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Objective: To determine the effect of a non-committal registration specifying the intention of patients to contact a particular general practitioner, on patient loyalty in Belgium., Setting: Antwerp and Liège, Design: Case control study., Method: Medical consumption was registered during one year by two health insurance companies for a group of 4000 participating patients (experimental group) and 4000 non-participants (control group) within two selected areas (Antwerp and Liège). Patient loyalty was measured by means of the normalised usual provider continuity index., Results: No relevant differences were found between the experimental group and the control group. Even when taking into account that a general practitioner is not available 20% of the time, the proportion of loyal patients hardly reached 70%., Conclusion: A non-committal registration had no influence on patient loyalty. There is a clear difference between intention and actual behaviour. More coercive measures are needed to reach a more loyal behaviour.

Objective: Determining the role of the general practitioner (GP) in the management of the postinfarction patient, the factors that influence this role, and the relation between GP and cardiologist., Design: Descriptive., Setting: Registration Network of Family Practice (RNF) of the University of Limburg, the Netherlands., Method: Data were obtained from a sample of 284 patients from 30 GPs, all participating in the RNF. The GPs completed a questionnaire about their own patients while the data concerning the cardiac state of the patients were obtained from their problem lists., Results: Postinfarction care was given in only 50% of the patients. Relatively more patients with a more severe cardiac condition were under regular medical follow-up than those with a less severe cardiac condition. However, the severity of the disease had no effect on the specialty of the doctor performing the follow-up (GP or cardiologist), nor had the time expired after the myocardial infarction. In almost 50% of the cases the GPs found continuation of the follow-up by the cardiologist not necessary, in 25% of the cases they were not satisfied with the complementary roles of both disciplines., Conclusion: Postinfarction care by the GPs was not uniform. They need guidelines for the management of such patients, based on the patient's risk profile. There is a need for better coordination between GP and cardiologist.

Objective: Investigating whether and how the prescribing behaviour of general practitioners (GPs) can be changed by the pharmacist's feedback., Design: Randomised, prospective., Setting: Residential home 'Bernlef', Groningen, the Netherlands., Method: In the period 2 February-18 March 1993 the effect of different ways of sending prescriptions by the pharmacist on medication use was investigated. The 43 GPs of the inhabitants were randomly divided in 3 groups. Group A formed the control group and was requested to send their prescriptions as before, group B moreover received a list with the medication used by their patients, group C also got a list with the actual medication of their patients as well as recommendations by the pharmacist. Effects on medication use were determined after 4 weeks., Results: The 196 inhabitants used an average of 6.5 drugs (range 0-19). No difference was found between group A and group B, but there was a difference with group C. In all three groups the number of added drugs increased by 5%, but the number of deleted drugs was 7% in group C, as against only 3% in groups A and B (p < 0.05). The feedback of the pharmacist that for 44% of GPs contained new information resulted 9 times in the ending of medication and 4 times in decreasing of the dose., Conclusion: Pharmacist's feedback by means of remarks on prescribed medication positively influences prescription behaviour of the GP.

Objective: Evaluation of an experimental transmural teaching programme for postgraduate students following a general practitioners' course., Design: Descriptive., Setting: Institute for General Practice, University of Limburg, the Netherlands., Method: Experiences of 100 students who followed a patient from referral in general practice to the hospital (and back) were evaluated by means of a questionnaire. Questions concerned to what extent learning goals (insight into transferral from general practice to the hospital and the consequences for the patient) had been reached., Results: The satisfaction of the students was moderately positive, but dependent on the briefing of the tutors and the exchange of experiences in the tutorial group. The information given by the general practitioner about the referral, the quality of the organisation in the hospital and the medical treatment received a positive judgment. The attention for the patient's views, and the quality of advice and information in the hospital were unsatisfactory in half of the referred cases, according to the student. Three quarters of the patients had a positive opinion regarding the referral in contrast to only half of the relatives. The pattern of the referred morbidity was comparable to the main health problems in general practice., Conclusion: The patient's view of his illness plays a central part in this transmural teaching programme. The results justify similar programmes in other disciplines.

Objective: Determining the factors which influence the success of training therapy in women suffering from urinary incontinence., Design: Descriptive., Setting: Thirteen general practices in Nijmegen and environs, the Netherlands., Method: A total of 110 women between 20 and 65 years old, suffering from urinary incontinence were examined by their general practitioners. Age, personality, parity, psychological features and type, duration, severity, beginning of the disease, as well as the presence of cystocele or prolapse were recorded. Women were asked about their own experiences regarding factors that influenced success. The treatment consisted of training of pelvic muscles in stress incontinence and bladder training in urge incontinence. Outcomes and compliance were measured 3 and 12 months after start of treatment by means of a so-called incontinence diary., Results: After 3 months the mean frequency of urine loss per week diminished from 21 to 8, and after 12 months to 6 times. Compliance was the most important contribution to success. Patients were more motivated to practise when the subjective burden of the urine loss was more severe. Other features did not influence success.

