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Abstract Background The aim of this study was to determine the - largely unexplored - extent of systematic variation in the work disability assessment by Dutch insurance physicians (IPs) of employees on long-term sick leave, and to ascertain whether this variation was associated with the individual characteristics and opinions of IPs. Methods In March 2008 we conducted a survey among IPs on the basis of the 'Attitude - Social norm - self-Efficacy' (ASE) model. We used the ensuing data to form latent variables for the ASE constructs. We then linked the background variables and the measured constructs for IPs (n = 199) working at regional offices (n = 27) to the work disability assessments of clients (n = 83,755) and their characteristics. These assessments were carried out between July 2003 and April 2008. We performed multilevel regression analysis on three important assessment outcomes: No Sustainable Capacity or Restrictions for Working Hours (binominal), Functional Incapacity Score (scale 0-6) and Maximum Work Disability Class (binominal). We calculated Intra Class Correlations (ICCs) at IP level and office level and explained variances (R2) for the three outcomes. A higher ICC reflects stronger systematic variation. Results The ICCs at IP level were approximately 6% for No Sustainable Capacity or Restrictions for Working Hours and Maximum Work Disability Class and 12% for Functional Incapacity Score. Background IP variables and the measured ASE constructs for physicians contributed very little to the variation - at most 1%. The ICCs at office level ranged from 0% to around 1%. The R2 was 11% for No Sustainable Capacity or Restrictions for Working Hours, 19% for Functional Incapacity Score and 37% for Maximum Work Disability Class. Conclusion Our study uncovered small to moderate systematic variations in the outcome of disability assessments in the Netherlands. However, the individual characteristics and opinions of insurance physicians have very little impact on these variations. Our findings provided no indications of other reasons for these variations. They may be related to different work routines or to different views on the workload of a 'normal' employee. If so, they could be reduced by well-developed and comprehensively implemented guidelines. Therefore, further research is needed.

Abstract Background Very little is known about the attitudes and views that might underlie and explain the variation in occupational disability assessment behaviour between insurance physicians. In an earlier study we presented an adjusted ASE model (Attitude, Social norm, Self-efficacy) to identify the determinants of the disability assessment behaviour among insurance physicians. The research question of this study is how Attitude, Social norm, Self-efficacy and Intention shape the behaviour that insurance physicians themselves report with regard to the process (Behaviour: process) and content of the assessment (Behaviour: assessment) while taking account of Knowledge and Barriers. Methods This study was based on 231 questionnaires filled in by insurance physicians, resulting into 48 scales and dimension scores. The number of variables was reduced by a separate estimation of each of the theoretical ASE constructs as a latent variable in a measurement model. The saved factor scores of these latent variables were treated as observed variables when we estimated a path model with Lisrel to confirm the ASE model. We estimated latent ASE constructs for most of the assigned scales and dimensions. All could be described and interpreted. We used these constructs to build a path model that showed a good fit. Results Contrary to our initial expectations, we did not find direct effects for Attitude on Intention and for Intention on self reported assessment behaviour in the model. This may well have been due to the operationalization of the concept of 'Intention'. We did, however, find that Attitude had a positive direct effect on Behaviour: process and Behaviour: Assessment and that Intention had a negative direct effect on Behaviour: process. Conclusion A path model pointed to the existence of relationships between Attitude on the one hand and self-reported behaviour by insurance physicians with regard to process and content of occupational disability assessments on the other hand. In addition, Intention was only related to the self reported behaviour with regard to the process of occupational disability assessments. These findings provide some evidence of the relevance of the ASE model in this setting. Further research is needed to determine whether the ASE variables measured for insurance physicians are related to the real practice outcomes of occupational disability assessments.

