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Background Since patient-centered communication is directly connected to clinical performance, it should be integrated with medical knowledge and clinical skills. Therefore, clinical communication skills should be trained and assessed as an integral part of the student’s clinical performance. We were unable to identify a tool, which helps when assessing patient-centered communication skills as an integrated component of medical history taking (‘the integrated medical interview’). Therefore, we decided to design a new tailor-made assessment tool, the BOCC (BeOordeling Communicatie en Consultvoering (Dutch), Assessment of Communication and Consultation (English) to help raters assess students’ integrated clinical communication skills with the emphasis on patient-centred communication combined with the correct medical content. This is a first initiative to develop such a tool, and this paper describes the first steps in this process. Methods We investigated the tool in a group of third-year medical students (n = 672) interviewing simulated patients. Internal structure and internal consistency were assessed. Regression analysis was conducted to investigate the relationship between scores on the instrument and general grading. Applicability to another context was tested in a group of fourth-year medical students (n = 374). Results PCA showed five components (Communication skills, Problem clarification, Specific History, Problem influence and Integration Skills) with various Cronbach’s alpha scores. The component Problem Clarification made the strongest unique contribution to the grade prediction. Applicability was good when investigated in another context. Conclusions The BOCC is designed to help raters assess students’ integrated communication skills. It was assessed on internal structure and internal consistency. This tool is the first step in the assessment of the integrated medical interview and a basis for further investigation to reform it into a true measurement instrument on clinical communication skills.

Objective Breaking bad news (BBN) should be trained, preferably early and following a helical model with multiple sessions over time, including feedback on performance. It’s unclear how medical students evaluate such an approach. Methods We gathered student opinions regarding a helical BBN training programme, the feedback and emotional support they received, and the applicability of the skills training immediately after BBN skills training (Q1) and after finishing their clinical clerkships (Q2). Results Students find a helical curriculum useful, but this declines on follow-up. At Q2 students report less satisfaction with the amount of feedback and emotional support they received and report that the skills training was less applicable in clinical practice compared to what they reported at Q1. Conclusion A helical BBN training programme with early exposure seems to lead to a shift from students being unconsciously incompetent to consciously incompetent. Students would have appreciated more emotional support and feedback. Practice implications We recommend more feedback and emotional support after BBN during clerkships. The gap between classroom and practice can be diminished by emphasizing real life role play and clinical role models should demonstrate continuity and agreement between the skills that are taught and those that are used in clinical practice.

Contains fulltext : 175755.pdf (Publisher’s version ) (Open Access) BACKGROUND: Cross-cultural communication in primary care is often difficult, leading to unsatisfactory, substandard care. Supportive evidence-based guidelines and training initiatives (G/TIs) exist to enhance cross cultural communication but their use in practice is sporadic. The objective of this paper is to elucidate how migrants and other stakeholders can adapt, introduce and evaluate such G/TIs in daily clinical practice. METHODS: We undertook linked qualitative case studies to implement G/TIs focused on enhancing cross cultural communication in primary care, in five European countries. We combined Normalisation Process Theory (NPT) as an analytical framework, with Participatory Learning and Action (PLA) as the research method to engage migrants, primary healthcare providers and other stakeholders. Across all five sites, 66 stakeholders participated in 62 PLA-style focus groups over a 19 month period, and took part in activities to adapt, introduce, and evaluate the G/TIs. Data, including transcripts of group meetings and researchers' fieldwork reports, were coded and thematically analysed by each team using NPT. RESULTS: In all settings, engaging migrants and other stakeholders was challenging but feasible. Stakeholders made significant adaptations to the G/TIs to fit their local context, for example, changing the focus of a G/TI from palliative care to mental health; or altering the target audience from General Practitioners (GPs) to the wider multidisciplinary team. They also progressed plans to deliver them in routine practice, for example liaising with GP practices regarding timing and location of training sessions and to evaluate their impact. All stakeholders reported benefits of the implemented G/TIs in daily practice. Training primary care teams (clinicians and administrators) resulted in a more tolerant attitude and more effective communication, with better focus on migrants' needs. Implementation of interpreter services was difficult mainly because of financial and other resource constraints. However, when used, migrants were more likely to trust the GP's diagnoses and GPs reported a clearer understanding of migrants' symptoms. CONCLUSIONS: Migrants, primary care providers and other key stakeholders can work effectively together to adapt and implement G/TIs to improve communication in cross-cultural consultations, and enhance understanding and trust between GPs and migrant patients.

It is important for health care workers to know the needs and expectations of their patients. Therefore, service users have to be involved in research. To achieve a meaningful dialogue between service users, healthcare workers and researchers, participatory methods are needed. This paper describes how the application of a specific participatory methodology, Participatory Learning and Action (PLA) can lead to such a meaningful dialogue. In PLA all stakeholders are regarded as equal partners and collaborators in research. During 2011–2015, a European project called RESTORE used PLA in Austria, Greece, Ireland, The Netherlands and the UK to investigate how communication between primary health care workers and their migrant patients could be improved. Seventy eight migrants, interpreters, doctors, nurses and other key stakeholders (see Table 2) participated in 62 PLA sessions. These dialogues (involving discussions, activities, PLA techniques and evaluations) were generally 2–3 h long and were recorded and analysed by the researchers. Participants reported many positive experiences about their dialogues with other stakeholders. There was a positive, trusting atmosphere in which all stakeholders could express their views despite differences in social power. This made for better understanding within and across stakeholder groups. For instance a doctor changed her view on the use of interpreters after a migrant explained why this was important. Negative experiences were rare: some doctors and healthcare workers thought the PLA sessions took a lot of time; and despite the good dialogue, there was disappointment that very few migrants used the new interpreting service. Background In order to be effective, primary healthcare must understand the health needs, values and expectations of the population it serves. Recent research has shown that the involvement of service users and other stakeholders and gathering information on their perspectives can contribute positively to many aspects of primary healthcare. Participatory methodologies have the potential to support engagement and dialogue between stakeholders from academic, migrant community and health service settings. This paper focuses on a specific participatory research methodology, Participatory Learning and Action (PLA) in which all stakeholders are regarded as equal partners and collaborators in research. Our research question for this paper was: "Does the application of PLA lead to meaningful engagement of all stakeholders, and if so, what elements contribute to a positive and productive inter-stakeholder dialogue?". Methods We explored the use of PLA in RESTORE, a European FP7-funded project, during 2011–2015 in 5 countries: Austria, Greece, Ireland, the Netherlands and the UK. The objective of RESTORE was to investigate and support the implementation of guidelines and training initiatives (G/TIs) to enhance communication in cross-cultural primary care consultations with migrants. Seventy eight stakeholders (migrants, interpreters, doctors, nurses and others – see Table 2) participated in a total of 62 PLA sessions (discussions, activities, evaluations) of approximately 2–3 h’ duration across the five sites. During the fieldwork, qualitative data were generated about stakeholders’ experiences of engagement in this dialogue, by means of various methods including participatory evaluations, researchers’ fieldwork reports and researcher interviews. These were analysed following the principles of thematic analysis. Results Stakeholders involved in PLA inter-stakeholder dialogues reported a wide range of positive experiences of engagement, and very few negative experiences. A positive atmosphere during early research sessions helped to create a sense of safety and trust. This enabled stakeholders from very different backgrounds, with different social status and power, to offer their perspectives in a way that led to enhanced learning in the group – they learned with and from each other. This fostered shifts in understanding – for example, a doctor changed her view on interpreted consultations because of the input of the migrant service-users. Conclusion PLA successfully promoted stakeholder involvement in meaningful and productive inter-stakeholder dialogues. This makes it an attractive approach to enhance the further development of health research partnerships to advance primary healthcare.