Objective: To determine the significance of dysmorphic erythrocytes in the urinary sediment for discrimination between urological and nephrological causes of haematuria., Design: Evaluation of diagnostic test., Setting: Departments of Nephrology and Pathology, University Hospital Nijmegen., Method: Of 107 patients with haematuria in whom renal parenchymal or urological disease was diagnosed, the percentage of dysmorphic erythrocytes was estimated in the unstained urinary sediment with normal light microscopy. By using a Receiver Operating Characteristic curve the cutoff point that provided the highest diagnostic value of the erythrocyte morphology was determined. In addition, the inter-observer variation was estimated in a separate series of 26 urinary sediments., Results: At a cutoff value of 40% dysmorphic erythrocytes the sensitivity for urological pathology was 100% and the specificity 66.7%. When presence of erythrocyte, haemoglobin or fatty casts was also considered as a criterion for a nephrological diagnosis, the specificity for urological pathology rose to 88.1%. The inter-observer variation showed a correlation coefficient of 0.90 (kappa: 0.77)., Conclusion: Evaluation of the erythrocyte morphology in the urinary sediment is a reliable aid in determining the strategy to be followed in patients with haematuria. It is important, however, that strict criteria for establishing erythrocyte dysmorphism are applied.

The Sickness Impact Profile (SIP) is a generic questionnaire developed to register the consequences of disease for daily life. We examined an open population (N = 232) aged 65 years and older irrespective of their health status by means of the SIP in order to obtain age related reference values. In addition to patient characteristics data on the patient's morbidity and health appraisal were collected. There appeared to be no relation between SIP-scores and sex. Age, however, as well as morbidity and health appraisal were significantly related to SIP-scores. These results emphasize the importance of the availability of age related reference values in outcome studies.

Objective: To evaluate the management of infections in a nursing home., Design: A descriptive study of yearly reviews of 1981-1992., Location: Nursing home De Bieslandhof, Delft., Patients and Method: Of all the patients admitted during a year in the nursing home, the prescribed antimicrobial therapy differentiated by localisation of infection was registered. Whenever prescription of antimicrobial therapy was considered, the use of an indwelling catheter was limited and urine was collected for culturing., Results: From 1981-1984 the number of patients with an indwelling catheter decreased to 50% as did the number of patients who needed recurrent antimicrobial therapy. From 1985 on, the patients receiving a simple or repeated antimicrobial therapy courses were 20% and 7%, respectively, of the total population. Per 1000 patient days 0.9 urinary and 1.1 airway infections were treated; other infections played a minor part. Non-catheterised nursing home patients or non-catheterised patients just admitted from the hospital had more urinary E. coli infections than patients who had been catheterised. The choice of antimicrobial therapy did not change during the study period except for the replacement of sulfamethizole by pipemidic acid in 1989., Conclusion: Nursing home doctors can collectively manage and control infections in a nursing home by using a restrictive policy on antimicrobial therapy and on the use of indwelling catheters. Infections not treated with antimicrobial agents are not included in this policy.

Objective: To estimate the risk of HIV or hepatitis B infection after pricking accidents in the ambulant care and treatment of drug addicts., Design: Risk estimation., Setting: Aid station for drug addicts in Nijmegen., Method: Inventorization of the pricking accidents at the above-named aid station and calculation of the risk of infection., Results: During 30 years on the job, a worker in addict care outside Amsterdam runs a 0.007% risk of job-related HIV infection and a 4.5% risk of hepatitis B infection. The corresponding figures for Amsterdam are 0.05% and 7%, respectively. The job-related risk for workers in general hospitals in Amsterdam is 0.0012-0.015% for a job-related HIV infection and 1-5% for a job-related hepatitis B infection., Conclusion: The risk of workers in an aid station for drug addicts of contracting a job-related HIV or hepatitis B infection is relatively high compared with workers in health care in general. An active infection prevention policy for workers in addict care is to be recommended.

