[Telephone accessibility of Dutch general practices: improvements can be made, but will not fully solve the problem]. / Telefonische bereikbaarheid van huisartsen: verbetering mogelijk, maar probleem niet geheel oplosbaar.

The Dutch Health Inspectorate published a research report on the accessibility by telephone of Dutch general practices. A large proportion of Dutch GPs have not organized their practices according to standard norms as far as accessibility by telephone is concerned. Several developments can explain this substandard accessibility, such as an increasing number of telephone calls and changes in staff practice routine. Technical solutions such as voice response systems or more incoming lines cannot resolve all the problems. More information on the accessibility for patients, smarter systems for repeat prescriptions and the use of email could improve the situation. The development of best practices and research into the efficacy of the proposed solutions is necessary.

Clinical databases in physical therapy.

Clinical databases in physical therapy provide increasing opportunities for research into physical therapy theory and practice. At present, information on the characteristics of existing databases is lacking. The purpose of this study was to identify clinical databases in which physical therapists record data on their patients and treatments and to investigate the basic aspects, data sets, output, management, and data quality of the databases. Identification of the databases was performed by contacting members of the World Confederation for Physical Therapy, searching Pubmed, searching the Internet, and snowball sampling. A structured questionnaire was used to study the characteristics of the databases. The search was restricted to North America, Australia, Israel, and Western Europe. Seven clinical databases on physical therapy were identified. Four databases collected data on specific patient categories, whereas the others collected data on all patients. All databases collected data on patient characteristics, referrals, diagnoses, treatments, and closure, whereas some databases also collected functional status information. The purposes of the databases were diverse, but they can be summarized as quality improvement, research, and performance management. Although clinical databases are new to the field, they offer great potential for physical therapy research. Potential can be increased by further cooperation among databases allowing international comparative studies.

[The practice guideline 'Problematic alcohol consumption' (second revision) from the Dutch College of General Practitioners; a response from the perspective of general practice]. / De standaard 'Problematisch alcoholgebruik' (tweede herziening) van het Nederlands Huisartsen Genootschap; reactie vanuit de huisartsgeneeskunde.

The recently revised version of the practice guideline 'Problematic alcohol consumption' from the Dutch College of General Practitioners offers realistic advice to general practitioners on how to manage problem drinkers. The number of patients with alcohol problems tends to increase among women of middle age. The proportion of patients that report an alcohol problem themselves is larger than is usually assumed. Questionnaires are oflimited value in the detection of an alcohol problem. The general practitioner should look at problem drinking as a chronic disease that demands structured disease management and monitoring. This perspective will lead to less frustration in handling both the problem and the patients.

[Prevalence of urinary and faecal incontinence among community-dwelling elderly patients in Nijmegen, The Netherlands, January 1999-July 2001]. / Prevalentie van incontinentie voor urine en ontlasting bij zelfstandig wonende ouderen in Nijmegen, januari 1999-juli 2001.

OBJECTIVE: To evaluate the prevalence of urinary, faecal and double incontinence in community-dwelling elderly patients. DESIGN: Cross-sectional population-based survey. METHOD: By means of a postal questionnaire, data were collected in the period January 1999-July 2001 from patients aged 60 and over from 9 general practices associated with the academic general practitioner registration network of the St Radboud University Medical Centre (the Nijmegen Monitoring Project). Excluded were patients living in a home for the elderly, as well as patients with dementia, patients who were too ill to participate and patients with a catheter. RESULTS: Of the 5278 patients who received a questionnaire, 4650 (88%) returned it. 885 (19%) respondents had involuntary loss of urine twice a month or more, 299 (6%) had involuntary loss of faeces and 153 (3%) had both. The prevalence of urinary, faecal and double incontinence increased with age in both men and women, in men especially in the age group > 80 years. Urinary incontinence was more prevalent in women (29%) than in men (9%). The prevalence of faecal incontinence showed no sex differences (women: 6%; men: 7%), but the loss of slimy faeces occurred twice as often in men as in women (60% versus 29%). Double incontinence was also more or less equally prevalent in men and women (men: 2%; women: 4%), except in the age group 65-74 years (men: 1%; women: 4%). CONCLUSION: Especially urinary, but also faecal incontinence was common in the community-dwelling elderly. The prevalence increased with age. Because of ageing of the population and the increasing life expectancy in the next decennia, the prevalence of incontinence can be expected to increase considerably.

Exacerbations and associated healthcare cost in patients with COPD in general practice.

