Social concordance and patient reported experiences in countries with different gender equality: a multinational survey.

BACKGROUND: Patient reported experiences (PREMs) are important indices of quality of care. Similarities in demography between patient and doctor, known as social concordance, can facilitate patient-doctor interaction and may be associated with more positive patient experiences. The aim of this research is to study associations between gender concordance, age concordance and PREMs (doctor-patient communication, involvement in decision making, comprehensiveness of care and satisfaction) and to investigate whether these associations are dependent on a countries' Gender Equality Index (GEI). METHODS: Secondary analysis on a multinational survey (62.478 patients, 7.438 GPs from 34 mostly European countries) containing information on general practices and the patient experiences regarding their consultation. Multi-level analysis is used to calculate associations of both gender and age concordance with four PREMs. RESULTS: The female/female dyad was associated with better experienced doctor-patient communication and patient involvement in decision making but not with patient satisfaction and experienced comprehensiveness of care. The male/male dyad was not associated with more positive patient experiences. Age concordance was associated with more involvement in decision making, more experienced comprehensiveness, less satisfaction but not with communication. No association was found between a country's level of GEI and the effect of gender concordance. CONCLUSION: Consultations in which both patient and GP are female are associated with higher ratings of communication and involvement in decision making, irrespective of the GEI of the countries concerned. Age concordance was associated with all PREMs except communication. Although effect sizes are small, social concordance could create a suggestion of shared identity, diminish professional uncertainty and changes communication patterns, thereby enhancing health care outcomes.

The influence of gender concordance between general practitioner and patient on antibiotic prescribing for sore throat symptoms: a retrospective study.

BACKGROUND: Patient gender as well as doctor gender are known to affect doctor-patient interaction during a medical consultation. It is however not known whether an interaction of gender influences antibiotic prescribing. This study examined GP's prescribing behavior of antibiotics at the first presentation of patients with sore throat symptoms in primary care. We investigated whether GP gender, patient gender and gender concordance have an effect on the GP's prescribing behavior of antibiotics in protocolled and non-protocolled diagnoses. METHODS: We analyzed electronic health record data of 11,285 GP practice consultations in the Netherlands in 2013 extracted from the Nivel Primary Care Database. Our primary outcome was the prescription of antibiotics for throat symptoms. Sore throat symptoms were split up in 'protocolled diagnoses' and 'non-protocolled diagnoses'. The association between gender concordance and antibiotic prescription was estimated with multilevel regression models that controlled for patient age and comorbidity. RESULTS: Antibiotic prescription was found to be lower among female GPs (OR 0.88, CI 95% 0.67-1.09; p = .265) and female patients (OR 0.93, 95% 0.84-1.02; p = .142), but observed differences were not statistically significant. The difference in prescription rates by gender concordance were small and not statistically significant in non-protocolled consultations (OR 0.92, OR 95% CI: 0.83-1.01; p = .099), protocolled consultations (OR 1.00, OR 95% CI: 0.68-1.32; p = .996) and all GP practice consultations together (OR 0.92, OR 95% CI: 0.82-1.02; p = .118). Within the female GP group, however, gender concordance was associated with reduced prescribing of antibiotics (OR 0.85, OR 95% CI: 0.72-0.99; p = 0.034). CONCLUSIONS: In this study, female GPs prescribed antibiotics less often than male GPs, especially in consultation with female patients. This study shows that, in spite of clinical guidelines, gender interaction may influence the prescription of antibiotics with sore throat symptoms.

Data quality issues impede comparability of hospital treatment delay performance indicators.

AIM: To assess the comparability of five performance indicator scores for treatment delay among patients diagnosed with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention in relation to the quality of the underlying data. METHODS: Secondary analyses were performed on data from 1017 patients in seven Dutch hospitals. Data were collected using standardised forms for patients discharged in 2012. Comparability was assessed as the number of occasions the indicator threshold was reached for each hospital. RESULTS: Hospitals recorded different time points based on different interpretations of the definitions. This led to substantial differences in indicator scores, ranging from 57 to 100 % of the indictor threshold being reached. Some hospitals recorded all the required data elements for calculating the performance indicators but none of the data elements could be retrieved in a fully automated way. Moreover, recording accessibility and completeness of time points varied widely within and between hospitals. CONCLUSION: Hospitals use different definitions for treatment delay and vary greatly in the extent to which the necessary data are available, accessible and complete, impeding comparability between hospitals. Indicator developers, users and hospitals providing data should be aware of these issues and aim to improve data quality in order to facilitate comparability of performance indicators.

