Radiating low back pain in general practice: incidence, prevalence, diagnosis, and long-term clinical course of illness.

OBJECTIVE: The aim of this study was to calculate the incidence and prevalence of radiating low back pain, to explore the long-term clinical course of radiating low back pain including the influence of radiculopathy (in a subsample of the study population) and non-radiating low back pain thereon, and to describe general practitioners' (GPs') treatment strategies for radiating low back pain. DESIGN: A historic prospective cohort study. SETTING: Dutch general practice. SUBJECTS: Patients over 18 years of age with a first episode of radiating low back pain, registered by the ICPC code L86. MAIN OUTCOME MEASURES: Incidence and prevalence, clinical course of illness, initial diagnoses established by the GPs, and treatment strategies. RESULTS: Mean incidence was 9.4 and mean prevalence was 17.2 per 1000 person years. In total, 390 patients had 1193 contacts with their GPs; 50% had only one contact with their GP. Consultation rates were higher in patients with a history of non-radiating low back pain and in patients with a diagnosis of radiculopathy in the first five years. In this study's subsample of 103 patients, L86 episodes represented radiculopathy in 50% of cases. Medication was prescribed to 64% of patients, mostly NSAIDs. Some 53% of patients were referred, mainly to physiotherapists and neurologists; 9% of patients underwent surgery. CONCLUSION: Watchful waiting seems to be sufficient general practice care in most cases of radiating low back pain. Further research should be focused on clarifying the relationship between radicular radiating low back pain, non-radicular radiating low back pain, and non-radiating low back pain.

Epidural steroids for lumbosacral radicular syndrome compared to usual care: quality of life and cost utility in general practice.

OBJECTIVE: To investigate the effect of adding segmental epidural steroid injections (SESIs) to usual care compared with usual care alone on quality of life and cost utility in lumbosacral radicular syndrome (LRS) in general practice. DESIGN: A pragmatic randomized controlled trial. Results were analyzed using mixed models. SETTING: Primary care. PARTICIPANTS: Patients (N=50) in the acute phase of LRS. INTERVENTIONS: One epidural injection containing 80mg of triamcinolone in normal saline. MAIN OUTCOME MEASURE: Back pain at 4 weeks after the start of the treatment. RESULTS: Both groups experienced a significant increase in quality of life in (especially) the physical domains of the Medical Outcomes Study 36-Item Short-Form Health Survey. The intervention group scored significantly better than the control group at certain time points in the physical domain. The differences were small. The cost-utility analysis showed that with a negligible loss of utility (3d in perfect health), societal costs (193,354 euros per quality-adjusted life year lost) would be saved because of more productivity in the intervention group. CONCLUSIONS: Although the beneficial effects of SESIs are small and the natural course of LRS is predominantly favorable, we think decision makers can consider implementing SESIs in daily practice with the purpose of saving resources. Caution must be taken, and further research should be directed at identifying patient subgroups who might benefit from SESIs, with additional focus on (costs of) complications and adverse effects.

Patients' preferences for post-treatment breast cancer follow-up in primary care vs. secondary care: a qualitative study.

OBJECTIVE: To explore patients' preferences for follow-up in primary care vs. secondary care. METHODS: A cross-sectional design was employed, involving semi-structured interviews with 70 female patients with a history of early-stage breast cancer. Using descriptive content analysis, interview transcripts were analysed independently and thematically by two researchers. FINDINGS: Patients expressed the strongest preference for annual visits (31/68), a schedule with a decreasing frequency over time (27/68), and follow-up > 10 years, including lifelong follow-up (20/64). The majority (56/61) preferred to receive follow-up care from the same care provider over time, for reasons related to a personal doctor-patient relationship and the physician's knowledge of the patient's history. About 75% (43/56) preferred specialist follow-up to other follow-up models. However, primary care-based follow-up would be accepted by 57% (39/68) provided that there is good communication between GPs and specialists, and sufficient knowledge among GPs about follow-up. Perceived benefits of primary care-based follow-up referred to the personal nature of the GP-patient relationship and the easy access to primary care. Perceived barriers included limited oncology knowledge and skills, time available, motivation among GPs to provide follow-up care and patients' confidence with the present specialist follow-up. CONCLUSIONS: More than half of the patients were open to primary care-based follow-up. Patients' confidence with this follow-up model may increase by using survivorship care plans to facilitate communication across the primary/secondary interface and with patients. Training GPs to improve their oncology knowledge and skills might also increase patients' confidence.

