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Background and aims: The majority of patients with inflammatory bowel disease (IBD) have a normal life expectancy and therefore should not be weighted when applying for life assurance. There is [...]

Objective: Geographic differences in disease course of Crohn's disease (CD) might possibly be related to differences in genetic and environmental factors encountered in different parts of the world. The aim of this study was to assess differences in treatment regimens within a European cohort of CD patients as a reflection of disease course, and to identify associated phenotypic risk factors at diagnosis., Material and Methods: A prospective European population-based inception cohort of 380 CD patients was studied. The patients were classified for phenotype according to the Vienna classification. Differences between Northern and Southern European centres in treatment over the first 10 years of disease were analysed using a competing risks survival analysis method., Results: Patients in the North were more likely to have had surgery (p<0.01), whereas patients in the South were more likely to have been treated medically (p<0.01). Phenotype at diagnosis was not predictive of differences in treatment regimens between North and South., Conclusions: In this study, a difference in management of CD was observed between Northern and Southern European centres. This suggests that there may be a North-South disease severity gradient across Europe. Phenotypic differences between patients in the North and South did not explain this observed difference.

Objective: To explore whether general practitioners who request spinal x-ray investigations are less likely to refer, prescribe medication, or order additional tests when they intend only to reassure patients rather than to exclude or confirm disease., Design: Cross-sectional survey. Physicians recorded reasons for requesting x-ray examinations and differential diagnoses on the request form. When they received a radiologist's report on a spinal x-ray test, GPs also received a questionnaire on their subsequent management., Setting: Maastricht region of the Netherlands., Participants: All 90 GPs in the Maastricht region who referred patients for spinal x-ray examinations during 19 consecutive weeks., Main Outcome Measures: Reason for requesting spinal x-ray investigations, results, and subsequent management., Results: We received completed questionnaires on 386 patient contacts. Physicians were significantly less likely to refer, prescribe medication, or order additional tests when they intended only to reassure patients rather than to exclude or confirm disease (odds ratio 0.3, 95% confidence interval 0.1 to 0.6). This effect was independent of the results of the x-ray examinations., Conclusion: Physicians seem to be aware that they have requested spinal x-ray examinations only to reassure patients, and they account for this in their management. These findings support debate on the negative consequences of requesting tests for other than purely medical reasons. Concerns about unjustified actions based on the results of x-ray examinations that were requested primarily to reassure patients should probably have only a minor role in the debate about unnecessary testing.

Objective: To study the correlation between pharmaceutical care and prescribing routines of general practitioners (GPs)., Methods: Cross-sectional study; 201 pharmacies, 408 general practices, The Netherlands, 2000/2001. The variation in prescribing behaviour was characterised using 20 validated prescribing indicators based on general practice guidelines. The general construct 'adherence to guidelines' served as the dependent variable and was formed by summing the scores of the prescribing indicators. Four possible determinants of the variation were determined on the basis of survey questions: the construct 'the pharmacist's attitude towards pharmaceutical care', and three partial constructs derived from the pharmacist's care-providing function: the care for the individual patient, the cooperation with general practitioners and the registration of the care provided. A multiple linear regression analysis was then performed., Main Outcome Measure: The weighted score for the prescribing indicators., Results: The weighted average score for the prescribing indicators was 65% (SD 3.7). The response rate to the survey was 71%. The pharmacist's attitude to pharmaceutical care, as well as the degree to which the pharmacist provided care for the individual patient, the degree to which he cooperated with the general practitioner and the degree to which he registered the care provided were not correlated with the 'adherence to guidelines' by the general practitioner with whom the pharmacist frequently cooperated., Conclusion: Variations between general practitioners in the quality of prescribing, as measured by their adherence to guidelines, were not correlated with pharmaceutical care by the pharmacist with whom they cooperated on a day-to-day basis.