Objective: To establish to which degree the guidelines of the Otitis media acuta standard of the Netherlands college of general practitioners (NHG) are followed in practice and what is GPs' opinion of them., Design: Survey., Setting: 65 general practitioners settled throughout the Netherlands., Method: The GPs were recruited for the study by means of an advertisement and a personal approach. Opinions and performances were inventoried using a questionnaire and self-completion forms for successive doctor-patient contacts, respectively., Results: Virtually all participants were familiar with the NHG standard and most were familiar with three central guidelines. Of these three, the recommendation of an active follow-up policy for children up to the age of 2 was known to the fewest GPs, and this recommendation also received the least support. In the 327 consultations recorded there was good agreement between actual performance and the guidelines, especially as regards history-taking, physical examination and diagnosing. Regarding management and patient information the agreement was less. Concerning the follow-up policy for young children and the prescribing of antibiotics, actual performance clearly differed from the NHG standard, possibly because the relevant guidelines were less well known., Conclusion: The results of this study are relevant to the planning of GP education and the evaluation of the guidelines themselves.

Objective: To describe the profile of regular users of benzodiazepines in a general practice., Design: Case-control study., Setting: A duo general practice in Nijmegen., Method: Of all regular users of benzodiazepines in a general practice, socio-demographic and morbidity data were collected and the use of benzodiazepines (duration, frequency, type of agent) was determined. By means of a semi-structured interview, the users' experiences and opinions were inventoried. Psychological and physical functioning were determined using the symptom checklist (SCL-90)., Results: In the group of 99 users (3.1% of the practice population), 53 (1.6% of the practice population) used benzodiazepines every day and had done so for over one year. Most were women over 65 years of age, living alone and with a low educational level. Over 25% were patients with psychiatric/psychogeriatric disorders. Users had frequent chronic diseases, particularly articular disorders and chronic skin diseases. The SCL-90 results indicated a high degree of psychoneuroticism. Most patients felt the medication enabled them to cope better with difficult situations, and the side effects reported were limited in number and severity., Conclusion: Users of benzodiazepines were in a high-risk position, both socio-economically and as regards health and mental well-being. Given a strict prescribing policy, the group of chronic users of benzodiazepines was small and easy to control in this practice.

Objective: In the Netherlands one-third of stroke patients are managed at home. This study describes the characteristics of these patients and the management by the GP from stroke onset till six months afterwards., Method: A community based cohort of 185 stroke patients were examined at fixed intervals during 6 months poststroke; mortality and functional status of patients managed at home (n = 73) were compared with those of patients admitted to hospital (n = 109); 3 patients were directly admitted to a nursing home; characteristics of the GPs' management were registered., Results: Patients managed at home were somewhat older (p < 0.05), lived more often in a residential home for the elderly (p < 0.05) and were more frequently known with comorbidity such as diabetes mellitus and Alzheimer (p < 0.05). Their poststroke disabilities were less grave; mortality rate was much lower than in the hospitalised group (p < 0.05). Recovery showed the same pattern in both groups. In the acute phase the GP made frequent housecalls; after a few days there was a decline in contact frequency. The mean 'treatment duration' was 12 weeks. The amount of care provided by the GP did not correlate with stroke severity., Conclusion: In the acute phase, when the patients' clinical condition was still unstable and the patients' families needed support, the GPs made frequent house-calls. During the stroke episode the number of contacts and the length of the treatment duration were defined more by comorbidity and social factors than by the severity of stroke. Regarding the pattern of stroke recovery the mean treatment duration of 12 weeks appears rather short for optimal support and rehabilitation.

This cross-sectional study comprised 223 patients with moderate asthma or chronic bronchitis (FEV1 > 50% of the predicted value) from 29 general practices in the catchment area of Nijmegen University. Fifty-six patients were treated by 19 chest physicians, the remaining 167 by 29 general practitioners, without specialist care. In the study population no relevant differences in sex, age, smoking behaviour or severity of the disease (symptoms, lung function, and bronchial hyperreactivity) could be observed between the two groups of patients, except for allergy. Chest physicians prescribed on average almost three times as much medication as general practitioners. We could identify only a weak relationship between the severity of the disease (symptoms and pulmonary function combined) and the prescribed pharmacotherapy: with rising degrees of severity the general practitioner prescribes more bronchodilators, the specialist more inhaled corticosteroids. No relationship could be observed between bronchial hyperreactivity and the prescribed pharmacotherapy. No response to prescribed bronchodilators was found in 16% of the patients treated by the general practitioner and in 20% of the patients treated by the specialist. On the basis of this cross-sectional study no well-defined treatment policy of patients with moderate asthma or chronic bronchitis either by the general practitioner or by the lung specialist could be found.