BACKGROUND: Acute exacerbations are a characteristic clinical expression of chronic obstructive pulmonary disease (COPD). The objective of this study was to investigate the occurrence rate, management, and healthcare costs of exacerbations in patients with COPD in Dutch general practice. METHODS: Baseline data set from the COPD on Primary Care Treatment (COOPT) trial was used. Details on the occurrence and management of exacerbations were collected by systematic medical record review for the 2-year period preceding trial inclusion. RESULTS: The mean age of the 286 study subjects involved was 59.2 (SD 9.6) years, postbronchodilator FEV1 67.1% (SD 16.2) of predicted. Following ERS criteria, subjects suffered from: no (26%); mild (19%); moderate (40%); or severe (15%) airflow obstruction. The overall mean and median annual exacerbation rates were 0.88 (SD 0.79) and 0.5 (IQR 1.0), respectively. Exacerbation rate was not related to severity of airflow obstruction (p=0.628). Mean annual exacerbation costs per subject were 40 Euro, 53 Euro, 61 Euro and 92 Euro for the respective severity subgroups (p=0.012). The increase of costs in the more severe subgroups was mainly attributable to more physician consultations, diagnostic procedures, and prescription of reliever medication (e.g., bronchodilators, cough preparations). CONCLUSIONS: Occurrence of exacerbations did not depend on the severity of airflow obstruction, whereas the healthcare cost associated with exacerbations increased along with the severity of the disease.

[Adenotonsillectomy in children only under exceptional circumstances]. / Adenotonsillectomie bij kinderen: neen, tenzij.

More and more evidence is becoming available that throws doubt on the value of adenotonsillectomy in children with frequent throat infections or hypertrophic tonsils and adenoids. Tonsillectomy and adenoidectomy have a limited range of indications. Objective symptoms such as the size of the tonsils and subjective symptoms of obstruction and sore throat are not always related to each other. Children with only moderate symptoms should not be operated on.

[The progestagen-containing implant (Implanon); who is responsible for what?]. / Progestageenhoudend implantaat (Implanon); wie is waarvoor verantwoordelijk?

Implanon is a contraceptive device with a high reliability in the prevention of pregnancy. The insertion is a simple procedure but the physician must master this skill. A number of cases have been recorded in which the rod appeared to have disappeared, which sometimes led to an unwanted pregnancy and sometimes ended in claims for compensation. There are a number of tips the physician can use to make sure that the insertion is done properly. At present, training in the insertion of this device is only offered by the company that sells Implanon. The question arises whether the professional group of GP's or gynaecologists should take over this responsibility.

Prevalence of urinary, fecal and double incontinence in the elderly living at home.

The aim of this study was to evaluate the prevalence of urinary, fecal and double incontinence in the elderly, through a population-based cross-sectional survey. The study included all patients aged 60 and over of nine general practices in the Nijmegen Monitoring Project. Patients living in a home for the elderly were excluded, as well as patients with dementia, patients who were too ill to participate and patients with a catheter. There were 5278 selected patients who received a postal questionnaire. Of these, 88% returned it. Nineteen percent of the respondents had involuntary loss of urine twice a month or more, 6% loss of feces and 3% both. The prevalence of urinary, fecal and double incontinence increased with age in both men and women, and especially in men in the oldest age group. Urinary incontinence was more prevalent in women than in men. The prevalence of fecal incontinence showed no sex differences, but the type of fecal incontinence did differ between men and women. In men loss of mucus was twice as common as in women. Double incontinence was also equally prevalent in men and women, except in the age group 65-74 years. In conclusion, urinary, fecal and double incontinence are common conditions in the community-dwelling population. The prevalence rates increase with age. Urinary incontinence is more prevalent in women. There were no sex differences in the prevalence of fecal incontinence but the type of fecal incontinence was different in men and women.

[The Dutch College of General Practitioners' practice guideline 'Diagnosis of breast cancer': reaction from the field of general practice]. / De standaard 'Diagnostiek van mammacarcinoom' van het Nederlands Huisartsen Genootschap; reactie vanuit de huisartsgeneeskunde.

In the revised practice guideline on the diagnosis of breast cancer, the general practitioner has an important role when, during screening, a woman is found to have an abnormality, before, during and after treatment. Breast clinics allow the situation to be dealt with rapidly, but patients also need time to cope with it all. In young women with breast complaints, but without palpable abnormalities, the practice guideline recommends mammography to be on the safe side. However, in a group with a low prevalence, this carries primarily disadvantages; the patient does need to be properly followed. The policy for patients with a positive family history of breast cancer has been clearly worded.

[Relationship between te general practice guidelines for the diagnosis of hypertension and the indication for treatment and practice in the Nijmegen region, the Netherlands, 1983-2001]. / Samenhang tussen de huisartsrichtlijnen voor diagnostiek van hypertensie en indicatie tot behandeling en de praktijk in de regio Nijmegen, 1983-2001.