Op 30 maart 2019 is professor Harry Crebolder op 81-jarige leeftijd overleden. Hij was emeritus hoogleraar en oud-vakgroepvoorzitter huisartsgeneeskunde van de Universiteit Maastricht.

Exacerbations and associated healthcare cost in patients with COPD in general practice. T.R.J. Schermer, C.G.J. Saris, W.J.H.M. van den Bosch, N.H. Chavannes, C.P. van Schayck, P.N.R. Dekhuijzen, C. van Weel. Background. Acute exacerbations are a characteristic clinical expression of chronic obstructive pulmonary dis- ease (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 Prima- ry Care Treatment (COOPT) trial was used. Details on the occurrence and management of exacerbations were col- lected by systematic medical record review for the 2-year period preceding trial inclusion. Results. The mean age of the 286 study subjects in- volved was 59.2 (SD 9.6) years, postbronchodilator FEV 1 67.1% (SD 16.2) of predicted. Following ERS criteria, sub- jects 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, € 53, € 61 and € 92 for the respective severity subgroups (p=0.012). The increase of costs in the more severe sub- groups was mainly attributable to more physician consul- tations, diagnostic procedures, and prescription of reliever medication (e.g., bronchodilators, cough preparations). Conclusions. Occurrence of exacerbations did not de- pend on the severity of airflow obstruction, whereas the healthcare cost associated with exacerbations increased along with the severity of the disease. Monaldi Arch Chest Dis 2006; 65: 3, 133-140.

Concepts of disease severity, activity, control and responsiveness to treatment are linked but different. Severity refers to the loss of function of the organs induced by the disease process or to the occurrence of severe acute exacerbations. Severity may vary over time and needs regular follow-up. Control is the degree to which therapy goals are currently met. These concepts have evolved over time for asthma in guidelines, task forces or consensus meetings. The aim of this paper is to generalize the approach of the uniform definition of severe asthma presented to WHO for chronic allergic and associated diseases (rhinitis, chronic rhinosinusitis, chronic urticaria and atopic dermatitis) in order to have a uniform definition of severity, control and risk, usable in most situations. It is based on the appropriate diagnosis, availability and accessibility of treatments, treatment responsiveness and associated factors such as comorbidities and risk factors. This uniform definition will allow a better definition of the phenotypes of severe allergic (and related) diseases for clinical practice, research (including epidemiology), public health purposes, education and the discovery of novel therapies.

The links between asthma and rhinitis are well characterized. The Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines stress the importance of these links and provide guidance for their prevention and treatment. Despite effective treatments being available, too few patients receive appropriate medical care for both diseases. Most patients with rhinitis and asthma consult primary care physicians and therefore these physicians are encouraged to understand and use ARIA guidelines. Patients should also be informed about these guidelines to raise their awareness of optimal care and increase control of the two related diseases. To apply these guidelines, clinicians and patients need to understand how and why the recommendations were made. The goal of the ARIA guidelines is to provide recommendations about the best management options for most patients in most situations. These recommendations should be based on the best available evidence. Making recommendations requires the assessment of the quality of available evidence, deciding on the balance between benefits and downsides, consideration of patients’ values and preferences, and, if applicable, resource implications. Guidelines must be updated as new management options become available or important new evidence emerges. Transparent reporting of guidelines facilitates understanding and acceptance, but implementation strategies need to be improved.

Chavannes NH, Schermer TRJ, Wouters EFM, Akkermans RP, Dekhuijzen PNR, Muris JWM, et al. Het nut van de orale prednisontest bij de behandeling van COPD in de eerste lijn. Huisarts Wet 2010;5:272-6. We gebruikten de orale prednisontest om te achterhalen welke COPD-patienten baat konden hebben bij behandeling met inhalatiesteroiden. Eerdere onderzoeken hadden betrekking op geselecteerde patienten die niet representatief zijn voor de grote groep COPD-patienten die onder behandeling staan van een huisarts. We includeerden rokers en voormalige rokers met chronische bronchitis of COPD. Voorafgaand aan randomisatie ondergingen zij een orale prednisontest (14 dagen 30 mg) in een driejarige gerandomiseerde klinische trial (COOPT-trial). We verrichtten voor en na de prednisontest longfunctiemetingen. Responders en non-responders classificeerden we aan de hand van (inter)nationale criteria. Met behulp van analysetechnieken voor herhaalde metingen vergeleken we daarna de effectiviteit van geinhaleerd fluticason (FLU) ten opzichte van placebo. Uitkomstmaten waren kwaliteit van leven (Chronic Respiratory Disease Questionnaire), exacerbatiefrequentie en eensecondevolume ( FEV1) na luchtwegverwijding. We randomiseerden 286 patienten uit 44 huisartspraktijken. Negen tot 16% van de COPD-populatie classificeerden we als responder, afhankelijk van de gebruikte criteria. Gemiddeld bereikten responders niet het minimaal klinisch relevante verschil op de kwaliteit van leven, al vonden we een borderline significant effect van FLU (0,29 punten/jaar, p = 0,05). We zagen mogelijk klinisch relevante reducties in exacerbatiefrequentie (rate ratio 0,67) en FEV1 -achteruitgang (39 ml/jaar), maar deze bereikten geen statistische significantie. De orale prednisontest onderscheidde een beperkt aantal eerstelijnspatienten met COPD bij wie geen klinisch relevant effect van inhalatiesteroiden op de kwaliteit van leven optrad. Daarnaast zagen we geen significante effecten op exacerbatiefrequentie of longfunctiedaling.