In 11 general medical practices which are part of the 'Huisartsen Peilstation Groningen', the nature and extent were investigated of cases of sexual violence previously unknown to the GP. Questions also investigated were who took the initiative to bringing up this subject, and whether the results yield guidelines for better detection of and attending to sexual violence. The GPs registered these items during 1990 and 1991 after the first contact with any patient about a case of sexual violence (as defined by Draijer) previously unknown to them. The number of registered cases was 64 (corresponding to 17 per 10,000 patients), half of which concerned adults with sexual violence problems in their childhood. Offenders, nature and extent of the violence did not differ from descriptions in the literature. No cases were reported of still continuing violence. The 11 GPs differed significantly in the number of registered cases. The extent to which GP or patient took the initiative to bringing up the subject was not related to the number of cases registered by the GP. Patients referred and those not referred did not differ significantly in nature or extent of the sexual violence. Few follow-up appointments were made with non-referred patients. On the basis of these results, two items were formulated for better detection of and attending to sexual violence problems: stimulating the GP to an open, inviting attitude as well as active continuation of questioning in the case of complaints with a signal value; and making a follow-up appointment for non-referred patients.

Since recent insights indicate that most patients with heart failure and a normal cardiac rhythm (HFNR) should not be treated with digitalis, we investigated the treatment policy of general practitioners in this respect. Our descriptive study consisted of a questionnaire followed by a computer based review of patient records of 14 family practices cooperating in the Registration Network of Family Practice (RNFP) and 10 'external' practices. All GPs (n = 51) received the questionnaire on the prescription policy of the GP and cooperating specialists, and on their experience with adverse effects of digitalis therapy. After 2-4 months the GPs of the RNFP (n = 41) received a floppy disc with an algorithm selecting from their problem lists patients with a registered diagnosis of heart failure. The external GPs (n = 10) received an algorithm selecting patients treated with digitalis, since their problem lists were not completely up to date. In all, data of 63,500 patients were examined. On anonymised standard forms, generated by the practice computer, the GPs provided data on the exact diagnosis, medication and adverse effects. Outcome measures of the study were: prescription attitudes (questionnaire) and actual digitalis use (in the selected cases). 33% of the GPs stated that they used digitalis as the preferred therapy of heart failure with normal cardiac rhythm; 30% of the 82 selected HFNR patients had digitalis, while in 42% of the 149 selected patients treated with digitalis a HFNR was registered. Adverse effects had been observed in 3 cases, but could not be excluded retrospectively in 70 cases (49%). Many GPs have not yet adapted their prescription behaviour to recently published insights. Development of a 'digitalis standard in general practice' is recommended.

Objective: In Rotterdam GPs have the possibility of requesting an exertion ECG for their patients from the Foundation Thrombosis Service and Physicians' Laboratory. A follow-up study was carried out in order to gain insight into the functioning of this service., Patients and Methods: Over a period of three months, 266 GPs referred 498 patients to the service for an exertion ECG. The GPs received an enquiry form with questions on the referral and the functioning of the service. The patients were followed up for two weeks in connection with any (cardiovascular) events and with the management by the GP. An ECG was regarded as positive if the ST showed a depression greater than or equal to 1.5 mm., Results: None of the patients died during the period of the investigation. Of the patients with positive and with negative ECGs, 41% and 37%, respectively, had no more complaints, 40% and 28% the same complaints, and 3% and 0.5% more complaints. Of the patients with a negative ECG (n = 439), 3.9% were referred to a cardiologist. If no ECG had been made, this proportion would have been 39%., Conclusion: The Foundation Thrombosis Service and Physicians' Laboratory Rotterdam provides an essential contribution to GPs' decision making concerning referral of patients with vague cardiac complaints to a cardiologist.

What is the influence of stroke on experienced burden, coping and well-being of the patient's spouse? To explore this problem we interviewed 22 spouses, living with their husband or wife at home. Stroke had occurred over 12 months ago. There appeared to be different consequences for the spouse, depending upon the kind of handicap: The physical handicaps in stroke-patients were associated with an increase of household tasks and caregiving, and with diminished opportunities for the spouse to relax. Mental deterioration after stroke was slightly associated with a lower level of well-being in the spouse. Spouses of patients with severely impaired communication had fewer opportunities to relax, reported more deterioration of the marital relationship and showed slightly more depression than spouses of patients with slightly impaired communication.

The interaction between the general practitioner (GP) and the medical specialist during the referral process was studied in 309 referrals by GPs to medical specialists in eight hospitals in the north of the Netherlands, notably the extent of agreement between the specialist care and the intention of the GP. Furthermore the influence of two factors on the referral process was investigated: 'the clarity of the question in the referral letter' and 'the view of each other's professional tasks'. In most of the cases the GPs allowed the specialists a free hand. In the few cases the GP wanted a restricted consultation the specialist did more than the GP wanted him to do. In one of five referrals the GP or the specialist thought that the specialist had not done what the GP had asked. In most of these cases this impression was not confirmed by the objective evaluation by independent doctors. According to these the referral question was ambiguous. The GP's would like to have more influence on specialist care than the specialists were prepared to allow. The two factors each had an influence on several moments in the referral process. The main conclusion of the study is: the behaviour of the GP does not fit his attitude.

