Correspondence between primary and secondary care about patients with cancer: a Delphi consensus study.

INTRODUCTION: To provide optimal care for patients with cancer, timely and efficient communication between healthcare providers is essential. In this study, we aimed to achieve consensus regarding the desired content of communication between general practitioners (GPs) and oncology specialists before and during the initial treatment of cancer. METHODS: In a two-round Delphi procedure, three expert panels reviewed items recommended for inclusion on referral and specialist letters. RESULTS: The three panels comprised 39 GPs (42%), 42 oncology specialists (41%) (i.e. oncologists, radiotherapists, urologists and surgeons) and 18 patients or patient representatives (69%). Final agreement was by consensus, with 12 and 35 items included in the GP referral and the specialist letters, respectively. The key requirements of GP referral letters were that they should be limited to medical facts, a short summary of symptoms and abnormal findings, and the reason for referral. There was a similar requirement for letters from specialists to include these same medical facts, but detailed information was also required about the diagnosis, treatment options and chosen treatment. After two rounds, the overall content validity index (CVI) for both letters was 71%, indicating that a third round was not necessary. DISCUSSION: This is the first study to differentiate between essential and redundant information in GP referral and specialist letters, and the findings could be used to improve communication between primary and secondary care.

Study protocol for the OPTion randomised controlled trial on the effect of prioritising treatment goals among older patients with cancer in a palliative setting.

PURPOSE: Traditionally, general practitioners (GPs) are not involved in cancer-related treatment decisions, despite their often long relationship with patients, and their unique position to explore patients' values, especially with older patients. Therefore, we designed a randomised controlled trial to study the effect, on self-efficacy related to treatment decisions, of a conversation about treatment goals between GPs and patients with cancer in a palliative setting. METHODS: We aim to include 168 patients aged ≥70 years with a diagnosis of non-curable cancer, due to consult their oncologist about treatment options. In the intervention group, patients will consult their GP using an Outcome Prioritisation Tool (OPT). The control group will receive care as usual. The primary outcome will be the score on a decision self-efficacy scale after the consultation with the oncologist. Secondary outcomes will be symptoms of depression, anxiety, or fatigue. In an embedded observational study of the intervention group, we aim to assess the prioritisation of treatment goals (i.e., OPT scores), and their determinants, over a six-month period. CONCLUSIONS: The OPTion study should provide relevant information about the effect on self-efficacy of a consultation between GPs and older patients with cancer, concerning preferred treatment goals in a palliative setting. Dutch Trial Register NTR5419.

Is there a need for a GP consultant at a university hospital?

BACKGROUND: Patients in hospital can develop complaints unrelated to the condition they are admitted for. The treating specialist will then call upon a co-specialist who is specialized in the clinical picture associated with the new complaint. For such a complaint, the GP is usually the first contact, when the patient is not in hospital. Normally specialists only encounter patients GPs have selected for referral. The risk of the specialist overestimating the predictive value of 'unselected' complaints and symptoms of a serious condition is high. This may lead to an overuse of diagnostic treatments. Such treatments weigh more heavily on the patient, cause inadequate use of hospital facilities and, as a consequence, generate higher costs. Because of these considerations, we wished to investigate if there is a need for the GP as a consultant for new complaints during hospital admittance. METHOD: The files of a random sample of patients who had an interdisciplinary consultation during their stay in hospital were judged by an expertpanel whether the consultation fitted the expertise of a GP. RESULTS: In 28 out of 84 files the consultation fitted the expertise of a GP; most cases concerned a specific condition that is not part of the specialist's expertise, most frequently dermatological problems. In a minority of cases the specialist is confronted with a clinical problem with symptoms of which the cause is not clear, for example fever. CONCLUSION: Generally, the consultations concern serious, often very complex conditions, i.e. cases that should be assessed by a specialist. Nevertheless, the expert panel's judgment of the interdisciplinary consultations shows that in more than half of the dermatological cases and in a limited number of consultations by a specialist of internal medicine and geriatrics the problems fit the GP's expertise. Given the morbidity in academic hospitals we suppose that the results of a similar study in a peripheral hospital might even show more perspective for a GP consultant. These results offer sufficient arguments to start a pilotstudy into the role of a GP consultant in hospital.