Do practice characteristics explain differences in morbidity estimates between electronic health record based general practice registration networks?

BACKGROUND: General practice based registration networks (GPRNs) provide information on population health derived from electronic health records (EHR). Morbidity estimates from different GPRNs reveal considerable, unexplained differences. Previous research showed that population characteristics could not explain this variation. In this study we investigate the influence of practice characteristics on the variation in incidence and prevalence figures between general practices and between GPRNs. METHODS: We analyzed the influence of eight practice characteristics, such as type of practice, percentage female general practitioners, and employment of a practice nurse, on the variation in morbidity estimates of twelve diseases between six Dutch GPRNs. We used multilevel logistic regression analysis and expressed the variation between practices and GPRNs in median odds ratios (MOR). Furthermore, we analyzed the influence of type of EHR software package and province within one large national GPRN. RESULTS: Hardly any practice characteristic showed an effect on morbidity estimates. Adjusting for the practice characteristics did also not alter the variation between practices or between GPRNs, as MORs remained stable. The EHR software package 'Medicom' and the province 'Groningen' showed significant effects on the prevalence figures of several diseases, but this hardly diminished the variation between practices. CONCLUSION: Practice characteristics do not explain the differences in morbidity estimates between GPRNs.

Understanding health care providers' reluctance to adopt a national electronic patient record: an empirical and legal analysis.

BACKGROUND: Several countries are implementing a national electronic patient record (n-EPR). Despite the assumed positive effects of n-EPRs on the efficiency, continuity, safety and quality of care, their overall adoption remains low and meets resistance from involved parties. The implementation of the Dutch n-EPR also raised considerable controversy, which eventually caused the Dutch government to stop its contribution to the national infrastructure. AIM: To explain Dutch health care providers' reluctance in adopting the n-EPR, we investigated their perceptions of problems associated with the n-EPR and their legal position regarding then-EPR. We hereby aim to provide suggestions about approaches that could promote successful implementation. METHODS: The study consisted of two parts. The empirical part of the study was conducted in three health care settings: acute care, diabetes care, and ambulatory mental health care. Two health care organisations were included per setting. Between January and June 2010, 17 stakeholders working in these organisations were interviewed to investigate health care providers' perceptions of problems associated with the n-EPR. In the legal part of the study, legal documents were analysed to study health care providers' legal position regarding the n-EPR and any associated problems. RESULTS: The respondents expressed concerns about the confidentiality and safety of information exchange and the reliability and quality of patient data in the n-EPR, and indicated that their liability in case of medical errors was not sufficiently clear. The perceived problems could partly be attributed to legal uncertainties. CONCLUSIONS: It is recommended to start the implementation of an n-EPR in limited geographical areas. This will allow health care providers to experience benefits of electronic information exchange before being asked to participate in information exchange at a larger scale. The problems that health care providers perceive in the n-EPR should be minimised. Legislation underlying the n-EPR should provide sufficient clarity about health care professionals' responsibilities and liabilities.

The influence of population characteristics on variation in general practice based morbidity estimations.

BACKGROUND: General practice based registration networks (GPRNs) provide information on morbidity rates in the population. Morbidity rate estimates from different GPRNs, however, reveal considerable, unexplained differences. We studied the range and variation in morbidity estimates, as well as the extent to which the differences in morbidity rates between general practices and networks change if socio-demographic characteristics of the listed patient populations are taken into account. METHODS: The variation in incidence and prevalence rates of thirteen diseases among six Dutch GPRNs and the influence of age, gender, socio economic status (SES), urbanization level, and ethnicity are analyzed using multilevel logistic regression analysis. Results are expressed in median odds ratios (MOR). RESULTS: We observed large differences in morbidity rate estimates both on the level of general practices as on the level of networks. The differences in SES, urbanization level and ethnicity distribution among the networks' practice populations are substantial. The variation in morbidity rate estimates among networks did not decrease after adjusting for these socio-demographic characteristics. CONCLUSION: Socio-demographic characteristics of populations do not explain the differences in morbidity estimations among GPRNs.

Ankylosing spondylitis: a risk factor for myocardial infarction?

OBJECTIVE: To ascertain the prevalence of myocardial infarction (MI) in ankylosing spondylitis (AS) relative to that in the general population. METHODS: A questionnaire was sent to 593 patients with AS, aged between 50 and 75 years and registered at the Jan van Breemen Institute or VU University Medical Centre. A total of 383 (65%) patients with AS returned their questionnaire that covered the primary outcome, (non-fatal) MI. The prevalence of MI was calculated with data from the general population provided by Netherlands Information Network of General Practice databases as reference. RESULTS: The overall prevalence for MI was 4.4% in patients with AS versus 1.2% in the general population, resulting in an age- and gender-adjusted odds ratio of 3.1 (95% CI 1.9 to 5.1) for patients with AS. When non-responders (35%) were considered as non-MI the odds ratio decreased to 1.9 (95% CI 1.2 to 3.2). CONCLUSIONS: These observations indicate that the prevalence of MI is increased in patients with AS.