To cite this article: van den Nieuwenhof L, Schermer T, Bosch Y, Bousquet J, Heijdra Y, Bor H, van den Bosch W, van Weel C. Is physician-diagnosed allergic rhinitis a risk factor for the development of asthma? Allergy 2010; 65: 1049–1055. Abstract Background: There is strong evidence that there is a relationship between allergic rhinitis (AR) and asthma, but it is unclear whether there is a causal relation between AR and asthma. The aim of this study was to assess prospectively whether AR is a risk factor for the diagnosis of asthma in a large primary care population. Methods: We performed a historic cohort study of life-time morbidity that had been recorded prospectively since 1967 in four general practices. Two groups of subjects were selected: (i) patients with diagnosis of AR, (ii) a control group matched using propensity scores. We assessed the risk of physician-diagnosed asthma in patients with physician-diagnosed AR compared to subjects without a diagnosis of AR (controls). Results: The study population consisted of 6491 subjects (n = 2081 patients with AR). Average study follow-up was 8.4 years. In patients with AR, the frequency of newly diagnosed asthma was 7.6% (n = 158) compared to 1.6% (n = 70) in controls (P

Contains fulltext : 87987.pdf (Publisher’s version ) (Closed access) Chronic obstructive pulmonary disease (COPD) is a highly prevalent disease, characterised by poorly reversible, obstructive airflow limitation. Alongside other comorbidities, COPD is associated with increased morbidity and mortality resulting from cardiovascular disease - mainly heart failure and ischemic heart disease. Both diseases share an important risk factor, namely, smoking. About 50% of COPD patients are active cigarette smokers. Bronchodilation is the cornerstone of pharmaceutical treatment for COPD symptoms, and half of all COPD patients use long-acting bronchodilating agents. Discussion about these agents is currently focusing on the association with overall mortality and morbidity in COPD patients, of cardiovascular origin in particular. Bronchodilation diminishes the hyperinflated state of the lung and facilitates the pulmonary deposition of cigarette smoke by deeper inhalation into the smaller airways. Smaller particles, as in smoke, tend to penetrate and depose more in these small airways. In addition, bronchodilation indeed increases carbon monoxide uptake in the lungs, an important gaseous compound of cigarette smoke. Since the number of cigarettes smoked is positively correlated to mortality from cardiac events, we therefore hypothesise that chronic bronchodilation increases cardiovascular disease and mortality in COPD patients who continue smoking by increasing pulmonary retention of pathogenic smoke constituents. Indeed, a recent meta-analysis is suggestive that long-acting anticholinergics might increase cardiovascular disease if patients exceed a certain number of cigarettes smoked. To demonstrate the fundamental mechanism of this pathogenic interaction we will perform a randomised placebo-controlled cross-over trial to investigate the effect of maximum bronchodilation on the retention of cigarette smoke constituents. In 40 moderate to severe COPD patients we measure the inhaled and exhaled amount of tar and nicotine, as well during maximum bronchodilation as during administration of placebo. The fraction of retention of tar and nicotine is subsequently calculated for both circumstances and analysed for association with bronchodilation. Further observational cohort studies or randomised clinical trials designed to monitor cardiovascular events may well evaluate the interaction. Since many patients are at risk for this possibly hazardous interaction, its relevance to our society and healthcare is potentially great. The implication will be that the urgency to quit smoking is intensified. Besides, chronic bronchodilation - specifically long-acting bronchodilators - needs to be discouraged in smoking COPD patients that refuse to quit. 01 februari 2010

Contains fulltext : 81520.pdf (Publisher’s version ) (Closed access) AIM: To assess the impact of two modes of spirometry expert support on Family physicians' (FPs') diagnoses and planned management in patients with apparent respiratory disease. METHOD: A cluster-randomised trial was performed with family practices as the unit of randomisation. FPs from 44 family practices recorded their diagnosis and planned management before and after spirometry for 868 patients. Intervention consisted of spirometry interpretation support by either a chest physician or expert software. Both interventions were compared with usual care (i.e. no additional interpretation support). Change in FPs' diagnoses after spirometry served as the primary outcome. Secondary outcomes were referral rate, additional diagnostic tests, and disease management changes. Effects were expressed as percentages and Odds Ratios (OR) with 95% confidence intervals. RESULTS: Diagnoses changed after intervention in all groups: 47.8% (95% CI 41.8 to 53.9) for chest physician support; 45.0% (95% CI 39.5 to 50.6) for software support; and 53.3% (95% CI 47.2 to 59.4) for usual care. Differences in the proportions of changed diagnosis were not statistically significant: chest physician support versus usual care OR 0.79 (95%CI 0.49 to 1.30); software support versus usual care OR 0.72 (95% CI 0.45 - 1.15). There were no differences in secondary outcomes. CONCLUSION: Neither chest physician spirometry support nor expert software spirometry support had a significant impact on FPs' diagnosis of respiratory conditions or management decisions. TRIAL NUMBER: http://www.clinicaltrials.gov/ct/show/NCT00131157?order=1.

Allergic rhinitis is a symptomatic disorder of the nose induced after allergen exposure by an IgE-mediated inflammation of the membranes lining the nose. It is a global health problem that causes major illness and disability worldwide. Over 600 million patients from all countries, all ethnic groups and of all ages suffer from allergic rhinitis. It affects social life, sleep, school and work and its economic impact is substantial. Risk factors for allergic rhinitis are well identified. Indoor and outdoor allergens as well as occupational agents cause rhinitis and other allergic diseases. The role of indoor and outdoor pollution is probably very important, but has yet to be fully understood both for the occurrence of the disease and its manifestations. In 1999, during the Allergic Rhinitis and its Impact on Asthma (ARIA) WHO workshop, the expert panel proposed a new classification for allergic rhinitis which was subdivided into 'intermittent' or 'persistent' disease. This classification is now validated. The diagnosis of allergic rhinitis is often quite easy, but in some cases it may cause problems and many patients are still under-diagnosed, often because they do not perceive the symptoms of rhinitis as a disease impairing their social life, school and work. The management of allergic rhinitis is well established and the ARIA expert panel based its recommendations on evidence using an extensive review of the literature available up to December 1999. The statements of evidence for the development of these guidelines followed WHO rules and were based on those of Shekelle et al. A large number of papers have been published since 2000 and are extensively reviewed in the 2008 Update using the same evidence-based system. Recommendations for the management of allergic rhinitis are similar in both the ARIA workshop report and the 2008 Update. In the future, the GRADE approach will be used, but is not yet available. Another important aspect of the ARIA guidelines was to consider co-morbidities. Both allergic rhinitis and asthma are systemic inflammatory conditions and often co-exist in the same patients. In the 2008 Update, these links have been confirmed. The ARIA document is not intended to be a standard-of-care document for individual countries. It is provided as a basis for physicians, health care professionals and organizations involved in the treatment of allergic rhinitis and asthma in various countries to facilitate the development of relevant local standard-of-care documents for patients.

Teunissen TAM, Van den Bosch WJHM, Van Weel C, Lagro-Janssen ALM. Handelt de huisarts bij ouderen anders dan de NHG-Standaard Incontinentie voor urine adviseert? En zo ja, waarom? Huisarts Wet 2008;51(2)70-5.