Costs and cost-effectiveness of epidural steroids for acute lumbosacral radicular syndrome in general practice: an economic evaluation alongside a pragmatic randomized control trial.

STUDY DESIGN: A pragmatic, randomized, controlled, single-blinded trial in Dutch general practice. OBJECTIVE: Assessing the costs and cost-effectiveness of adding segmental epidural steroid injections to care as usual in radiculopathy in general practice. SUMMARY OF BACKGROUND DATA: Lumbosacral radicular syndrome (radiculopathy) is a benign, generally self-limiting but painful condition caused by a herniated lumbar intervertebral disc, which results in an inflammatory process around the nerve root. Segmental epidural steroid injections could lessen pain. Low back pain and sciatica form a large financial burden on national health care systems. Improving pain treatment could lower costs to society by diminishing loss of productivity. METHODS: Patients with acute radiculopathy were included by general practitioners. All patients received usual care. Patients in the intervention group received one segmental epidural steroid injection containing 80 mg of triamcinolone as well. Follow-up was performed using postal questionnaires at 2, 4, 6, 13, 26, and 52 weeks. Main outcomes were pain, disability and costs. Economic evaluation was performed from a societal perspective with a time horizon of 1 year. RESULTS: Sixty-three patients were included in the analysis. Mean total costs were €4414 or $5985 in the intervention group and €5121 or $6943 in the control group. This difference was mostly due to loss of productivity. The point estimate for the incremental cost-effectiveness ratio was -€730 or -$990 (1-point diminishment on the numerical rating scale back pain score in 1 patient in the course of 1 yr would save €730 or $990). Bootstrapping showed a 95% confidence interval of -€4476 to €951 or -$6068 to $1289. The cost-effectiveness acceptability curve showed that without additional investment the probability that epidural steroids are cost-effective is more than 80%. CONCLUSION: The effect on pain and disability of epidural steroids in lumbosacral radicular syndrome is small but significant, and at lower costs with no reported complications or adverse effects. Segmental epidural steroid injections could be considered by policy makers as an additional treatment option.

Maintenance use of antidepressants in Dutch general practice: non-guideline concordant.

BACKGROUND: There is hardly evidence on maintenance treatment with antidepressants in primary care. Nevertheless, depression guidelines recommend maintenance treatment i.e. treatment to prevent recurrences, in patients with high risk of recurrence, and many patients use maintenance treatment with antidepressants. This study explores the characteristics of patients on maintenance treatment with antidepressants in general practice, and compares these characteristics with guideline recommendations for maintenance treatment. METHODS: We used data (baseline, two-year and four-year follow-up) of primary care respondents with remitted depressive disorder (≥6 months) from the Netherlands Study of Depression and Anxiety (n = 776). Maintenance treatment was defined as the use of an antidepressant for ≥12 months. Multilevel logistic regression was used to describe the association between sociodemographic, clinical and care characteristics and use of maintenance treatment with antidepressants. RESULTS: Older patients, patients with a lower education, those using benzodiazepines or receiving psychological/psychiatric care and patients with a concurrent history of a dysthymic or anxiety disorder more often received maintenance treatment with antidepressants. LIMITATIONS: Measurements were not made at the start of an episode, but at predetermined points in time. Diagnoses were based on interview (CIDI) data and could therefore in some cases have been different from the GP diagnosis. CONCLUSIONS: Since patients with chronic or recurrent depression do not use maintenance treatment with antidepressants more often, characteristics of patients on maintenance treatment do not fully correspond with guideline recommendations. However, patients on maintenance treatment appear to be those with more severe disorder and/or more comorbidity.

Examination of skin lesions for cancer: which clinical decision aids and tools are available in general practice?

BACKGROUND: While skin cancer incidence is rising throughout Europe, general practitioners (GP) feel unsure about their ability to diagnose skin malignancies. Objectives To evaluate whether the GP has sufficient validated clinical decision aids and tools for the examination of potentially malignant skin lesions. METHODS: We conducted a review searching Medline and the Cochrane Library. In addition, reference lists and personal archives were examined. Outcome measures were sensitivity and specificity but also the advantages and disadvantages of different clinical decision aids and tools. RESULTS: No clinical decision aids or tools for the examination of non-pigmented lesions are available. Clinical decision aids and tools for the examination of pigmented lesions have mostly been studied in secondary care and, in primary care, randomised clinical trials comparing the additional value of a clinical decision aid or tools to care are scarce. CONCLUSION: Sufficiently validated clinical decision aids and tools for the examination of potentially malignant skin lesions are lacking in general practice. The clinical decision aids and tools available in primary care need to be studied.