Morbidity is related to a green living environment.

BACKGROUND: As a result of increasing urbanisation, people face the prospect of living in environments with few green spaces. There is increasing evidence for a positive relation between green space in people's living environment and self-reported indicators of physical and mental health. This study investigates whether physician-assessed morbidity is also related to green space in people's living environment. METHODS: Morbidity data were derived from electronic medical records of 195 general practitioners in 96 Dutch practices, serving a population of 345,143 people. Morbidity was classified by the general practitioners according to the International Classification of Primary Care. The percentage of green space within a 1 km and 3 km radius around the postal code coordinates was derived from an existing database and was calculated for each household. Multilevel logistic regression analyses were performed, controlling for demographic and socioeconomic characteristics. RESULTS: The annual prevalence rate of 15 of the 24 disease clusters was lower in living environments with more green space in a 1 km radius. The relation was strongest for anxiety disorder and depression. The relation was stronger for children and people with a lower socioeconomic status. Furthermore, the relation was strongest in slightly urban areas and not apparent in very strongly urban areas. CONCLUSION: This study indicates that the previously established relation between green space and a number of self-reported general indicators of physical and mental health can also be found for clusters of specific physician-assessed morbidity. The study stresses the importance of green space close to home for children and lower socioeconomic groups.

Time trends in primary-care morbidity, hospitalization and mortality due to pneumonia.

Most studies reporting pneumonia morbidity are restricted to hospitalized patients, although only a minority of pneumonia patients are admitted to hospital. To get a better understanding of the burden of disease in the general population, we conducted a population-based retrospective study to examine trends in pneumonia incidence in general practice, hospitalization, and mortality due to pneumonia in The Netherlands between 1997 and 2007. Between 2001/2002 and 2006/2007 there was an adjusted yearly increase of 12% in the clinical diagnosis of pneumonia in patients consulting general practitioners. Hospitalizations increased 5% per year between 1999/2000 and 2006/2007, while mortality annually decreased by 2% between 1997/1998 and 2006/2007. Our study suggests that the morbidity of pneumonia in the Dutch population increased considerably over this period, especially in primary-care settings, and that focusing only on hospitalization might underestimate the increasing public health burden of pneumonia.

Estimating morbidity rates from electronic medical records in general practice. Evaluation of a grouping system.

OBJECTIVES: In this study, we evaluated the internal validity of EPICON, an application for grouping ICPC-coded diagnoses from electronic medical records into episodes of care. These episodes are used to estimate morbidity rates in general practice. METHODS: Morbidity rates based on EPICON were compared to a gold standard; i.e. the rates from the second Dutch National Survey of General Practice. We calculated the deviation from the gold standard for 677 prevalence and 681 incidence rates, based on the full dataset. Additionally, we examined the effect of case-based reasoning within EPICON using a comparison to a simple, not case-based method (EPI-0). Finally, we used a split sample procedure to evaluate the performance of EPICON. RESULTS: Morbidity rates that are based on EPICON deviate only slightly from the gold standard and show no systematic bias. The effect of case-based reasoning within EPICON is evident. The addition of case-based reasoning to the grouping system reduced both systematic and random error. Although the morbidity rates that are based on the split sample procedure show no systematic bias, they do deviate more from the gold standard than morbidity rates for the full dataset. CONCLUSIONS: Results from this study indicate that the internal validity of EPICON is adequate. Assuming that the standard is gold, EPICON provides valid outcomes for this study population. EPICON seems useful for registries in general practice for the purpose of estimating morbidity rates.

GP income in relation to workload in deprived urban areas in The Netherlands. Before and after the 1996 pay review.

BACKGROUND: General practitioner workload is higher in deprived urban areas and for the elderly. This led to the introduction of additional GP payments regarding these patients, in the UK and in the Netherlands. This study examines whether this has resulted in more equal payment for work done in the Netherlands. METHODS: GP workload and income have been assessed on the basis of a survey among 1154 GPs (response: 62%). RESULTS: Suggest that total GP income is still lower in deprived areas, but per hour and per patient contact the additional payments gave equity. CONCLUSION: It is thus concluded that Dutch deprivation payments effectively compensate GPs in deprived areas for their higher workload.