Primary care spirometry is a uniquely valuable tool in the evaluation of patients with respiratory symptoms, allowing the general practitioner to diagnose or exclude chronic obstructive pulmonary disease (COPD), sometimes to confirm asthma, to determine the efficacy of asthma treatment and to correctly stage patients with COPD. The use of spirometry for case finding in asymptomatic COPD patients might become an option, once early intervention studies have shown it to be beneficial in these patients. The diagnosis of airway obstruction requires accurate and reproducible spirometric measurements, which should comply with the American Thoracic Society (ATS)/European Respiratory Society (ERS) guidelines. Low acceptability of spirometric manoeuvres has been reported in primary care practices. This may hamper the validity of the results and affect clinical decision making. Training and refresher courses may produce and maintain good-quality testing, promote the use of spirometric results in clinical practice and enhance the quality of interpretation. Softening the stringent ATS/ERS criteria could enhance the acceptability rates of spirometry when used in a general practice. However, the implications of potential simplifications on the quality of the data and clinical decision making remain to be investigated. Hand-held office spirometers have been developed in recent years, with a global quality and user-friendliness that makes them acceptable for use in general practices. The precision of the forced vital capacity measurements could be improved in some of the available models.

Contains fulltext : 69188.pdf (Publisher’s version ) (Closed access) The aim of the present study was to establish the agreement between two recommended definitions of airflow obstruction in symptomatic adults referred for spirometry by their general practitioner, and investigate how rates of airflow obstruction change when pre-bronchodilator instead of post-bronchodilator spirometry is performed. The diagnostic spirometric results of 14,056 adults with respiratory obstruction were analysed. Differences in interpretation between a fixed 0.70 forced expiratory volume in one second (FEV(1))/forced vital capacity (FVC) cut-off point and a sex- and age-specific lower limit of normal cut-off point for this ratio were investigated. Of the subjects, 53% were female and 69% were current or ex-smokers. The mean post-bronchodilator FEV(1)/FVC was 0.73 in males and 0.78 in females. The sensitivity of the fixed relative to the lower limit of normal cut-off point definition was 97.9%, with a specificity of 91.2%, positive predictive value of 72.0% and negative predictive value of 99.5%. For the subgroup of current or ex-smokers aged > or =50 yrs, these values were 100, 82.0, 69.2 and 100%, respectively. The proportion of false positive diagnoses using the fixed cut-off point increased with age. The positive predictive value of pre-bronchodilator airflow obstruction was 74.7% among current or ex-smokers aged > or =50 yrs. The current clinical guideline-recommended fixed 0.70 forced expiratory volume in one second/forced vital capacity cut-off point leads to substantial overdiagnosis of obstruction in middle-aged and elderly patients in primary care. Using pre-bronchodilator spirometry leads to a high rate of false positive interpretations of obstruction in primary care.

Contains fulltext : 71356.pdf (Publisher’s version ) (Closed access) Allergic rhinitis (AR) is a very common disease with over 600 million people (200 million of them with concomitant asthma) worldwide suffering from it. The majority of patients who seek medical advice are seen in primary care. Although there is a selection of guidelines focused on the management of AR, there is a paucity of guidance on how best to identify patients who would most benefit from treatment. The aim of this paper was to review the best practice for primary care with respect to the diagnosis of AR within that clinical environment.

Plat E, Scherer M, Van Weel C. De behandeling van aspecifieke nekklachten. Huisarts Wet 2007;50(13):660-5. Inleiding Aspecifieke nekklachten zijn, na lage rugpijn en schouderklachten, de meest voorkomende klachten van het bewegingsapparaat. In Nederland is geen richtlijn beschikbaar voor de behandeling van aspecifieke nekklachten. Doel van dit literatuuronderzoek is in kaart te brengen welke onderzochte eerstelijnsbehandelingsmogelijkheden effectief zijn. Methode Wij verrichtten een systematisch literatuuronderzoek naar de behandeling van aspecifieke nekpijn in de databanken Cinahl, EMBASE, MEDLINE en Cochrane. Twee onderzoekers includeerden onderzoeken onafhankelijk van elkaar en beoordeelden de artikelen onafhankelijk van elkaar op wetenschappelijke bewijskracht. Resultaten Na selectie van 157 artikelen, bleven er 41 over die aan de inclusiecriteria voldeden. Over medicamenteuze behandeling bij nekpijn is slechts zeer weinig gepubliceerd. Paramedische behandelingen zijn uitgebreid bestudeerd, maar de kwaliteit van de onderzoeken laat te wensen over. Beschouwing Acute nekpijn benadert men bij voorkeur expectatief of met analgetica. Voor subacute en chronische nekpijn is manuele therapie in combinatie met oefentherapie veruit de beste behandelingsoptie. Andere behandelingen worden besproken. Er is behoefte aan kwalitatief goed onderzoek naar de effecten van paramedische behandelingen.

Contains fulltext : 52985.pdf (Publisher’s version ) (Closed access) BACKGROUND: Skin diseases are a substantial part of the problems dealt with by general practitioners. Although the psychosocial consequences of skin diseases in secondary care has been extensively studied, little is known about the psychosocial well-being of patients with skin diseases in primary care. OBJECTIVE: To investigate the psychosocial well-being of patients with skin diseases in primary care. PATIENTS/METHODS: Questionnaires about the psychosocial consequences of skin diseases were sent to patients with a skin disease who were registered within a research network (continuous morbidity registration) of general practices that continuously have recorded morbidity data since 1971. Questionnaires completed by 532 patients were eventually suitable for analyses. RESULTS: Compared with the general population, patients with skin diseases reported significantly lower scores for psychosocial well-being. Furthermore, a lower psychosocial wellbeing was significantly related with higher levels of disease-severity, lower disease-related quality of life, longer disease duration, more comorbidity and more physical symptoms of itch, pain and fatigue. After demographic variables and comorbidity were controlled for, sequential regression analyses showed that disease duration, disease severity and physical symptoms (itch, pain and fatigue) were significant predictors of psychosocial well-being. CONCLUSION: The psychosocial well-being of patients with skin diseases in primary care is lower than that of the general population. Special attention has to be directed to those patients with lowered psychosocial well-being who might be at risk of developing severe psychosocial impairments such as clinical depression.