Background & Aims: Economic analysis in chronic diseases is a prerequisite for planning a proper distribution of health care resources. We aimed to determine the cost of inflammatory bowel disease, a lifetime illness with considerable morbidity., Methods: We studied 1321 patients from an inception cohort in 8 European countries and Israel over 10 years. Data on consumption of resources were obtained retrospectively. The cost of health care was calculated from the use of resources and their median prices. Data were analyzed using regression models based on the generalized estimating equations approach., Results: The mean annual total expenditure on health care was 1871 Euro/patient-year for inflammatory bowel disease, 1524 Euro/patient-year for ulcerative colitis, and 2548 Euro/patient-year for Crohn's disease (P < .001). The most expensive resources were medical and surgical hospitalizations, together accounting for 63% of the cost in Crohn's disease and 45% in ulcerative colitis. Total and hospitalization costs were much higher in the first year after diagnosis than in subsequent years. Differences in medical and surgical hospitalizations were the primary cause of substantial intercountry variations of cost; the mean cost of health care was 3705 Euro/patient-year in Denmark and 888 Euro/patient-year in Norway. The outlay for mesalamine, a costly medication with extensive use, was greater than for all other drugs combined. Patient age at diagnosis and sex did not affect costs., Conclusions: In this multinational, population-based, time-dependent characterization of the health care cost of inflammatory bowel disease, increased expenditure was driven largely by country, diagnosis, hospitalization, and follow-up year.

Objective: To give a general outline of a 10-year clinical follow-up study of a population-based European cohort of inflammatory bowel disease (IBD) patients and to present the first results in terms of clinical outcome parameters and risk factors., Materials and Methods: A population-based cohort of newly, prospectively, diagnosed cases was initiated between 1991 and 1993. The 2201 patients with IBD (706 had Crohn's disease (CD), 1379 had ulcerative colitis (UC) and 116 had indeterminate colitis) originated from 20 different areas in 11 different European countries and Israel. For the 10-year follow-up of this cohort, electronic data-collecting instruments were made available through an Internet-based website. Data concerning vital status, disease activity, medication use, surgical events, cancer, pregnancy, fertility, quality of life and health-care costs were gathered. A blood sample was obtained from patients and controls to perform genotypic characterization., Results: Thirteen centres from eight European countries and Israel participated. In 958 (316 CD and 642 UC) out of a total of 1505 IBD patients (64%) from these 13 centres, a complete dataset was obtained at follow-up. Even though an increased mortality risk was observed in CD patients 10 years after diagnosis, a benign disease course was observed in this patient group in terms of disease recurrence. A correlation between ASCA and CARD15 variants in CD patients and complicated disease course was observed. A north-south gradient was observed regarding colectomy rates in UC patients. Direct costs were found to be highest in the first year after diagnosis and greater in CD patients than in UC patients, with marked differences between participating countries., Conclusions: This 10-year clinical follow-up study of a population-based European cohort of IBD patients provides updated information on disease outcome of these patient groups.

Aim: To describe an Internet-based data acquisition facility for a European 10-year clinical follow-up study project of a population-based cohort of inflammatory bowel disease (IBD) patients and to investigate the influence of demographic and disease related patient characteristics on response rates., Methods: Thirteen years ago, the European Collaborative study group of IBD (EC-IBD) initiated a population-based prospective inception cohort of 2 201 uniformly diagnosed IBD patients within 20 well-described geographical areas in 11 European countries and Israel. For the 10-year follow-up of this cohort, an electronic patient questionnaire (ePQ) and electronic physician per patient follow-up form (ePpPFU) were designed as two separate data collecting instruments and made available through an Internet-based website. Independent demographic and clinical determinants of ePQ participation were analyzed using multivariate logistic regression., Results: In 958 (316 CD and 642 UC) out of a total number of 1 505 (64%) available IBD patients, originating from 13 participating centers from nine different countries, both ePQ and ePpPFU were completed. Patients older than 40 years at ePQ completion (OR: 1.53 (95%CI: 1.14-2.05)) and those with active disease during the 3 mo previous to ePQ completion (OR: 3.32 (95%CI: 1.57-7.03)) were significantly more likely to respond., Conclusion: An Internet-based data acquisition tool appeared successful in sustaining a unique Western-European and Israelian multi-center 10-year clinical follow-up study project in patients afflicted with IBD.