[Summary of the practice guideline 'CVA' from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'CVA' van het Nederlands Huisartsen Genootschap.

The practice guideline 'CVA' from the Dutch College of General Practitioners provides guidelines for the management of stroke patients. The guideline is in agreement with the changing insights about the benefits of stroke-units and thrombolysis. The most important recommendations are the following. In the acute phase, most patients with a cerebrovascular accident should be referred for admission to a stroke-unit. Exceptions are patients with only slight neurological disability and patients with severe comorbidity. Patients with a CVA that started less than three hours ago should be referred for emergency thrombolytic therapy in regions where this possibility exists. In situations in which the general practitioner considers a home visit to involve an unacceptable loss of time, he may decide to refer on the basis of the results of the 'face-arm-speech-time' (FAST) test, which can be administered by telephone. For patients that remain at home, the general practitioner sees to the early start of a rehabilitation programme, and takes the initiative if necessary. The general practitioner can support stroke patients with permanent neurological deficits by considering them to be chronically ill patients requiring regular check-ups.

[Patient information after a stroke: the needs in relation to the different phases]. / Voorlichting na een beroerte: fasering en samenhang.

A 78-year-old woman felt uncertain 4 days after a stroke, while a 65-year-old man wanted to do too much 6 weeks after a stroke. An 81-year-old man was depressive 6 months after a stroke. By paying attention to the need for information and the burden on the carer, the general practitioner tried to improve the quality of life in both cases. The patient's and carer's ability to cope with post-stroke disability is enhanced by providing adequate information. The three consecutive phases in the post-stroke process have specific characteristics and corresponding needs for information: clinical information in the acute phase, coping information in the rehabilitation phase, and practical information in the chronic phase. In each phase, the information should be tuned to the individual needs of the patient and the carer. Coordination with other professionals is necessary.

[Hospital care at home; a review of the literature on the effects of a form of transmural care]. / Ziekenhuisopnamevervangende zorg; een literatuurstudie naar effecten van een vorm van transmurale zorg.

OBJECTIVE: To evaluate the effects of hospital at home on health outcomes and quality of life of patients and carers; to evaluate the costs of this form of care and the experiences of the (para)medics involved. DESIGN: Literature study. METHOD: Using Medline, EMBASE-Excerpta Medica, Sci-search and Cinahl, a search was carried out for Dutch- and English-language studies from 1990-2001 which compared hospital at home with conventional inpatient care. RESULTS: Twenty-seven (randomised) controlled trials and cross-over studies from seven different countries were found, which resulted in 37 publications. No differences were found in health outcomes between patients allocated to hospital at home and inpatient care, providing there was careful patient selection and the home met a number of basic conditions. Patients and their carers rated hospital at home positively. The expected reduction in costs to the health services was disappointing. Good organisation, communication and funding were essential boundary conditions to the success of this form of care. Health benefits appear to be primarily attained with schemes designed to avoid admission to hospital for the elderly.

[Patients with a chronic recurring psychosis in general practice: the need for close follow-up]. / Patiënten met een chronische psychose in de huisartsenpraktijk: actief volgen.