Teunissen TAM, Van Weel C, Lagro-Janssen ALM. Urine-incontinentie bij zelfstandig wonende ouderen: wie zoekt er hulp bij de huisarts? Huisarts Wet 2007;50(1)4-10. Doel Bepaling van ziekte- en patientfactoren die mede beinvloeden of zelfstandig wonende ouderen met urine-incontinentie hulp zoeken. Onderzoeksopzet Kwalitatieve en kwantitatieve analyse van gegevens uit interviews. Methode Alle zelfstandig wonende ouderen van 60 jaar en ouder uit 9 huisartssenpraktijken werden thuis geinterviewd (56 mannen en 314 vrouwen). We gebruikten hierbij gevalideerde vragenlijsten en open vragen. Resultaten De helft van de geinterviewden had hulp gezocht bij de huisarts. De beslissing om hulp te gaan zoeken was gerelateerd aan de duur en de ernst van de klachten, de emotionele en/of fysieke gevolgen, en de aanwezigheid van begeleidende urogenitale klachten, met name bemoeilijkte mictie. Alleen de duur van de incontinentie (odds-ratio 2,37) en de begeleidende urogenitale klachten (odds-ratio 2,75) waren significante voorspellers voor het zoeken van hulp. De belangrijkste redenen om geen hulp te zoeken waren de geringe ernst van de incontinentie en ideeen als ‘het hoort bij de leeftijd’ en ‘er is toch niets aan te doen’. Verergering van de klachten en behoefte aan incontinentiemateriaal waren redenen om uiteindelijk wel naar de huisarts te gaan. Conclusie Of zelfstandig wonende ouderen met urine-incontinentie hulp zoeken wordt bepaald door de ervaren hinder en de aanwezigheid van begeleidende urogenitale klachten. Te weinig hinder en de veronderstelling dat er toch niets aan te doen is, zijn belangrijke redenen om van hulp af te zien.

Contains fulltext : 154329.pdf (Publisher’s version ) (Open Access) BACKGROUND: Most patients with advanced cancer, debilitating COPD or chronic heart failure (CHF) live at home. General practitioners (GPs) asked for guidance in how to recognize patients in need of palliative care in a timely way and to structure anticipatory care. For that reason, we developed a training for GPs in identifying patients in need of palliative care and in structuring anticipatory palliative care planning and studied its effect on out-of-hours contacts, contacts with their own GP, hospitalizations and place of death. METHODS: We performed a cluster randomised controlled trial. GPs in the intervention group were trained in identifying patients in need of palliative care and anticipatory care planning. Next, for each identified patient, they were offered a coaching session with a specialist in palliative care to fine-tune a structured care plan. The GPs in the control group did not receive training or coaching, and were asked to provide care as usual. After one year, characteristics of patients deceased of cancer, COPD or CHF in both study groups were compared with mixed effects models for out-of-hours contacts (primary outcome), contacts with their own GP, place of death and hospitalizations in the last months of their life (secondary outcomes). As a post-hoc analysis, of identified patients (of the intervention GPs) these figures were compared to all other deceased patients, who had not been identified as in need of palliative care. RESULTS: We did not find any differences between the intervention and control group. Yet, only half of the trained GPs (28) identified patients (52), which was only 24 % of the deceased patients. Those identified patients had significantly more contacts with their own GP (B 4.5218; p

Schermer TRJ, Chavannes NH, Hendriks AJC, Dekhuijzen PNR, Wouters EFM, Van den Hoogen H, Van Schayck CP, Van Weel C. Stoppen van onderhoudsbehandeling met inhalatiesteroiden bij COPD. Huisarts Wet 2006;49(11):544-9. Doel (1) De kans op een negatieve respiratoire uitkomst te bepalen na het stoppen van een onderhoudsbehandeling met inhalatiesteroiden bij eerstelijnspatienten met chronisch obstructief longlijden (COPD) en (2) na te gaan of die kans verband houdt met patientkenmerken.Methode Prospectief open stoponderzoek in 45 huisartsenpraktijken bij 201 patienten met lichte tot ernstige COPD die een onderhoudsbehandeling met inhalatiesteroiden ontvingen. De onderzochte effectmaten waren de kans op, en tijd tot,een negatieve respiratoire uitkomst (dat wil zeggen exacerbatie of aanhoudende toename van de luchtwegklachten) na het discontinueren van de inhalatiesteroiden.Resultaten De gemiddelde leeftijd van de deelnemende patienten was 60,6 (SD 9,5) jaar, de postbronchodilatatoire FEV1 was 65,6% (SD 15,7) van de voorspelde waarde. De totale kans op een negatieve respiratoire uitkomst na het stoppen met de inhalatiesteroiden was 0,37 (95%-BI 0,31-0,44). Multivariate survivalanalyse liet zien dat leeftijd, geslacht, rookstatus en reversibiliteit van de luchtwegobstructie onafhankelijke voorspellers zijn van een negatieve respiratoire uitkomst. Voor vrouwen was het gecorrigeerde risico (hazardratio) 2,14 (95%-BI 1,31-3,50), vergeleken met mannen. Voor leeftijd was de hazardratio 1,05 (95%-BI 1,02-1,08) per levensjaar.Conclusie Het staken van een onderhoudsbehandeling met inhalatiesteroiden vergroot de kans op een exacerbatie of toename van luchtwegklachten aanzienlijk. Leeftijd, geslacht, rookstatus en reversibiliteit van de luchtwegobstructie zijn daarop mede van invloed. Als men overweegt om een COPD-patient te laten stoppen met inhalatiesteroiden, is het aan te bevelen vooraf een gedegen inschatting te maken van de kans op een negatieve uitkomst, en vroege uitingen daarvan zorgvuldig te monitoren.

Schonberger HJAM, Dompeling E, Knottnerus JA, Muris JWM, Van Weel C, Van Schayck CP. Het klinisch effect van een voorlichtingsprogramma om astma bij kinderen te voorkomen. Het Prevask-onderzoek. Huisarts Wet 2005;48(11):542-7. Achtergrond Aangezien astma de meest voorkomende chronische aandoening is bij kinderen, krijgt primaire preventie van astma veel aandacht. Wij onderzochten de klinische effectiviteit van een niet-medicamenteus preventieprogramma van astma bij kinderen. Methode Huisartsen en verloskundigen rekruteerden aanstaande moeders van babys met een hoog risico op astma door het voorkomen van astma in het gezin. Zij werden door het lot toegewezen aan een controlegroep die gebruikelijke zorg ontving of aan een interventiegroep die het preventieprogramma kreeg. Verpleegsters instrueerden de ouders op welke wijze zij de blootstelling van hun pasgeborene aan allergenen van de huisstofmijt, huisdieren, voedselallergenen en passief roken het beste konden vermijden. Resultaten Van de 476 kinderen hebben wij 443 kinderen gedurende 2 jaar gevolgd. Aan het einde van het tweede levensjaar had de interventiegroep (n=222) minder astmatische symptomen – piepen en nachtelijk hoesten – dan de controlegroep (n=221) (OR 0,73; 95%-BI 0,56-0,96), kortademigheid (OR 0,76; 95%-BI 0,61-0,96) en nachtelijk hoesten (OR 0,72; 95%-BI 0,55-0,95). Het totale en specifieke IgE was niet verschillend tussen de groepen. De incidentie van astmatische symptomen in de eerst twee levensjaren was gelijk in beide groepen, maar bleek in subgroepanalyse significant verminderd in de meisjesinterventiegroep, maar niet in de jongensinterventiegroep. Conclusie Het preventieprogramma verminderde astmatische klachten in de eerste twee jaar niet, maar wel enigszins aan het einde van het tweede jaar. Follow-up is noodzakelijk om te bevestigen of met het preventieprogramma de ontwikkeling van astma kan worden voorkomen.