[Hypothyroidism after radiotherapy of the neck area: monitoring of thyroid function is important]. / Hypothyreoïdie na bestraling van de hals: controle van de schildklierfunctie is belangrijk.

We present three patients with primary hypothyroidism after previous radiotherapy of the neck area. Myxoedema coma occurred in one of these patients. Lifelong follow-up of thyroid function is recommended after radiotherapy of the neck. Monitoring of thyroid function should be performed at least once a year by the radiation oncologist or by the general practitioner.

Skin lesions suspected of malignancy: an increasing burden on general practice.

BACKGROUND: Skin cancer is believed to impose a heavy burden on healthcare services, but the burden of skin lesions suspected of malignancy on primary healthcare has never been evaluated. Therefore the aim of this study was to determine the demand for care in general practice due to these suspected skin lesions (i.e. lesions that are suspected of malignancy by either the patient or the GP). METHODS: Registry study based on data (2001-2010) from the Registration Network Groningen. This is a general practice registration network in the northern part of the Netherlands with an average annual population of approximately 30,000 patients. All patient contacts are coded according to the International Classification of Primary Care (ICPC). Consultations for skin lesions suspected of malignancy were selected according to the assigned ICPC codes. Subsequently, the number of consultations per year and the annual percent change in number of contacts (using the JoinPoint regression program) were calculated and analysed. Additionally, the percentage of patients referred to secondary care or receiving minor surgery within one year after the first contact were calculated. RESULTS: From 2001 onwards we found an annual increase in demand for care due to skin lesions suspected of malignancy of 7.3% (p < 0.01) and in 2010 the benign:malignant ratio was 10:1. In total 13.0% of the patients were referred and after 2006, minor surgery was performed on 31.2% of the patients. Most surgeries and referrals took place within 30 days. CONCLUSIONS: Suspected skin lesions impose an increasing burden on primary healthcare and most likely on healthcare costs as well. General practitioners should therefore be trained in diagnosing skin lesions suspected of malignancy, as a high diagnostic accuracy can save lives in the case of melanoma, and may also prevent unnecessary, costly, excisions and referrals to secondary healthcare.

Are lower urinary tract symptoms in men associated with cardiovascular diseases in a primary care population: a registry study.

BACKGROUND: Although lower urinary tract symptoms (LUTS) seem to be related to cardiovascular disease (CVD) in men, it is unclear whether this relationship is unbiased. In order to investigate this relationship, we used longitudinal data for establishing the possible predictive value of LUTS for the development of CVD in a primary care population. METHODS: We performed a registry study using data from the Registration Network Groningen (RNG). All data from men aged 50 years and older during the study period from 1 January 1998 up to 31 December 2008 were collected. Cox proportional hazard regression analysis was used to determine the association between the proportions of CVD (outcome) and LUTS in our population. RESULTS: Data from 6614 men were analysed. The prevalence of LUTS increased from 92/1000 personyears (py) in 1998 up to 183/1000 py in 2008. For cardiovascular diseases the prevalence increased from 176/1000 py in 1998 up to 340/1000 py in 2008. The incidence numbers were resp. 10.2/1000 py (1998) and 5.1/1000 py (2008) for LUTS, and 12.9/1000 py (1998) and 10.4/1000 py (2008) for CVD. Of all men, 23.2% reported CVD (41.1% in men with LUTS vs 19.5% in men without LUTS, p < 0.01). The hazard ratio of LUTS for cardiovascular events, compared to no LUTS, in the adjusted multivariate model, was 0.921(95% CI: 0.824 - 1.030; p = 0.150). CONCLUSION: Based on the results, LUTS is not a factor that must be taken into account for the early detection of CVD in primary care.

Skin autofluorescence as proxy of tissue AGE accumulation is dissociated from SCORE cardiovascular risk score, and remains so after 3 years.