The demands for medical care of patients with chronic non-specific lung disease (CNSLD) and the prevalence of CNSLD will increase. The need, therefore, for behavioural research on CNSLD will also grow. In order to steer behavioural research in CNSLD, research programming is of great importance. Forty-seven Dutch and 13 foreign expert medical and behavioural scientists were asked via an interview about the most prominent topics and conditions for future research in this field. In addition a literature survey with the same aim was carried out. Important topics for future research include: quality of life of CNSLD patients, patient needs, psychophysiological investigation, social and psychosocial aspects of CNSLD, compliance, problems at work and school, and the education of those involved in patient care.

Purpose: Description of stroke patient characteristics, outcome in the acute phase (the first 3 weeks post-stroke) and management by the general practitioner (GP)., Design: Community based prospective study., Methods: During the research period GPs reported all stroke patients (first event as well as recurring); these patients were followed at fixed intervals post-stroke regardless of treatment., Results: The 98 GPs reported 185 patients. Stroke patients are predominantly old to very old people with a lot of comorbidity and an impaired pre-stroke functional status. The GP treated one third of the patients himself; half of the patients were instantly referred to a hospital. Younger patients are referred for further examination, probably because of possible therapeutic consequences. The very old are referred if their impairment makes home care impossible. Mortality, especially in the hospital group is high; 10% died within 24 hours, while after 1 week this figure was 17% and after 3 weeks 23%. In 21% of the referred patients no CT scan was made; the motive for referral was to provide sufficient care for the patient. In nine referred patients (8%) the diagnosis was changed., Conclusion: In choosing a strategy the GP considers several factors, of which impairment and the possibilities of home care are the most important. Diagnostic uncertainty played a minor role.

Objective: To describe general practitioners' approach to and management of urethritis in men, and to compare this with a general practice protocol for urethritis., Design: Descriptive., Setting: General practices in Amsterdam., Patients and Methods: In 13 general practices in Amsterdam (23,510 patients, of whom 11,627 men) all episodes of urethritis in men (n = 55) were recorded during one year (complaints, medical management, diagnosis, medication, follow-up)., Outcome Measures: Description of the diagnostic and therapeutic approach and the course of episodes; rough comparison with the urethritis protocol., Results: In 25% the urine sediment was examined; other office tests were rarely performed. In 30 to 40% out of office microbiological tests were performed. In 50% of new diagnoses medication was underdosed, in some cases medication was wrong or not broad enough. In 25% explicit education was offered. In 22% new medication was given in the follow-up encounter., Conclusions: (Comparison with protocol.) Urine sediment examination as an effective test is performed insufficiently often. Other office tests are rarely performed, in accordance with the protocol. Out of office microbiological tests are performed too often, judged by the few changes of diagnosis and the character of new medication in the follow-up. First treatment is often underdosed and sometimes wrong. First treatment should preferably be broad, adequately dosed and independent of out of office microbiology. Too little education is given concerning the risks of ascending infections in female partners and of HIV infection. The referral rate is very low. It is important to pay attention to the outcome of this study in (postgraduate) education for general practitioners, as they treat the vast majority of urethritis patients.

A pilot-study on the prevalence of depressive symptoms and GPs' assessment of depressed mood in elderly attenders of two general practices. The aim of this pilot was to gather information on both depressive symptoms and GP's' assessments of depressive mood in persons over 65 coming for a consultation in two general practices. To assess the prevalence of depressive symptomatology, 87 patients were asked to complete the Zung Self-Rating Depression Scale (ZSDS) and the Geriatric Depression Scale (GDS). Six patients were identified as having depressive symptoms on the ZSDS and seven on the GDS. Information on GP's' assessments of depressive mood was gathered by asking GP's to what extent they thought patients had been depressed recently. With regard to patients identified by the GP's as being mildly or severely depressed, the GP's answered additional questions on diagnostic and therapeutic approaches. The GP's identified eleven out of 87 patients as being mildly depressed, nobody was classified as being severely depressed. Five out of six patients with a ZSDS score of 50 and higher were not identified by the GP's as being mildly depressed. The prevalence of depressive symptoms based on ZSDS-scores was somewhat lower than expected (7.5%).