Contains fulltext : 48515.pdf (Publisher’s version ) (Closed access) Social support is important to achieve beneficial changes in risk factors for disease, such as overweight and obesity. This paper presents the theoretical and practical framework for social support, and the mechanisms by which social support affects body weight. The theoretical and practical framework is supported with a literature review addressing studies involving a social support intervention for weight loss and weight loss maintenance. A major aspect in social support research and practice is the distinction between structural and functional support. Structural support refers to the availability of potential support-givers, while functional support refers to the perception of support. Interventions often affect structural support, for example, through peer groups, yet functional support shows a stronger correlation with health. Although positive correlations between social support and health have been shown, social support may also counteract health behaviour change. Most interventions discussed in this review showed positive health outcomes. Surprisingly, social support was clearly defined on a practical level in hardly any studies, and social support was assessed as an outcome variable in even fewer studies. Future social support intervention research would benefit from clear definitions of social support, a clear description of the intended mechanism of action and the actual intervention, and the inclusion of perceived social support as a study outcome.

Contains fulltext : 48446.pdf (Publisher’s version ) (Closed access) Systematic reviews that include nonrandomized studies (NRS) face a number of logistical challenges. However, the greatest threat to the validity of such reviews arises from the differing susceptibility of randomized controlled trials (RCTs) and NRS to selection bias. Groups compared in NRS are unlikely to be balanced because of the reasons leading study participants to adopt different health behaviours or to be treated differentially. Researchers can try to minimize the susceptibility of NRS to selection bias both at the design stage, for example, by matching participants on key prognostic factors, and during data analysis, for example, by regression modelling. However, because of logistical difficulties in matching, imperfect knowledge about the relationships between prognostic factors and between prognostic factors and outcome, and measurement limitations, it is inevitable that estimates of effect size derived from NRS will be confounded to some extent. Researchers, reviewers and users of evidence alike need to be aware of the consequences of residual confounding. In poor quality RCTs, selection bias tends to favour the new treatment being evaluated. Selection bias need not necessarily lead to systematic bias in favour of one treatment but, even if it acts in an unpredictable way, it will still give rise to additional, nonstatistical uncertainty bias around the estimate of effect size. Systematic reviews of NRS studies run the risk of compounding these biases. Nutritional choices and uptake of health education about nutrition are very likely to be associated with potential confounding factors. Therefore, pooled estimates of the effects of nutritional exposures and their confidence intervals are likely to be misleading; reviewers need to take into account both systematic and uncertainty bias.

This paper was based on collaborative research efforts from Wageningen University and the University Medical Centre St Radboud in The Netherlands and describes the rationale for web-based nutrition counselling applications in general practice as well as some of the frequently used models and theories (predominantly the Stages of Change Model). General practitioners can play an important role in cardiovascular risk reduction by giving nutrition counselling to patients at elevated cardiovascular risk. Unfortunately, general practitioners perceive barriers that may limit their nutrition counselling practices. Some of these barriers may be overcome using computer and Internet technologies. Computerized reminders for preventive services, and websites with reliable high-quality information may prove to be valuable additions to usual care. Cooperation with dieticians may also lead to improvements in nutrition counselling in general practice. For example, general practitioners could use their unique position to create awareness and motivation among patients. They could subsequently refer motivated patients to dieticians for detailed personal dietary advice. © 2005 Nature Publishing Group. All rights reserved.

Contains fulltext : 47622.pdf (Publisher’s version ) (Open Access) BACKGROUND: It has been suggested that severe COPD is associated with depressive symptoms, possibly linked to exacerbations, dyspnea and hospitalisation. However, scarce data are available in primary care where most patients suffer from mild or moderate disease. OBJECTIVE: We aimed to reveal associations of depressive symptoms with demographic and clinical characteristics in mild to moderate COPD. METHODS: Cross-sectional data on lung function measurements, exacerbation frequency, dyspnea, comorbidity, smoking behaviour, body mass index (BMI), age, gender and depressive symptoms (Beck Depression Inventory) of 147 primary care patients were assessed in multiple logistic regression analyses. RESULTS: Patients suffered from mild to moderate obstruction (FEV1 63.6% pred, range 45.1% to 82.1%). Female gender (OR 4.8, 95% CI 2.1 to 10.8), BMI > 25 (OR 0.4, 95% CI 0.2 to 0.8) and current smoking (OR 2.3, 95% CI 1.01 to 5.3) were univariately associated with depressive symptoms, while in a multivariate logistic model only female gender (OR 4.0, 95% CI 1.6 to 9.9), BMI > 25 (OR 0.3, 95% CI 0.1 to 0.7) and dyspnea (OR 1.8, 95% CI 1.1 to 2.9) were independently associated with depressive symptoms. Conclusion. These data suggest that in primary care depressive symptoms in COPD seem to be related with female gender, BMI and dyspnea. In this study, lung function, exacerbation rate, smoking behaviour, age and comorbidity are not independently associated with depressive symptoms in COPD of mild to moderate severity.

Contains fulltext : 47892.pdf (Publisher’s version ) (Closed access) As asthma is the most common chronic disease in childhood, much attention is directed towards primary prevention. Here, the clinical effectiveness of a multifaceted educational prevention was studied. A total of 476 high-risk children were recruited during the prenatal period by general practitioners and randomised to either: 1) a control group, receiving usual care; or 2) an intervention group in which families received instruction from nurses on how to reduce exposure of newborns to mite, pet and food allergens, and passive smoking. A total of 443 infants were followed-up for 2 yrs. At 2 yrs of age, the intervention group (n = 222) had less asthma-like symptoms, including wheezing, shortness of breath and night-time cough, than the control group (n = 221). No significant differences in total and specific immunoglobulin E were found between the groups. During the first 2 yrs of life, the incidence of asthma-like symptoms was similar in both groups; however, subanalysis revealed a significant reduction in the female, but not in the male, intervention group. In conclusion, the intervention used in this study was not effective in reducing asthma-like symptoms in high-risk children during the first 2 yrs of life, although it was modestly effective at 2 yrs. Follow-up is necessary to confirm whether the intervention can actually prevent the development of asthma.