BACKGROUND: Skin autofluorescence (SAF), as a proxy of AGE accumulation, is predictive of cardiovascular (CVD) complications in i.a. type 2 diabetes mellitus and renal failure, independently of most conventional CVD risk factors. The present exploratory substudy of the Groningen Overweight and Lifestyle (GOAL)-project addresses whether SAF is related to Systematic COronary Risk Evaluation (SCORE) risk estimation (% 10-year CVD-mortality risk) in overweight/obese persons in primary care, without diabetes/renal disease, and if after 3-year treatment of risk factors (change in, Δ) SAF is related to ΔSCORE. METHODS: In a sample of 65 participants from the GOAL study, with a body mass index (BMI) >25-40 kg/m2, hypertension and/or dyslipidemia, but without diabetes/renal disease, SAF and CVD risk factors were measured at baseline, and after 3 years of lifestyle and pharmaceutical treatment. RESULTS: At baseline, the mean SCORE risk estimation was 3.1±2.6%, mean SAF 2.04±0.5AU. In multivariate analysis SAF was strongly related to age, but not to other risk factors/SCORE. After 3 years ΔSAF was 0.34±0.45 AU (p<0.001). ΔSAF was negatively related to Δbodyweight but not to ΔSCORE%, or its components. At follow-up, SAF was higher in 11 patients with a history of CVD compared to 54 persons without CVD (p=0.002). CONCLUSIONS: Baseline and 3-year-Δ SAF are not related to (Δ)SCORE, or its components, except age, in the studied population. ΔSAF was negatively related to Δweight. As 3-year SAF was higher in persons with CVD, these results support a larger study on SAF to assess its contribution to conventional risk factors/SCORE in predicting CVD in overweight persons with low-intermediate cardiovascular risk.

Which patient and treatment factors are related to successful cardiovascular risk score reduction in general practice? Results from a randomized controlled trial.

BACKGROUND: Cardiovascular disease is a leading cause of death. It is important to identify patient and treatment factors that are related to successful cardiovascular risk reduction in general practice. This study investigates which patient and treatment factors are related to changes in cardiovascular risk estimation, expressed as the Systematic Coronary Risk Evaluation (SCORE) 10 year risk of cardiovascular mortality. METHODS: 179 general practice patients with mild-moderately elevated cardiovascular risk followed a one-year programme which included structured lifestyle and medication treatment by practice nurses, with or without additional self-monitoring. From the patient and treatment data collected as part of the "Self-monitoring and Prevention of RIsk factors by Nurse practitioners in the region of Groningen" randomized controlled trial (SPRING-RCT), the contribution of patient and treatment factors to the change in SCORE was analysed with univariate and multivariate analyses. RESULTS: In multivariate analyses with multiple patient and treatment factors, only SCORE at baseline, and addition of or dose change in lipid lowering or antihypertensive medications over the course of the study were significantly related to change in SCORE. CONCLUSIONS: Our analyses support the targeting of treatment at individuals with a high SCORE at presentation. Lipid lowering medication was added or changed in only 12% of participants, but nevertheless was significantly related to ΔSCORE in this study population. Due to the effect of medication in this practice-based project, the possible additional effect of the home monitoring devices, especially for individuals with no indication for medication, may have been overshadowed. TRIAL REGISTRATION: trialregister.nl NTR2188.

Survival of stroke patients after introduction of the 'Dutch Transmural Protocol TIA/CVA'.

BACKGROUND: Earlier research showed that healthcare in stroke could be better organized, aiming for improved survival and less comorbidity. Therefore, in 2004 the Dutch College of General Practitioners (NHG) and the Dutch Association of Neurology (NVN) introduced the 'Dutch Transmural Protocol TIA/CVA' (the LTA) to improve survival, minimize the risk of stroke recurrence, and increase quality of life after stroke. This study examines whether survival improved after implementation of the new protocol, and whether there was an increase in contacts with the general practitioner (GP)/nurse practitioner, registration of comorbidity and prescription of medication. METHODS: From the primary care database of the Registration Network Groningen (RNG) two cohorts were composed: one cohort compiled before and one after introduction of the LTA. Cohort 1 (n = 131, first stroke 2001-2002) was compared with cohort 2 (n = 132, first stroke 2005-2006) with regard to survival and the secondary outcomes. RESULTS: Comparison of the two cohorts showed no significant improvement in survival. In cohort 2, the number of contacts with the GP was significantly lower and with the nurse practitioner significantly higher, compared with cohort 1. All risk factors for stroke were more prevalent in cohort 2, but were only significant for hypercholesterolemia. In both cohorts more medication was prescribed after stroke, whereas ACE inhibitors were prescribed more frequently only in cohort 2. CONCLUSION: No major changes in survival and secondary outcomes were apparent after introduction of the LTA. Although, there was a small improvement in secondary prevention, this study shows that optimal treatment after introduction of the LTA has not yet been achieved.