The impact of area deprivation on differences in health: does the choice of the geographical classification matter?

OBJECTIVE: Many studies show the average health status in deprived areas to be poorer and the use of health care to be higher, but there is hardly any information on the impact of the geographical classification on the size of these differences. This study examines the impact of the geographical classification on the clustering of poor health per area and on the size of the differences in health by area deprivation. DESIGN: Data on self reported health regarding 5121 people were analysed using three classifications: neighbourhoods, postcode sectors and boroughs. Multilevel logistic models were used to determine the clustering of poor health per area and the size of the differences in health by area deprivation, without and subsequently with adjustment for individual socioeconomic status. SETTING: General population aged 16 years and over of Amsterdam, The Netherlands. MAIN OUTCOME MEASURES: Self rated health, mental symptoms (General Health Questionnaire, 12-item version), physical symptoms and long term functional limitations. MAIN RESULTS: The clustering of poor health is largest in neighbourhoods and smallest in postcode sectors. Health differences by area deprivation differ only slightly for the three geographical classifications, both with and without adjustment for individual socioeconomic status. CONCLUSIONS: In this study, the choice of the geographical classification affects the degree of clustering of poor health by area but it has hardly any impact on the size of health differences by area deprivation.

Is there a geography of alternative medical treatment in The Netherlands?

An increasing number of people are using alternative medical care. The literature suggests that there are important between place variations, however. This paper tries to assess the extent of these variations and mechanisms behind them for the utilization of homeopathy, paranormal healing and manual therapy. Are these variations a matter of level of supply, degree of urbanization, GP characteristics or simply a matter of composition of populations? Data are derived from the Dutch National Surgery of General Practice and analyzed using multilevel logistic regression models. Between place variation in utilization of homeopathy is mainly a matter of composition of populations with respect to health locus of control and religion. With respect to paranormal healing, it is exclusively a matter of religion. With respect to manual therapy, place variations are a matter of individual, GP, as well as area characteristics, but a relatively large amount remains unexplained.

Urban-rural variations in health in The Netherlands: does selective migration play a part?

STUDY OBJECTIVE: Urban-rural health differences are observed in many countries, even when socioeconomic and demographic characteristics are controlled for. People living in urban areas are often found to be less healthy. One of the possible causes for these differences is selective migration with respect to health or health risk factors. This hypothesis is hardly ever empirically tested. This paper tries to assess the existence of selective urban-rural migration. DESIGN: Health indicators and health risk factors were measured in a 1991 population sample. Moves were registered between 1991 and 1995. Using logistic regression analyses, comparisons were made between, firstly, urban to rural movers and rural to urban movers and secondly, between movers and stayers. SETTING: Region surrounding the city of Eindhoven in south eastern part of the Netherlands. SUBJECTS: Data were used of 15,895 respondents aged 20-74 in 1991. By 1995 613 subjects had moved from urban to rural and 191 subjects from rural to urban. MAIN RESULTS: Bivariate nor multivariate analyses show hardly and differences between movers into urban and movers into rural areas. Bivariate analyses on movers and stayers show that movers are healthier than stayers. However, when socioeconomic and demographic variables are controlled for, movers appear to be less healthy, with the exception of the younger age groups. CONCLUSIONS: Areas that attract many migrants from and lose few migrants to other degrees of urbanicity will in the long run obtain healthier populations, because of demographic and socioeconomic characteristics. However, if these characteristics are accounted for, the opposite is true, with the exception of younger age groups. In extreme cases this may cause spurious findings in cross sectional research into the relation between urbanicity and health. Absolute numbers of migrants need to be very high, however, to make this noticeable at the aggregate level.

Explaining urban-rural variations in health: a review of interactions between individual and environment.

In order to gain insight into the relation between health and people's environment, literature published between 1985 and 1994 was gathered from several international databases. An introduction into existing theory regarding geographic disparities is presented: geographical drift and breeder hypotheses are discussed. This is followed by a critical review focusing on interaction effects of urbanicity and individual characteristics on health. This leads to two major conclusions. First, emphasis in past research has been primarily on urban constraints rather than opportunities. Positive aspects of urban living are often insufficiently appreciated. Second, positive and negative environmental aspects have an effect on health that is often dependent on individual characteristics. The extent to which the environment exerts influence on a person's health is dependent on that person's individual characteristics. These conclusions are relevant only for further developing the breeder hypothesis, however. Large scale individual based longitudinal data should be studied in order to gain more insight into the relative importance of the geographical drift hypothesis.