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The article assesses the effect of AsthmaCritic on monitoring and treatment of asthma and chronic obstructive pulmonary disease as issued by the Dutch College of General Practitioners in the Netherlands. The guideline-based critiquing system AsthmaCritic changed the manner in which the physicians monitored their patients and , to a lesser extent, their treatment behavior and the physicians changed their data-recording habits. The number of forced expiratory volume, peak-flow measurements and the ratio of coded measurements increased, whereas the number of cromoglycate prescriptions decreased in the age of 12-39 years.

This article focuses on a study related to assessing the preventive activities of general practitioners (GPs) regarding the four conventional risk factors and the associated measurements for cardiovascular risk factors by GPs in relation to the time of the first clinical presence of cardiovascular disease (CVD). The prevalence of conventional risk factors in the data set corresponds to previously published data on conventional risk factors. All of the 2,594 patients in this study were required to have had at least 1 year of observation before the first CVD event was diagnosed, a time during which they were eligible for primary prevention.

Presents letters to the editor of the 'British Medical Journal'. How indiscriminate investigations have adverse effects; Statement that simple presentation of test accuracy may lead to inflated disease probabilities; How assortative mating may explain spouses' risk of same disease; Others.

Background: Introducing decision-support systems as a tool to stimulate the dissemination of clinical guidelines in daily practice has been disappointing. Researchers have argued that integration of such systems with clinical practice is a prerequisite for acceptance. The big question concerns the feasibility of a true integration--if only routinely recorded data are used for such a system, can patient-specific feedback be produced?Objective: The aim of this study was to assess the feasibility of generating patient-specific feedback based on routinely recorded data in general practice by AsthmaCritic, a decision-support system for asthma and chronic obstructive pulmonary disease (COPD).Methods: We built the decision-support system AsthmaCritic and assessed its ability to detect asthma and COPD patient records and generate patient-specific feedback by retrospective analysis of routinely recorded data in 103 713 electronic patient records from primary care practices. We grouped feedback into categories of comments by age group (<12 years and > or =12 years). The main outcome measures were the number and percentage of "triggered" (selected) asthma and COPD patient records, and the number and percentage of records on which AsthmaCritic produced at least one feedback comment during the 1-year study period, by category of comments.Results: AsthmaCritic detected 8784 (8.5%) asthma and COPD patient records. During the study period, AsthmaCritic generated 255 664 feedback comments (mean 3.4 per patient visit). The most frequently generated category of comments in the case of patients aged > or =12 years was "non-compliant prescription" (23.7%), whereas the most frequent category in the case of patients <12 years was "non-compliant route" (31.1%).Conclusions: This study shows that, using routinely recorded data only, AsthmaCritic is able to detect asthma and COPD patient records for further analysis and to produce patient-specific feedback. [ABSTRACT FROM AUTHOR]

Objective To determine the consistency among the practice guidelines of the Dutch College of General Practitioners with respect to the use of blood tests. Methods The authors evaluated 64 practice guidelines of the Dutch College of General Practitioners. For each guideline, they analyzed each sentence that contained a reference to a blood test to determine the clinical situation in which the test should be performed () and to determine the tests that should be performed in that situation (). An refers to a guideline that mentioned a blood test but did not identify the indication for that test. An refers to the situation in which one guideline recommended a certain test for a given indication whereas another guideline mentioned the same indication but did not recommend the same test. Results Twenty-seven practice guidelines mentioned blood tests. Of these, three explicitly recommended to request blood tests. Five guidelines contained incomplete recommendations, and the authors encountered two inconsistencies among the guidelines. Twenty-three guidelines mentioned blood tests and allowed the authors to identify indications and recommended tests. Conclusion The identification of indications and recommended tests allows evaluation of consistency among practice guidelines. Although some incomplete recommendations and inconsistencies were discovered, the majority of the guidelines provide clear and unambiguous recommendations for blood-test ordering in primary care. [ABSTRACT FROM PUBLISHER]

Chronic diarrhoea occurs in patients of all ages and is a very common reason for patient visits to a general practitioner or medical specialist. The differential diagnosis of chronic diarrhoea is extensive and identification of the underlying cause can be challenging. In this article we answer 12 topical questions concerning the management of chronic diarrhoea in practice.