Discharge of breast cancer patients to primary care at the end of hospital follow-up: a cross-sectional survey.

AIM: The present study explored (a) the discharge of breast cancer patients to primary care by specialists, at the end of hospital follow-up and (b) the experiences and views of general practitioners (GPs) regarding transfer of follow-up to the primary care setting. METHODS: A cross-sectional survey was performed by sending a self-administered questionnaire to 960 GPs working in the three northern provinces of the Netherlands. Data were analysed using descriptive statistics. RESULTS: Of 949 eligible questionnaires, 502 were returned, providing an adjusted response rate of 53%. In the year before the survey took place, one or more patients aged >60 years, and 5 years after breast-conserving therapy, were discharged to 22% of GPs (n=112) for follow-up. According to 56% of these GPs, transfer of follow-up was communicated by the hospital. The initiative to arrange follow-up visits and mammography appointments was mainly taken by patients. In this survey, 40% of GPs (n=200) were willing to accept exclusive responsibility for follow-up earlier than 5 years after completion of active treatment. Perceived barriers in current and future primary care-based follow-up included: communication with breast cancer specialists, patients' preference for specialist follow-up, GPs' oncology knowledge and skills and the organisation of follow-up in general practice. CONCLUSIONS: Primary care-based follow-up might be improved if breast cancer specialists discharge patients more actively to their GPs. Survivorship care plans are needed to facilitate communication across the primary/secondary interface and with patients. Training of GPs and developing administrative tools may be helpful in arranging follow-up care and using guidelines in general practice.

Cost-effectiveness of cardiovascular risk management by practice nurses in primary care.

BACKGROUND: Cardiovascular disease (CVD) is largely preventable and prevention expenditures are relatively low. The randomised controlled SPRING-trial (SPRING-RCT) shows that cardiovascular risk management by practice nurses in general practice with and without self-monitoring both decreases cardiovascular risk, with no additional effect of self-monitoring. For considering future approaches of cardiovascular risk reduction, cost effectiveness analyses of regular care and additional self-monitoring are performed from a societal perspective on data from the SPRING-RCT. METHODS: Direct medical and productivity costs are analysed alongside the SPRING-RCT, studying 179 participants (men aged 50-75 years, women aged 55-75 years), with an elevated cardiovascular risk, in 20 general practices in the Netherlands. Standard cardiovascular treatment according to Dutch guidelines is compared with additional counselling based on self-monitoring at home (pedometer, weighing scale and/ or blood pressure device) both by trained practice nurses. Cost-effectiveness is evaluated for both treatment groups and patient categories (age, sex, education). RESULTS: Costs are €98 and €187 per percentage decrease in 10-year cardiovascular mortality estimation, for the control and intervention group respectively. In both groups lost productivity causes the majority of the costs. The incremental cost-effectiveness ratio is approximately €1100 (95% CI: -5157 to 6150). Self-monitoring may be cost effective for females and higher educated participants, however confidence intervals are wide. CONCLUSIONS: In this study population, regular treatment is more cost effective than counselling based on self-monitoring, with the majority of costs caused by lost productivity. TRIAL REGISTRATION: Trialregister.nl identifier: http://NTR2188.

Increased primary healthcare utilisation among women with a history of breast cancer.