Background: Community pharmacists, pharmaceutical industry and differences in prescribing between GPs., Objective: To explore the role of the pharmacists and pharmaceutical industry representatives., Methods: A cross-sectional survey was undertaken of 1434 GPs in The Netherlands in 2001. Prescribing indicators based on general practice guidelines were used to assess the quality of prescribing. Three constructs, based on survey questions, were used as possible determinants for the quality of prescribing: cooperation with the pharmacist; quality of the Pharmacotherapeutic audit meeting (PTAM); and the GP's attitude towards the pharmacist's role. Data were collected about the frequency of visits by pharmaceutical industry representatives. Responses from 324 solo GPs were analysed using multiple linear regression., Results: Response rate: 71%. For the 324 solo GPs the average score for the 20 prescribing indicators was 64% (SD 3.7). For the non-solo GPs this score was 65% (SD 3.8, P < 0.05). The differences between solo and group practices were: the number of visits from pharmaceutical industry representatives (5.7 versus 3.8 visits per month), full time GPs (93% versus 50%), the number of patients per GP (2151, SD 693 versus 1506, SD 742), and the presence of a GP trainer (21 versus 38%). Of the solo GPs, 4.6% are female, compared with 26% of the GPs in non-solo practices. The quality of prescribing in solo practices was not correlated with the GP's attitude towards the pharmacist's role, the way in which GPs cooperated with pharmacists or the quality of the PTAM. More frequent visits from pharmaceutical industry representatives was associated with a lower quality of prescribing., Conclusion: There was a negative correlation between quality of prescribing by solo GPs and frequency of visits by pharmaceutical industry representatives. In day-to-day practice, no measurable effects of the cooperation between solo GP and pharmacist on the quality of prescribing were observed.

Background: Differences in prescribing behaviour among general practitioners (GPs)., Aim: To formulate and validate clinical prescribing indicators based on general practice guidelines., Design: Validatory study., Setting: Pharmacies and general practices in the Netherlands in 2003., Participants: A total of 379 pharmacies, 947 general practices and 3.8 million patients., Methods: A total of 51 potential indicators were formulated, based on medicinal recommendations from the evidence-based guidelines of the Dutch College of General Practitioners and the corresponding recommendations from the Commission Pharmaceutical Help of the Health Care Insurance Board. These indicators were submitted to an expert panel to assess content validity. The panel assessment was analysed using the RAND-UCLA appropriateness method (RAM). Then, for the remaining indicators, it was assessed to what extent these could be used to determine the prescribing behaviour of GPs and the level to which this behaviour varies among GPs. This was done using a prescribing analyses and cost (PACT) database that was compiled from prescription databases from 379 pharmacies, with all prescriptions from 1,434 GPs over an entire year to 3.8 million patients., Results: The panel considered 34 of the 51 potential indicators to be valid with respect to providing an adequate reflection of the central recommendations in the guideline and in terms of relevance with respect to health gain and/or efficiency. Of these 34 indicators, 20 revealed considerable differences in the prescribing behaviour of GPs., Conclusion: On the basis of existing general practice guidelines, 20 prescribing indicators could be formulated that were assessed by an expert panel to be sufficiently valid and which could also discriminate the prescribing behaviour of GPs as reflected in the prescription databases of pharmacies.

Background and Aims: Patients with Crohn's disease are at increased risk of osteoporosis. Disease activity and circulating proinflammatory cytokines are thought to play a role in this process. Infliximab, a chimaeric antitumour necrosis factor-alpha antibody is effective in the treatment of Crohn's disease. The aim of this study was to investigate the impact of treatment with infliximab on bone turnover in Crohn's disease patients., Methods: This was a prospective trial. Twenty-four patients with active Crohn's disease were treated with infliximab (5 mg/kg). Bone markers were assayed pre- and post-treatment. Bone formation was measured using serum bone-specific alkaline phosphatase and total osteocalcin and bone resorption using serum N-telopeptide cross-linked type 1 collagen., Results: Infliximab therapy caused a significant increase in both markers of bone formation in patients with active Crohn's disease. No significant change in the bone resorption marker serum N-telopeptide cross-linked type 1 was found., Conclusion: Infliximab therapy had a significant beneficial effect on bone metabolism in patients with active Crohn's disease. These findings further support the theory that active ongoing inflammation and high levels of circulating cytokines play a pivotal role in the pathogenesis of bone loss in patients with Crohn's disease.

Objective: To identify determinants of the care-providing function of the community pharmacists (CPs) to explain variations in professional practice., Setting: The Netherlands 2001., Participants: 328 CPs., Method: A cross-sectional questionnaire survey was performed. Questionnaires were used to collect data about the care provided in pharmacies. As dependent variables three partial constructs: 'individual patient care', 'registration of the care', and 'cooperation with GPs', and one total construct: 'care function' were formed. Independent variables were: gender, work experience, attitude to the care-providing function, tenure, relationship with GPs, pharmacist trainer, frequency of postgraduate training, workload, part-time working, frequency of contact with pharmaceutical representatives, presence of technicians with a specialised caring duty, size of the pharmacy, urbanisation, competition, franchise pharmacy, presence of sufficient personnel. A multiple-regression analysis was performed., Results: Respondents 71%; of the respondents 29% never enquired about the patient's experience when supplying a medication for the second time. The supply of self-care remedies was never registered by 11% of respondents. Ninety percent of pharmacists participate more than four times per year in Pharmacotherapy Audit Meetings. The attitude of the pharmacist, relationship with the GP, presence of specialised technicians, frequency of postgraduate training and the type of tenure are significantly positively correlated with a care-providing function. Being a pharmacist trainer is significantly positively related with 'individual patient care', the frequency of postgraduate training is significantly positively correlated with 'registration of the care' and the number of years in service is significantly negatively correlated with 'cooperation with GPs'. There is a negative correlation between the cooperation with GPs and the number of years a pharmacist has been in service., Conclusion: Based on this survey, the development of programmes focused on optimal attitude, and cooperation between pharmacists and GPs is recommended.