Three patients, a man aged 45, and two women aged 48 and 51 years, were suffering from chronic recurring psychoses for which they were taking medication. Their general practitioner was alerted to signals of psychotic relapse by the first patient himself and for the other two patients by the next of kin. The first two patients decided to discontinue their medication, one because he wanted to live 'a normal life' and the other because she thought the medication made her gain weight. The third patient had a psychic decompensation because her son had decided to live on his own and because she had also moved. The first two patients were successfully treated by restoring their medication, although the second patient also had to be referred to a psychiatrist. The third patient had lost confidence in the general practitioner, and was eventually admitted to a psychiatric clinic for treatment. Nowadays, increasing numbers of chronic psychiatric patients are living outside of hospitals. The adequate response of general practitioners to psychotic relapse in such patients warrants regular contact to evaluate the patient's network and to detect a relapse in an early phase. A proactive attitude and being adequately informed by locum general practitioners are also important. The extent to which the patient cooperates will depend upon the quality of the patient/general practitioner relationship.

What are the characteristics of the competent general practitioner trainer?

BACKGROUND: Increasing attention is being given to the training of doctors to become teachers. This does not apply only to the schooling of teachers in undergraduate medical education: at the postgraduate level, general practitioner trainers (GP-trainers) receive special schooling to prepare them for their role. Yet the skills, knowledge and traits that should be expected in the competent GP-trainer have not been elucidated precisely. OBJECTIVES: The aim of this research project is to determine the traits, knowledge and skills required for a competent GP-trainer. METHOD: We used a qualitative method to answer the question. Ten focus-group meetings were held involving three Departments of Vocational Training in The Netherlands. Each group consisted of GP-trainers, GP-trainees or staff members. The transcriptions of these meetings were analysed, resulting in a description of what makes a competent GP-trainer. RESULTS: Five hundred items were obtained from the focus-group meetings, each of which was formulated in the form "A good GP-trainer is/can/knows. ", etc. These items were divided into the following categories: teaching knowledge, teaching skills, teaching attitude and personality traits of the GP-trainer. A competent GP-trainer must understand basic teaching methods and be able to apply this knowledge. The skill to give good feedback was seen as an important asset for a competent GP-trainer, as were observation skills, the skill to analyse and the skill to foster reflection in the trainee. The teaching attitude of a competent GP-trainer is characterized by giving latitude to and having respect for and interest in the trainee, and being available for consultation, while the teaching approach should be individualized. Enthusiasm, flexibility, patience and self-insight were some of the personality traits identified. CONCLUSION: Many characteristics were identified as a result of this research. The next logical step will involve a Delphi consensus procedure to obtain a profile of the competent GP-trainer. This profile will then be suitable in setting the standards for curricula for future GP-trainers.

Adherence to the guidelines of a regional formulary.

BACKGROUND: Pharmacotherapeutical guidelines, called formularies, have been developed to facilitate effective, efficient and cost-conscious prescribing. Monitoring adherence to such guidelines may be a reasonable way of assessing prescribing practices. OBJECTIVE: The aim of this study was to assess how strictly the GPs participating in our department's registration network adhere to the guidelines of the regional formulary, and which indications and drugs the GPs used. METHODS: This is a descriptive study, concerning 1000 consecutive prescriptions from each of the 17 participating GPs. The third edition of the Groningen formulary (GFIII), published in 1995, was used. If the drug prescribed was advised in the formulary, we considered it to be global adherence. If the indication was mentioned in the formulary, and the drug prescribed was advised for that indication in the formulary, it was considered to be specific adherence. Both the medications prescribed and the health problems registered by the GPs, but not mentioned in the GFIII, were analysed. RESULTS: The 17 000 prescriptions chosen for analysis formed approximately 25% of all prescriptions written by the GPs in 1 year. The indications for only 24 prescriptions (0. 14%) were missing. Among the 17 GPs, the number of different drugs prescribed varied between 167 and 219 per 1000 prescriptions. The global adherence varied from 76 to 89% among the GPs, and the specific adherence varied from 55 to 71%. Of the 17 000 prescriptions, 11 457 (67%) concerned indications mentioned in the GFIII. Prescriptions for indications not mentioned in the GFIII contained 4353 (78.5%) drugs advised in the formulary. Of the 251 medications mentioned in the GFIII, only 15 (6%) were not prescribed. DISCUSSION: The GPs in our study were neither representative, nor were they chosen at random. Their patient population was comparable in age, sex and insurance status. These findings are an example of what level of adherence is obtainable. The formulary covered approximately two-thirds of the indications registered by GPs, and did not contain many unnecessary medications (6%).

