with NIDDM. Caution is needed, however, when HCTZ is added, since this may adversely affect metabolic control and renal function whereas the effect on blood pressure may be variable.

Automation of the patient history--evaluation of ergonomic aspects.

In this study it was investigated in quantitative terms how patient reactions were on automated history-taking. The study is part of a comprehensive project, in which also physicians participated in the validation of such computerized medical records. In total 99 patients, visiting the outpatient clinic of Internal Medicine for the first time, took part in this in-depth study, in which they could express themselves via an interactive and modified terminal and keyboard. The questionnaire that was used in the system contains 28 different screens. Patient complaints are entered together with data on frequency, severity, onset, and duration. The patient may indicate his physical complaints on a stylized picture of the human body. Of the 99 patients, 67 answered the full questionnaire, and another 16 the main part. On the average, 66 min were needed. Younger patients do complete the history in a significantly shorter time than older patients, resulting in relatively more completed histories for the younger group. Quick patients answered on the average 3.5 questions per minute, the slow patients only 2.5. This was strongly correlated with patient familiarization, that has also been investigated: patients who had a quick familiarization were able to finish within 50 min. Patients who needed no help at all in using the system had even answering rates of 3.9/min.

Comparisons between written and computerised patient histories.

Patient histories were obtained from 99 patients in three different ways: by a computerised patient interview (patient record), by the usual written interview (medical record), and by the transcribed record, which was a computerised version of the medical record. Patient complaints, diagnostic hypotheses, observer and record variations, and patients' and doctors' opinions were analysed for each record, and records were compared with the final diagnosis. About 40% of the data in the patient record were not present in the medical record. Two thirds of the patients said that they could express all or most of their complaints in the patient record. The doctors found that the medical record expressed the main complaints better (52%) than the patient record (15%) but that diagnostic hypotheses were more certain in the patient record (38%) than in the medical one (26%). The number of diagnostic hypotheses in the patient record was about 20% higher than that in the medical record. Intraobserver agreement (51%) was better than interobserver agreement (32%), while the inter-record agreement varied from 25% (between the medical and patient records) to 35% (between the transcribed and patient records). One third of final diagnoses were seen in the medical record, with 29% and 22% for the transcribed and patient records, respectively. Interobserver agreement in the final diagnosis was 35%. The results of the study suggest that computerised history taking is suitable for certain patients in addition to, and not as a substitute for, the oral interview with a doctor.

Appraisal of computerized medical histories: comparisons between computerized and conventional records.

Automated patient histories in internal medicine have been compared with written medical records by investigating the diagnostic statements that were generated for both types of records by three internists. Also the intra and interobserver variability was evaluated. In addition, the opinion of the internists about the usability of the different records was investigated. To have a fair comparison, the written record was transcribed to a computerized form and also offered to the internists. Each internist evaluated in total 72 records (from 18 patients) and altogether 529 diagnostic hypotheses were generated. The intraobserver agreement was for the written record 55%, for the automated history 46% and for the transcribed record 38%. Interobserver agreement was 23.5%, the agreement between the automated patient history and the written record was 24%, between the former and the transcribed record it was 36%.

Patient appreciations of computerized medical interviews.

In a research project on the automation of patient histories, 99 patients in internal medicine were questioned about their opinions on computerized medical records, after having answered an automated questionnaire. Patients were very positive on being able to express their medical complaints and the large majority found it useful (94%); 68% could express all or most of their complaints, but some of their physical complaints could not be entered (47% women against 25% men). Of the male patients 74% found the range of answers from which to choose sufficient, against 52% of the women. The printed report was positively rated, with a higher appreciation by men.

A data management system to assist hypertension treatment in primary health care.

A data management system has been developed with respect to the treatment of hypertension and other cardiovascular risk factors. With this data management system as a tool, cooperation between the general practitioner and a specialist physician could be implemented. The system was successfully tested in a group-practice of two general practitioners. Individual follow-up became more tangible. Observations in the patients as a group warranted a modest opinion about hypertension management in view of the number of undetected hypertensives, the number of drop-outs, and the failures in treatment. The set-up functioned satisfactorily. Further application of the system on a wider scale is feasible. Improvement of treatment by a cautiously operating specialist physician is within reach of general practice, even if health care is not regionalized.

Referral to medical outpatients department at teaching hospitals in Birmingham and Amsterdam.

A method of comparing the referral of patients by general practitioners to medical outpatients departments at teaching hospitals in Amsterdam and Birmingham was devised. This was applied to 89 referral letters to medical specialists at the Free University Medical School Policlinic in Amsterdam and to 88 referral letters to clinics at Birmingham University Medical School, UK. The standards of referral were lower in the Netherlands than in Britain, and this may be related to differences in the health care systems, in the culture, or in the organisation of general practice. The delay between the general practitioner's referral and the consultation to the outpatient department was four times greater in Britain than in the Netherlands.

Prazosin once or twice daily?

In 20 patients with long-standing essential hypertension, a comparison was made in a randomized cross-over study of the effect of once and twice daily prazosin administration on blood pressure levels. Concurrent medication (beta-blocker and/or saluretic once daily) remained constant throughout the study. Blood pressure measurements were carried out by a nurse using a Hawksley random zero sphygmomanometer, both in the clinic and at home, and using a Roche Kontron Arteriosonde SR-2 at home. Observations made in the morning and in the evening showed no significant difference in blood pressure between the once and twice daily treatments. Eight patients complained of dizziness and faintness half an hour after taking the once daily dose. However, they felt quite well on the twice daily regimen. The mean daily dose in these 8 patients was prazosin 8.4 mg, range 6-12 mg. No indication was found that the subjective adverse side effects were correlated with the serum prazosin level. The complaints noted may possibly be overcome by taking the once daily dose late in the evening, just before retiring. Better still, the development of a slow-release formulation for daily dosages of 6 mg and over is suggested.