OBJECTIVE: To determine whether patients with hypertension in general practice are diagnosed and treated according to the criteria of the Dutch College of General Practitioners guidelines. DESIGN: Retrospective, descriptive. METHOD: Using data from 9 general practices belonging to the general practice research network of the Academic Medical Centre St Radboud, Nijmegen, the Netherlands, all intake data of newly diagnosed hypertensive patients were collected. Three periods (1983-1991, 1992-1996 and 1997-2001) were studied and compared to the 1991 and 1997 versions of the guidelines. RESULTS: During the study period, 1959 patients with hypertension were registered. In 4% of the men and 3% of the women the hypertension criteria of the time were not met. These figures decreased during the course of the research period. Mean blood pressure at diagnosis was above 160/100 mmHg, even in patients with diabetes. The additional risk factors were recorded increasingly frequently (cholesterol level, smoking behaviour, body-mass index). In 1991, 63% were treated with medication (the other 37% only received lifestyle advice). During the last period, 86% received medication, while the indication to prescribe medication according to the guidelines increased from 40% to 81%. The increase may be ascribed to the new guideline recommendation of one risk factor as an indication to treat patients with mild hypertension instead of two. CONCLUSION: Almost all patients in whom the participating general practitioners diagnosed hypertension fulfilled the criteria. The difference in threshold values for diagnostic measurements and medicinal treatment means that people with mild hypertension are not always registered and consequently risk being forgotten by their general practitioner.

[The Dutch College of General Practitioners' practice guideline "Dizziness"; reaction from a general practitioner's perspective]. / De standaard 'Duizeligheid' van het Nederlands Huisartsen Genootschap; reactie vanuit de huisartsgeneeskunde.

The Dutch College of General Practitioners' practice guideline entitled 'Dizziness' concerns a complaint experienced by many people, yet it provides few scientific data to support the recommendations. The standard does, however, provide the general practitioner with some concrete advice: the diagnostic work-up should, in the first instance, aim to differentiate vertigo from other forms of dizziness, and medicinal treatment is not indicated as it has not been proven to be effective. However, when it comes to further diagnostic procedures and non-medicinal therapy, the standard tends to list options and give less direction.

[The Dutch College of General Practitioners practice guideline 'The menopause'; reaction of the field of general practice]. / De standaard 'De overgang' van het Nederlands Huisartsen Genootschap; reactie vanuit de huisartsgeneeskunde.

The Dutch College of General Practitioners' practice guideline on the menopause will not be any major cause for discussion. The hot issue of giving oestrogens to peri- and postmenopausal women to prevent osteoporosis or cardiovascular disease was already covered in the practice guideline on osteoporosis. This guideline on the menopause shows that there is no consensus on when it is safe to stop contraception. The advice to use supplementary contraception, such as condoms, until 1 year after the last menstruation will not be met with a high rate of compliance. If oestrogen therapy is necessary in women with serious vasomotor symptoms who still have their uterus, calendar packets containing 14-16 oestrogen-only pills and 12-14 oestrogen/progesterone combination pills can be used. Administration of transdermal oestrogens has no added value and is more expensive. Tibolone is even more expensive and has more side effects. Clonidine is less effective but can be an alternative for women who choose not to take hormones or in whom oestrogens are contraindicated.

[Pneumococcal vaccination for persons 65 years of age and older]. / Pneumokokkenvaccinatie voor personen vanaf 65 jaar.

In the Netherlands, in contrast to other countries, pneumococcal vaccination for older people and people at risk is not routine, except for patients under special circumstances, such as after a splenectomy. Although pneumococcal vaccination is an effective way to prevent invasive pneumococcal disease in young healthy persons, there is no conclusive evidence that it is effective in older people and people at risk without a good immune response. Pneumococcal disease can be an important complication of an ordinary flu. Because there is a high level of vaccination against influenza in the Netherlands, the risk of pneumococcal disease is low compared to other countries in the world. Adding a pneumococcal vaccine to the influenza vaccination could decrease the degree of protection against influenza. The experimental introduction of pneumococcal vaccination does not seem to lead to an increase in the number of patients that refuse vaccination against influenza.

Cardiovascular risk factors and disease in general practice: results of the Nijmegen Cohort Study.

The relationship between risk factors and cardiovascular disease (CVD) was determined using data from the Nijmegen Cohort study, an 18-year prospective study. In 1977, cardiovascular risk factors were measured in 7092 Caucasian males and females from six general practices: age, smoking, serum cholesterol, blood pressure, body mass index and a family history of CVD were related to subsequent CVD mortality and morbidity. Most patients had more than one risk factor in particular among men. A significant relationship between risk factors and CVD was demonstrated. In men, a relative risk (RR) of 1.8 was found for both high blood pressure and smokers. A positive family history yielded a RR of 1.8. The risk increased gradually with the number of risk factors; 38% of the group with all risk factors suffered a CVD within 18 years. In women, comparable RRs were found but the low absolute risk of CVD should indicate against the treatment of cardiovascular risk factors.