PURPOSE: Little is known about the current role of the general practitioner (GP) in breast cancer follow-up care. This study explores primary healthcare use in the period after completion of primary breast cancer treatment. METHODS: A total of 336 women with a history of early-stage breast cancer treated with curative intent were identified in the primary care database of the Registration Network Groningen (RNG) (1998-2007) and matched with a reference population of 983 women without breast cancer on birth year and GP. RESULTS: Over the entire follow-up period (starting 1 year post-diagnosis), the median numbers of face-to-face contacts, drug prescriptions, and referrals in the patient group were significantly higher than those in the reference group: 4.0 vs. 3.2/year, 12.3 vs. 8.4/year, and 0.4 vs. 0.3/year, Mann-Whitney (M-W) test p < 0.001 for all differences. At least one annual face-to-face contact was observed for 96.7 % of patients and 92.9 % of women from the reference population (Chi-square test p = 0.011). More patients than women from the reference population had face-to-face contacts for reasons related to breast cancer or were prescribed hormone antagonists and aromatase inhibitors to treat breast cancer. The main predictor of higher rates of face-to-face contacts and drug prescriptions was a higher age at diagnosis. CONCLUSIONS: This study shows increased primary healthcare utilisation among women with a history of breast cancer, especially among the elderly. When follow-up is transferred to the primary care setting, new responsibilities of GPs might be incorporated into existing primary healthcare delivery.

The midregional fragment of pro-A-type natriuretic peptide, blood pressure, and mortality in a prospective cohort study of patients with type 2 diabetes (ZODIAC-25).

OBJECTIVE: Evidence that midregional fragment of pro-A-type natriuretic peptide (MR-proANP) is a marker of mortality in patients with type 2 diabetes is limited. Therefore, we aimed to investigate the capabilities of MR-proANP in predicting mortality. We also investigated whether MR-proANP influences the relationship between blood pressure and mortality in old age. RESEARCH DESIGN AND METHODS: In 1998, 1,143 primary care patients with type 2 diabetes participated in the ZODIAC study. Because blood was drawn for 867 patients (76%) and confounders were missing for 19 patients, the final study sample comprised 848 patients. After a follow-up time of 10 years, we used Cox proportional hazard models to evaluate the relationship between MR-proANP and (cardiovascular) mortality. Harrell C statistic was used to compare models with and without MR-proANP. The regression analyses were repeated without MR-proANP for patients aged older than 75 years. RESULTS: Median MR-proANP in the total study sample was 75 pmol/L (interquartile range, 48-124 pmol/L). During follow-up, 354 (42%) out of 848 patients had died, of whom 152 (43%) deaths were attributable to cardiovascular factors. MR-proANP was independently associated with all-cause and cardiovascular mortality, irrespective of age. During old age, there was a significant inverse relationship between blood pressure and mortality. This relationship did not change after adjustment for MR-proANP. CONCLUSIONS: MR-proANP is independently associated with mortality in patients with type 2 diabetes. MR-proANP did not influence the inverse relationship between blood pressure and mortality in elderly patients.

Effect of exercise and weight loss in people who have hip osteoarthritis and are overweight or obese: a prospective cohort study.

BACKGROUND: Osteoarthritis (OA) is the most common joint disorder in the world and is recognized as a substantial source of disability. For people with OA of the knee, exercise in combination with weight loss is a proven, effective, conservative treatment option, yet evidence is lacking for people with hip OA. OBJECTIVE: The aim of this study was to obtain preliminary evidence of the effect of a program of exercise in combination with weight loss on physical function in people who have hip OA and are overweight or obese. DESIGN: This investigation was a prospective cohort study. METHODS: Thirty-five people who were 25 years or older, had clinical and radiological evidence of hip OA, and were overweight or obese (body mass index of >25 kg/m(2)) were included. They participated in an 8-month program of exercise in combination with weight loss. A body mass index of 40 kg/m(2) was used as the upper limit. The primary outcome was self-reported physical function, as measured with a subscale of the Western Ontario and McMaster Universities Osteoarthritis Index. Secondary outcome measures included pain and walking tests as quantitative measures of function. RESULTS: Participation in the combination program resulted in a 32.6% improvement in self-reported physical function after 8 months, a finding that could be considered clinically relevant. Significant improvements also were seen in pain and on walking tests. LIMITATIONS: The lack of a control group was a limitation of this study. CONCLUSIONS: This appears to be the first study investigating the effect of exercise and weight loss as a combination treatment in people with hip OA. The results provide preliminary evidence that this combination treatment is effective in people with hip OA.

Orthostatic hypotension, diabetes, and falling in older patients: a cross-sectional study.