Abstract Background Variation in assessments is a universal given, and work disability assessments by insurance physicians are no exception. Little is known about the considerations and views of insurance physicians that may partly explain such variation. On the basis of the Attitude - Social norm - self Efficacy (ASE) model, we have developed measurement instruments for assessment behaviour and its determinants. Methods Based on theory and interviews with insurance physicians the questionnaire included blocks of items concerning background variables, intentions, attitudes, social norms, self-efficacy, knowledge, barriers and behaviour of the insurance physicians in relation to work disability assessment issues. The responses of 231 insurance physicians were suitable for further analysis. Factor analysis and reliability analysis were used to form scale variables and homogeneity analysis was used to form dimension variables. Thus, we included 169 of the 177 original items. Results Factor analysis and reliability analysis yielded 29 scales with sufficient reliability. Homogeneity analysis yielded 19 dimensions. Scales and dimensions fitted with the concepts of the ASE model. We slightly modified the ASE model by dividing behaviour into two blocks: behaviour that reflects the assessment process and behaviour that reflects assessment behaviour. The picture that emerged from the descriptive results was of a group of physicians who were motivated in their job and positive about the Dutch social security system in general. However, only half of them had a positive opinion about the Dutch Work and Income (Capacity for Work) Act (WIA). They also reported serious barriers, the most common of which was work pressure. Finally, 73% of the insurance physicians described the majority of their cases as 'difficult'. Conclusions The scales and dimensions developed appear to be valid and offer a promising basis for future research. The results suggest that the underlying ASE model, in modified form, is suitable for describing the assessment behaviour of insurance physicians and the determinants of this behaviour. The next step in this line of research should be to validate the model using structural equation modelling. Finally, the predictive value should be tested in relation to outcome measurements of work disability assessments.

The number of employees applying for a labour disability benefit due to whiplash has gradually decreased during the last 25 years in the Netherlands. The total number of applicants seems to stabilise around 30% of the number around the turn of the century. This is surprising given that the professional standards for social insurance physicians emphasise the importance of rehabilitation, while courts hardly ever judge in favour of benefit claimants. We investigate the underlying reasons for the changing statistics and make a recommendation on how social insurance physicians can best approach a claimant.

Perioperative monitoring has demonstrated that administration of heparin on an empirical basis is associated with a wide variation in patient response and elimination rate. This problem may be overcome by intervention on the basis of perioperative monitoring or by using forms of heparin with different pharmacokinetic properties. When compared with unfractionated heparin, low-molecular-weight heparin has a higher bioavailability after subcutaneous administration, a linear clearance mechanism with a prolonged half-life, and is at least as effective in preventing postoperative vein thrombosis. Theoretically these characteristics of low-molecular-weight heparin could lead to more predictable levels of heparin activity. In this study we compared the pharmacokinetics of low-molecular-weight heparin and unfractionated heparin after an intravenous injection in patients undergoing aortic graft surgery. Heparin activity was measured before heparin administration and at 5, 20, 35, 50, 65, 80, 95, and 110 minutes after administration. The anti-Xa activity in the low-molecular-weight heparin group showed less variation and was more sustained when compared to the unfractionated heparin group. Fibrin degradation products were moderately correlated with the anti-factor Xa levels of the low-molecular-weight heparin group, but no correlation was found in the unfractionated heparin group. The anti-factor Xa activity of low-molecular-weight heparin was, in contrast to that of unfractionated heparin, not completely reversible by protamine administration. The blood loss was comparable in both groups. In contrast to what was expected, the pharmacokinetic profiles of low-molecular-weight heparin and unfractionated heparin showed a similarity after intravenous injection in patients undergoing aortobifemoral bypass grafting. Factors that could have influenced the pharmacokinetic behavior of heparin are discussed.

We have studied the diagnostic value for deep venous thrombosis (DVT) of an enzyme immunoassay (EIA) for the detection of D-dimer in plasma of 239 consecutive outpatients suspected of having DVT by their general practitioner. DVT was confirmed by impedance plethysmography in 60 patients. Using the 95th percentile range of 42 healthy volunteers, the sensitivity for the detection of DVT was 92%, with a specificity of 21%. In our population with a prevalence of 25%, the D-dimer EIA showed a negative predictive value of 88% and a positive predictive value of 28%. We conclude that this D-dimer ELISA has limited value, either to confirm or to exclude DVT in outpatients.

From 1977-1984, 56 patients with colon cancer adherent to other organs were operated. Twenty-three patients (41%) underwent palliative treatment without resection. The mean survival in this group was 6 months. In this retrospective study the results were analysed of 33 patients (59%) who underwent a resection with curative intent. Pathological staging was based on the Dukes, Astler & Coller classification. The 4-year survival rate was as follows: Dukes B 47%, Dukes C 29%, Dukes D 0%. The 4-year survival rate for the whole group was 33%. The postoperative morbidity and mortality were 6% and 3% respectively. Colon cancer with involvement of adjacent structures should not be regarded as an incurable Dukes D cancer: extended resection is indicated.