Background: When analyzing the effect of environmental exposure reduction measures on asthma in high-risk children, one must know how far asthmatic families already have applied such measures, because this would affect the effectiveness and efficiency of interventions aimed at reducing environmental exposure., Objective: To describe the room for improvement by asthmatic families in mite, pet, and food allergen reducing measures and in parental passive smoking and to determine the resulting levels of mite and pet allergens by the applied sanitation measures., Methods: Data were sampled by observation, weekly diary entries, and questionnaire when the infant was 6 months old and 1 year old. Dust samples were collected by vacuuming the living room floor and the parental and infant mattresses. Multiple logistic regression analyses were applied with the use of mattress encasing, having a smooth floor covering, having pets, exclusive breast-feeding and/or hypoallergenic formula during the infant's first 6 months, and passive smoking as the dependent variables., Results: Frequencies of applied measures were as follows: having a smooth floor covering, 36%; daily house cleaning, 27%; use of parental and infant antimite mattress encasings, 13% and 9%, respectively; keeping no pets, 66%; no cow's milk-based regular formula, 13%; no solid foods in the first 6 months of life, 28%; and abstinence of smoking by the mother prenatally, 89%; by the mother postnatally, 85%; and by her partner, 76%. Having a smooth floor covering and daily cleaning but not use of antimite mattress encasings resulted in significantly lower mite and pet allergen levels., Conclusions: There is (still) enough room for improvement to reduce exposure to inhalant and food allergens, especially by application of mattress encasings, exclusive breast-feeding and/or hypoallergenic formula feeding, and postponing the time until first solids are given.

Context: Numbers of diagnostic tests ordered by primary care physicians are growing and many of these tests seem to be unnecessary according to established, evidence-based guidelines. An innovative strategy that focused on clinical problems and associated tests was developed., Objective: To determine the effects of a multifaceted strategy aimed at improving the performance of primary care physicians' test ordering., Design: Multicenter, randomized controlled trial with a balanced, incomplete block design and randomization at group level. Thirteen groups of primary care physicians underwent the strategy for 3 clinical problems (arm A; cardiovascular topics, upper and lower abdominal complaints), while 13 other groups underwent the strategy for 3 other clinical problems (arm B; chronic obstructive pulmonary disease and asthma, general complaints, degenerative joint complaints). Each arm acted as a control for the other., Setting: Primary care physician groups in 5 regions in the Netherlands with diagnostic centers recruited from May to September 1998., Study Participants: Twenty-six primary care physician groups, including 174 primary care physicians., Intervention: During the 6 months of intervention, physicians discussed 3 consecutive, personal feedback reports in 3 small group meetings, related them to 3 evidence-based clinical guidelines, and made plans for change., Main Outcome Measure: According to existing national, evidence-based guidelines, a decrease in the total numbers of tests ordered per clinical problem, and of some defined inappropriate tests, is considered a quality improvement., Results: For clinical problems allocated to arm A, the mean total number of requested tests per 6 months per physician was reduced from baseline to follow-up by 12% among physicians in the arm A intervention, but was unchanged in the arm B control, with a mean reduction of 67 more tests per physician per 6 months in arm A than in arm B (P =.01). For clinical problems allocated to arm B, the mean total number of requested tests per 6 months per physician was reduced from baseline to follow-up by 8% among physicians in the arm B intervention, and by 3% in the arm A control, with a mean reduction of 28 more tests per physician per 6 months in arm B than in arm A (P =.22). Physicians in arm A had a significant reduction in mean total number of inappropriate tests ordered for problems allocated to arm A, whereas the reduction in inappropriate test ordered physicians in arm B for problems allocated to arm B was not statistically significant., Conclusion: In this study, a practice-based, multifaceted strategy using guidelines, feedback, and social interaction resulted in modest improvements in test ordering by primary care physicians.