BACKGROUND: Although orthostatic hypotension (OH) is more prevalent in old age, and in patients with diabetes, the prevalence of OH in older patients with type 2 diabetes mellitus is unknown. AIM: To establish the prevalence of OH, and its association with falling, in home-dwelling older participants with and without type 2 diabetes. DESIGN AND SETTING: A cross-sectional study in primary care in the Netherlands. METHOD: A total of 352 patients with type 2 diabetes, and 211 without participated in this study. OH was defined as a fall in blood pressure of at least 20 mmHg systolic or 10 mmHg diastolic after either 1 or 3 minutes in an upright position. Feelings of dizziness, light-headedness, or faintness during the standing period were documented as orthostatic complaints. Fall risk was assessed with a validated risk profile instrument. RESULTS: The prevalence of OH was 28% (95% CI = 24% to 33%) and 18% (95% CI = 13% to 23%) in participants with and without type 2 diabetes, respectively. OH was not related to falling, while the presence of orthostatic complaints in itself was associated with both previous fall incidents as well as a high fall risk, even after adjustment for OH. The adjusted odds ratios were 1.65 (95% CI = 1.00 to 2.72) and 8.21 (95% CI = 4.17 to 16.19), respectively. CONCLUSION: OH is highly prevalent in home-dwelling older people with and without type 2 diabetes. Those with orthostatic complaints had an increased risk for falling, whereas those with OH were not.

Cardiovascular screening in general practice in a low SES area.

BACKGROUND: Lower social economic status (SES) is related to an elevated cardiovascular (CV) risk. A pro-active primary prevention CV screening approach in general practice (GP) might be effective in a region with a low mean SES. This approach, supported by a regional GP laboratory, was investigated on feasibility, attendance rate and proportion of persons identified with an elevated risk. METHODS: In a region with a low mean SES, men and women aged ≥ 50/55 years, respectively, were invited for cardiovascular risk profiling, based on SCORE 10-year risk of fatal cardiovascular disease and additional risk factors (family history, weight and end organ damage). Screening was performed by laboratory personnel, at the GP practice. Treatment advice was based on Dutch GP guidelines for cardiovascular risk management. Response rates were compared to those in five other practices, using the same screening method. RESULTS: 521 persons received invitations, 354 (68%) were interested, 33 did not attend and 43 were not further analysed because of already known diabetes/cardiovascular disease. Eventually 278 risk profiles were analysed, of which 60% had a low cardiovascular risk (SCORE-risk <5%). From the 40% participants with a SCORE-risk ≥ 5%, 60% did not receive medication yet for hypertension/hypercholesterolemia. In the other five GPs response rates were comparable to the currently described GP. CONCLUSION: Screening in GP in a low SES area, performed by a laboratory service, was feasible, resulted in high attendance, and identification and treatment advice of many new persons at risk for cardiovascular disease.

Discontinuation of reimbursement of benzodiazepines in the Netherlands: does it make a difference?

BACKGROUND: In an attempt to control chronic benzodiazepine use and its costs in the Netherlands, health care insurance reimbursement of this medication was stopped on January 1st 2009. This study investigates whether benzodiazepine prescriptions issued by general practitioners changed during the first two years following implementation of this regulation. METHODS: Registry study based on data from all benzodiazepine users derived from the Registration Network Groningen. This general practice-based research network collects longitudinal data on the primary care administered to about 30,000 patients. Based on the number of quarterly accumulated prescription days, a comparison was made of benzodiazepine prescriptions issued between 2007/2008 and 2009/2010. Also investigated was which type of user (i.e. short-term or long-term) showed the most change. RESULTS: Information on benzodiazepine prescriptions among 5,200 patients from 16 consecutive trimesters between 2007 and 2010 was available for analysis. A significant reduction in prescription days was observed between 2007/2008 and 2009/2010. Overall, an estimated 1.73 (CI:-1.94 to -1.53; p<0.001) days were less prescribed per trimester after the termination of reimbursement. In particular, short-term users experienced a reduction in prescription days in 2009 and 2010. The number of long-term users decreased by 2.3%, while the number of individuals that did not use increased by 4.2%. CONCLUSIONS: A total reduction of almost 14 prescription days was observed over eight trimesters after implementation of the regulation to terminate the reimbursement of benzodiazepines. Short-term users were mainly responsible for this reduction in prescription days in 2009 and 2010. Although long-term users did not alter their benzodiazepine use in 2009 and 2010, the number of long-term users decreased slightly.