The Cochrane Collaboration helps people make well-informed decisions about health care by preparing, maintaining and promoting the accessibility of systematic reviews of the effects of healthcare interventions. In all, 51 Cochrane Review Groups are responsible for preparing and maintaining the reviews. Most of these Review Groups are problem-based. However, there are a number of areas or dimensions of health care, such as the setting of care (eg primary care) or the type of patient/consumer (eg older persons), that cannot be usefully conceptualised as ‘health problems’. In order to reflect the interests of these dimensions, or ‘fields’, of health care more effectively, the Cochrane Collaboration created another type of entity: Cochrane Fields or Networks. The core functions of these Fields are described. It is proposed that a new Cochrane Subfield for Diet and Nutrition should be set up to attract a cadre of new reviewers in order to ensure the proper representation of diet and nutrition expertise in the relevant Collaborative Review Groups. The methodological pitfalls of the use of nonrandomised studies will be a key issue for the new Subfield, since the focus of the Cochrane Collaboration's programme of searching databases, journals and conference proceedings has been on the identification of reports of randomised controlled trials (RCTs). Some of these sources will be need to be searched again for non-RCT studies. The financial considerations of establishing of a Cochrane Subfield for Diet and Nutrition are discussed.

This paper reviews the experience of international exchange of medical students for general practice. The experience is based on the EU Socrates programme 'Primary Health Care' that offers, since 1992, clinical attachments and research electives in primary care. This programme involves 11 university departments of general practice/primary care in eight countries: Austria - Vienna; Belgium - Gent; Germany Düsseldorf; Italy - Monza, Udine; Netherlands Nijmegen; Slovenia - Ljubljana; Sweden - Göteborg; and the UK - Edinburgh, Imperial College London and Nottingham. More than 150 students have taken part in the programme, most in the last four years. For clinical attachment communication to patients is essential, and students should be able to speak the language of the host university. A research elective in primary care is less demanding and requires students' ability to communicate in English. Despite marked differences in health care structure in the countries involved, it is quite possible to provide a valuable teaching environment in general practice, and the experience gained by students in the exchanges more than equals that what they would gain at home. The added value is in experiencing the influence of another health care system and of working in another academic primary care centre. A substantial number of research electives have been published in international peer reviewed scientific journals with the student as first (occasionally second) author and staff members of the student's host and home university as co-authors. A further benefit of the exchange programme lies in the transfer teaching innovations between universities.

Contains fulltext : 59248.pdf (Publisher’s version ) (Closed access) BACKGROUND: Compliance to and the effect of pre- and post-natal exposure reduction measures to prevent asthma in high-risk children from asthmatic families were studied. METHOD: Families were randomized to a special care group (n=222) and a control group (n=221). Educational advice on measures to reduce their newborn's exposure to allergens and smoke was provided to the special care group during three visits (two pre-natal and one post-natal). The control group (n=221) received usual care. RESULT: After the intervention, the special care group differed significantly (P

Dutch nursing home care today includes a broad range of institutional and outreaching care functions. Medical care is an essential part of this care. Nursing home medicine in The Netherlands has developed as an officially acknowledged medical specialty. This is unique because The Netherlands is the only country in which nursing home medicine is a specific medical discipline. Because of this, a continuum in the medical care for the elderly has been developed: the family physician for medical care in the community, the nursing home physician for the institutionalized elderly, and the clinical geriatrician plus other medical specialists for elderly who require hospital care. This article describes the characteristics of Dutch nursing home care and nursing home medicine and the advantages of this system. The article also shows that the combination of the medical knowledge of family physician and nursing home physician can be expected to increase the quality of medical care for the disabled elderly in institutions and in the community.

Nursing home medicine in the Netherlands is an official medical specialism. The authors focus on the characteristics and benefits of this specific, resident-oriented type of care.

Item does not contain fulltext OBJECTIVE: To investigate the validity of spirometric tests performed in general practice. METHOD: A repeated within subject comparison of spirometric tests with a "gold standard" (spirometric tests performed in a pulmonary function laboratory) was performed in 388 subjects with chronic obstructive pulmonary disease (COPD) from 61 general practices and four laboratories. General practitioners and practice assistants undertook a spirometry training programme. Within subject differences in forced expiratory volume in 1 second and forced vital capacity (DeltaFEV1 and DeltaFVC) between laboratory and general practice tests were measured (practice minus laboratory value). The proportion of tests with FEV1 reproducibility

Objective To determine associations among lower urinary tract symptoms (LUTS), symptom severity, subjective beliefs and social influences when seeking primary medical care in men aged ≥ 50 years. Subjects and methods A population-based survey was conducted among 5052 men aged ≥ 50 years, using patient registers of 22 general practitioners (GPs) in the Netherlands from November 1999 to May 2000. The questionnaire contained items concerning age, educational level, International Prostate Symptom Score (IPSS), bothersome score (BS), and questions from the Health Belief Model on attitude and social influences. The study population comprised men with an IPSS openface> 7. The odds ratios (ORs) corrected for the IPSS were calculated. Results In all, 3544 questionnaires (70.2%) were returned. Two groups of men with an IPSS openface> 7 were compared: those who consulted their GP in the previous 2 years because of voiding problems (268 cases) and the controls (272) who did not visit a GP for these symptoms. Cases more often thought a physician could improve their condition (OR 2.85), appeared to be more often advised by others to seek medical care (OR 6.36) and thought more often that this advice influenced their decision (OR 13.95). They also had more frequently received information from the media (OR 2.66) which affected their attendance (OR 12.52). In a multiple regression analysis, advice from others or information from the media were stronger predictors of seeking care than the influence of symptoms on daily life, the IPSS or the BS. Conclusion Social influences, i.e. advice from others or the media, were more important factors in the decision to seek medical care than symptom severity.

De arts zal de klacht kortademigheid zoveel mogelijk vertalen naar objectiveerbare afwijkingen, waardoor gericht medisch handelen mogelijk wordt. Anamnese en lichamelijk onderzoek dienen met name om de ernst van de klacht te bepalen. Voor het stellen van een diagnose is vaak aanvullend onderzoek nodig. Meestal is dit spirometrie, een X-thorax of een ECG. Bij de meest voorkomende diagnosen (infecties, obstructief longlijden, hyperventilatie en hartfalen) wordt de diagnose gesteld op basis van waarschijnlijkheid en niet op een of meer pathognomonische kenmerken. Omdat een gouden standaard in veel gevallen ontbreekt, is de waarde van diagnostische bevindingen niet altijd goed in te schatten. Vaak blijven meerdere diagnosen aannemelijk en is het een probleem om het een van het ander te onderscheiden of de aanwezigheid van meerdere diagnosen te bevestigen. Juist met dit spanningsveld van het een aantonen en het ander niet uitsluiten heeft de praktiserend arts het meest te maken.