Patient education to users of oral hypoglycemic agents: the perspective of Dutch community pharmacists.

The purpose of this study was to indicate which patient education activities directed at users of oral hypoglycemic agents are desirable in Dutch community pharmacies and to explore which preconditions should be considered when implementing the desired activities. A qualitative study was conducted with a panel composed of seven pharmacists and seven technicians with considerable experience in giving advice to people with diabetes mellitus type 2. A consensus method was used, which consisted of a written questionnaire and a feedback discussion, to determine which activities were considered desirable and to identify which other health care providers should be involved. The way these activities should be implemented was explored by a focus-group discussion. The following goals of patient education activities were studied: 1) adherence to the dosage regimen, 2) adherence to lifestyle advices, 3) gaining awareness of effects and 4) self-monitoring. According to the members of the panel, patient education activities should be directed primarily at stimulating adherence to the dosage regimen, increasing awareness of side effects and improving the correct technical use of blood glucose meters. Activities directed at lifestyle advice seemed to be less desirable to the pharmacy staff. Preconditions that should be considered when implementing these activities were structural cooperation with GPs and diabetic nurses and specialization of tasks of pharmacy technicians. Our results indicate that deepening of existing tasks, such as stimulating adherence to the dosage regimen is desirable in developing patient education activities at users of oral hypoglycemic agents.

Risks and causes of death in a community-based stroke population: 1 month and 3 years after stroke.

We performed a community-based study on a cohort of 221 stroke patients followed for 3 years. In this paper, we tried to answer the following questions: Is the risk of dying increased throughout the first 3 years after stroke? What are the causes of death after the 1st month? What factors at stroke onset are independent predictors of early and late mortality? The relative risk of death was estimated using age- and sex-specific mortality rates for the Netherlands. Causes of death were registered by the attending physicians, mostly general practitioners. During the 1st month 26% of the patients died. At 1, 2 and 3 years, the cumulative mortality rates were 37, 46 and 54%, respectively. Stroke patients had an increased risk of dying, approximately twice that of the general population, during the 3 years of follow-up. In women, this increased risk was more pronounced than in men. After 1 month, cardiovascular pathology, stroke and diseases resulting from stroke were the causes of death in 70% of the patients, i.e. substantially higher than in the general population, matched for age and sex. Factors predicting mortality after stroke varied over time. Severity of the stroke, preexisting atrial fibrillation and congestive heart failure were associated with early mortality (within 30 days). For 1-month survivors, incontinence and preexisting atrial fibrillation were associated with mortality in the 1st year after stroke. After 1 year, only age was associated with mortality.

Comparative study of a foam mattress and a water mattress.

In order to determine the effectiveness of high-quality foam replacement mattresses in the treatment of pressure ulcers, one such mattress (TheraRest) was compared with a water mattress (Secutex). One hundred and twenty nursing home patients with pressure ulcers were randomised into two groups and nursed on one of the mattresses for four weeks. After four weeks, 45% of the patients using the foam mattress were completely healed, compared with 48.3% of those using the water mattress. This difference is not significant. Since high-quality foam mattresses are cheaper in the long term than water mattresses, and are easier for nursing staff to manage, it is suggested that these mattresses are preferable.

[How to continue after an error in family practice?]. / Hoe gaat de huisarts verder na een fout?