Vraagstelling Kunnen inhalatiecorticosteroiden bij COPD de achteruitgang van de longfunctie (FEV1) vertragen? Methoden Er werden wee artikelen geselecteerd en een abstract. Patienten met ‘astmatische kenmerken’ werden uitgesloten. In deze meta-analyse werden 95 geselecteerde patienten behandeld met inhalatiecorticosteroiden (87 met 1500/1600 µg beclomethason of budesonide per dag, 8 met 800 µg beclomethason per dag), en 88 met placebo. Het effect op FEV1 werd geanalyseerd met behulp van de multiple repeated measurement-methode. Resultaten De patienten waren gemiddeld 61 jaar oud en hadden matig tot ernstig COPD (FEV1 = 45 % van voorspeld). Er was een significant verschil in de prebronchodilatoire FEV1 over twee jaar van +0,034 l/jaar (95%-BI +0,005-0,063) in het voordeel van de met inhalatiecorticosteroiden behandelde groep, vergeleken met placebo, maar niet in postbronchodilatoire FEV1 (95%-BI -0,006-0,084). Het aantal exacerbaties werd niet beinvloed door de behandeling. Conclusies De meta-analyse van patienten met duidelijk gedefinieerd matig tot ernstig COPD liet een beter verloop van de FEV1 zien bij behandeling met relatief hoge doseringen inhalatiecorticosteroiden over twee jaar. In vier andere grote onderzoeken werd geen effect van inhalatiecorticosteroiden vastgesteld op het longfunctieverloop bij patienten met diversen ernstgraden van COPD.

AIMS: To assess the course of microalbuminuria in patients with Type 2 diabetes mellitus in general practice and the predictive value of urinary albumin concentration on all-cause mortality, cardiovascular mortality and cardiovascular morbidity. METHODS: Cohort study in Type 2 diabetic patients tested for microalbuminuria in 1992, and re-tested in 1998. During follow-up all cardiovascular morbidity and mortality were recorded. RESULTS: Of the original sample of 317 patients, 163 patients were re-tested. The mean change in urinary albumin concentration was +16.2 mg/l (range -122.0 to +602 mg/l). Seventy-five per cent of the patients without microalbuminuria in 1992 still had no microalbuminuria in 1998 and 40% of those with microalbuminuria in 1992 reverted to normoalbuminuria in 1998. Cox survival analysis, stratified for age, showed that microalbuminuria at baseline resulted in a risk ratio of all-cause mortality of 1.4 (95% confidence interval 0.8-2.7), of cardiovascular mortality of 1.2 (0.5-2.8) and of new cardiovascular events (including cardiovascular mortality) of 1.4 (0.8-2.3). CONCLUSIONS: In the majority of patients the change of urinary albumin excretion was small, but the range was wide. A weak non-significant relationship between microalbuminuria and all-cause mortality and cardiovascular morbidity was observed.

Background. A large, population-based intervention (the DIMCA study) has shown substantial underdiagnosis of chronic obstructive pulmonary disease and asthma. Detection of undiagnosed patients by means of screening and subsequent monitoring was relatively inexpensive per detected patient, compared with other mass screening programs. The objectives of this study were to assess whether early detection according to the DIMCA protocol leads to increased utilization of health care resources and cost, other than the cost of the scheduled visits. Methods. In a prospective randomized consent trial, the utilization of health care resources and cost were ascertained in two groups: a screened group ( n = 416) and a control group ( n = 462). In a subsample of 100 screened subjects, consultation frequency before screening was compared with the frequency after screening. Subjects were a random sample from the general population of between 25 and 70 years of age. Results. During an average follow-up of 3.6 years, there were no significant differences in health care resource utilization and cost between the screened subjects and the controls. Resource utilization before screening was not significantly different from resource utilization after screening. Statistically significant differences were found within the screened group: subjects with a positive screening result (i.e., with signs or symptoms of obstructive airway disease) consulted their general practitioners 3.7 times more frequently ( P = 0.001) for respiratory reasons than subjects with a negative screening result. The total health care cost due to respiratory disease in screen-positive subjects was 6.4 times higher ( P = 0.008). Conclusion. There were no indications that screening for obstructive airway disease led to increased cost, above that of average care.

Background: Chronic Fatigue Syndrome (CFS) is characterized by severe debilitating fatigue for at least six months. The lack of a known origin could have consequences for the way general practitioners deal with the diagnosis CFS and their perception of CFS patients. The aims of the study were to investigate the use of the diagnosis CFS by GPs and their reactions to self-diagnosis and to explore opinions of GPs about causes of CFS and the communication with CFS patients as well as opinions of CFS patients about their GPs.Method: One hundred twenty-one GPs completed questionnaires and 12 were interviewed. Data of 211 CFS patients were analyzed as well.Results: Only half of the GPs used the diagnosis CFS. The main reason for not diagnosing CFS was ignorance of the criteria. GPs reported self-diagnosis in 68% of the CFS patients. More than half of the GPs could sympathize less with the complaints of CFS patients compared with other patients. These GPs experienced more problems in communicating with CF...

OBJECTIVES: This review was conducted to determine the effectiveness of different interventions to improve the delivery of preventive services in primary care. METHODS: MEDLINE searches and manual searches of 21 scientific journals and the Cochrane Effective Professional and Organization of Care of trials were used to identify relevant studies. Randomized controlled trials and controlled before-and-after studies were included if they focused on interventions designed to improve preventive activities by primary care clinicians. Two researchers independently assessed the quality of the studies and extracted data for use in constructing descriptive overviews. RESULTS: The 58 studies included comprised 86 comparisons between intervention and control groups. Postintervention differences between intervention and control groups varied widely within and across categories of interventions. Most interventions were found to be effective in some studies, but not effective in other studies. CONCLUSIONS: Effective interventions to increase preventive activities in primary care are available. Detailed studies are needed to identify factors that influence the effectiveness of different interventions.

The use of spirometry is becoming more and more widespread in non-laboratory situations such as general practice or occupational medicine. In these non-laboratory situations, volume calibration with a 3000 ml syringe is often the only feasible method to ensure that the spirometer produces valid and reproducible data. Sophisticated equipment to calibrate forced manoeuvres with standard waveforms are not present.In this study, we assessed whether volumetric calibration is a guarantee for valid and comparable spirometric results.Two portable spirometers were tested. On 8 consecutive test days, both spirometers were calibrated with a 3000 ml syringe in accordance with the American Thoracic Society (ATS) guidelines. The comparability of the spirometric results (forced expiratory volume in 1 S, FEV1) was tested in two ways. Firstly, the spirometers were compared to each other using the results from 43 volunteers on the same 8 test days. The spirometers were presented in a randomized order and volunteers were asked to perform a series of reproducible manoeuvres in both spirometers. Paired observations were analysed, using Bland and Altman plots. Secondly, the spirometers were compared to a ‘gold standard’, a computer-driven syringe (CDS).Calibration with the 3000 ml syringe showed that both spirometers complied with the ATS criteria for volume calibration for diagnostic spirometry. However, paired FEV1 data obtained in subjects showed a systematic, volume-dependent difference between the two spirometers (mean difference: 289ml, P