Not just malfunctioning doctors make mistakes and errors, all doctors do. Patients suffer through errors, while the doctor is burdened by feelings of guilt and self-reproach. Furthermore the taboo on errors in medicine impedes doctors from learning from mistakes. Adequate management of these situations is of great importance. In order to minimise emotional damage to the patient and his relatives and to improve the quality of medical practice, acknowledgement of having made a mistake comes first; the general practitioner should be aware of personal defence mechanisms such as projection, denial or rationalisation. He should share his experience with some colleagues; in an atmosphere of trust the emotions of regret, shame and anger can be aired. Next the peer group assists in analysing the incident step by step. This analysis makes it possible to learn from the error and perhaps to take measures to prevent recurrence. Thereafter management with respect to the patient or his relatives should be established with aid of the group. Guidelines are: make an appointment with the patient without delay; take ample time and avoid disturbance; listen to the patient and respect his feelings; express regret with regard to the consequences for the patient; contact the patient again after an interval to check if new questions have arisen. This approach is helpful in restoring the patient-doctor relation after a mistake.

A stroke-adapted 30-item version of the Sickness Impact Profile to assess quality of life (SA-SIP30).

BACKGROUND AND PURPOSE: In view of the growing therapeutic options in stroke, measurement of quality of life has become increasingly relevant as an outcome parameters. The Sickness Impact Profile (SIP) is one of the most widely used measures to assess quality of life. To overcome the major disadvantage of the SIP, its length, we constructed a short stroke adapted 30-item SIP version (SA-SIP30). METHODS: Data on the original SIP version were collected for 319 communicative patients at 6 months after stroke. The 12 subscales and the 136 items of the original SIP were reduced to 8 subscales with 30 items in a three step procedure, on the basis of relevancy and homogeneity. Reliability of the SA-SIP30 was evaluated by means of an analysis of homogeneity (Cronbach's alpha coefficient). Different types of validity were assessed: construct, clinical, and external validities. RESULTS: Homogeneity of the SA-SIP30 was demonstrated by a high Cronbach's alpha (0.85). Principal component analyses revealed the same two dimensions as in the original SIP (a physical and a psychosocial dimension). The SA-SIP30 could explain 91% of the variation in scores of the original SIP in the same cohort of patients, and 89% in a different cohort. Furthermore, the SA-SIP30 was related to other functional health measures similar to how the original SIP was. We could demonstrate that the SA-SIP30 was able to distinguish patients with lacunar infarctions from patients with cortical or subcortical lesions. CONCLUSIONS: We conclude that the SA-SIP30 is a feasible and clinimetrically sound measure to assess quality of life after stroke.

The workload of trainees in general practice.

During their first training period in general practice the authors felt that they did not encounter the balanced workload which is the foundation for learning to be a GP. Previous studies confirmed the existence of differences in overall and specific workload between trainees and trainers. From their own experience and from the relevant literature they addressed several factors which might affect the workload of trainees. A study was undertaken to determine differences in workload between trainees and trainers, and to investigate whether certain characteristics of practice and of trainees affect the workload of trainees. Details of surgery consultations with 34 trainee-trainer partnerships were recorded in the north of the Netherlands over 2 weeks. Questionnaires were filled in by trainers, trainees and practice assistants from these 34 general practices. The total number of contacts recorded was 10,103. It was found that trainees see fewer elderly and female patients, less chronic and oncological conditions, but more minor illnesses. They see only 30% of patients with problem behavior. Factors that influence the trainees' workload, as compared to their trainers' are: list size; selection in the allocation of patients; trainee's experience prior to starting the training stage, and the trainee's sex. Except for problem behaviour, trainees generally see a cross-section of their trainer's practice population. Selection would provide a more balanced workload for trainees.

[Polypharmacy in the elderly with chronic diseases: conflicting interests]. / Polyfarmacie bij ouderen met chronische ziekten: tegenstrijdige belangen.

Polypharmacy patients are elderly people with multiple chronic diseases, such as hypertension, heart failure, atrial fibrillation, diabetes mellitus and chronic obstructive pulmonary disease. Many specialists are involved, each of them trying to optimise the function of a particular organ system. The general practitioner has the overall picture and assesses the consequences for the quality of life of the patient. Specialists and pharmacists should consult with the general practitioner, who ought to be in charge of treatment.