Background: Indirect evidence shows that alerting users with clinical decision support systems seems to change behavior more than requiring users to actively initiate the system. However, randomized trials comparing these methods in a clinical setting are lacking. We studied the effect of both alerting and on-demand decision support with respect to screening and treatment of dyslipidemia based on the guidelines of the Dutch College of General Practitioners., Methods and Results: In a clustered randomized trial design, 38 Dutch general practices (77 physicians) and 87,886 of their patients (39,433 men 18 to 70 years of age and 48,453 women 18 to 75 years of age) who used the ELIAS electronic health record participated. Each practice was assigned to receive alerts, on-demand support, or no intervention. We measured the percentage of patients screened and treated after 12 months of follow-up. In the alerting group, 65% of the patients requiring screening were screened (relative risk versus control=1.76; 95% confidence interval, 1.41 to 2.20) compared with 35% of patients in the on-demand group (relative risk versus control=1.28; 95% confidence interval, 0.98 to 1.68) and 25% of patients in the control group. In the alerting group, 66% of patients requiring treatment were treated (relative risk versus control=1.40; 95% confidence interval, 1.15 to 1.70) compared with 40% of patients (relative risk versus control=1.19; 95% confidence interval, 0.94 to 1.50) in the on-demand group and 36% of patients in the control group., Conclusions: The alerting version of the clinical decision support systems significantly improved screening and treatment performance for dyslipidemia by general practitioners.

Background: The economic consequences of interventions to promote rational, evidence-based use of laboratory tests by physicians are not yet fully understood. We evaluated the cost consequences of a computer-based, guideline-driven decision-support system (CDSS) for ordering blood tests in primary care., Methods: We installed the CDSS in 118 practices [159 general practitioners (GPs)] throughout The Netherlands and calculated the costs of the intervention in this group. During a period of 6 months before and 6 months after installation of the CDSS, the test-ordering behavior of 87 (109 GPs) of these 118 study practices was studied and the results were compared with those of a nonhistorical control group that did not receive the CDSS. In addition the costs of laboratory requests were calculated for both groups., Results: Total intervention costs, comprising development costs and installation costs, amounted to 79,000 euro (670 euro per practice). Whereas the introduction of the CDSS did not affect the number of order forms submitted to the laboratories, it did reduce the number of blood tests per order form. As a result, the CDSS yielded mean savings on the costs of laboratory requests of 847 euro per practice per 6 months., Conclusions: This study demonstrates that providing electronic decision support for ordering blood tests in primary care represents an economically promising concept. Savings on laboratory costs are achievable and not offset by disproportionally high intervention costs.

Unlabelled: Presenting guidelines relating to cardiovascular disease (CVD) in a clinical decision support system (CDSS) is viewed as a mechanism for introducing evidence based practice in to daily practice. Analysis of guidelines on consistency is needed before constructing such a system. We analyzed 74 electronically available Dutch general practice guidelines for statement inconsistencies with respect to the management of CVD, and for each inconsistency, whether incomplete cross referencing existed between the guidelines., Results: Six of the 74 guidelines had either CVD or CVD risk factors as subject of the guideline, all adhering to a common structure corresponding to four sections reflecting distinctive clinical management stages, which correspond to the subjective, objective, assessment and plan stages of SOAP methodology for structured patient data recording. Ten statement inconsistencies were found and for each a reference inconsistency was present., Conclusions: In a CDSS, statement inconsistencies will lead to poor system functioning. With electronically published guidelines, guideline developers could link statements in guidelines, to comparable statements in previously issued guidelines, facilitating the review process with respect to inconsistencies in related guidelines, and consistent cross referencing. Furthermore, it could enable the updating of existing guidelines with new evidence. Despite the determined statement inconsistencies, the authors would be able to construct a CDSS based on the DCGP guidelines dealing with the management of CVD risk factors

Background: Guidelines are viewed as a mechanism for disseminating a rapidly increasing body of knowledge. We determined the compliance of Dutch general practitioners with the recommendations for blood test ordering as defined in the guidelines of the Dutch College of General Practitioners., Methods: We performed an audit of guideline compliance over a 12-month period (March 1996 through February 1997). In an observational study, a guideline-based decision support system for blood test ordering, BloodLink, was integrated with the electronic patient records of 31 general practitioners practicing in 23 practices (16 solo). BloodLink followed the guidelines of the Dutch College of General Practitioners. We determined compliance by comparing the recommendations for test ordering with the test(s) actually ordered. Compliance was expressed as the percentage of order forms that followed the recommendations for test ordering., Results: Of 12 668 orders generated, 9091 (71%) used the decision-support software rather than the paper order forms. Twelve indications accounted for >80% of the 7346 order forms that selected a testing indication in BloodLink. The most frequently used indication for test ordering was "vague complaints" (2209 order forms; 30.1%). Of the 7346 order forms, 39% were compliant. The most frequent type of noncompliance was the addition of tests. Six of the 12 tests most frequently added to the order forms were supported by revisions of guidelines that occurred within 3 years after the intervention period., Conclusions: In general practice, noncompliance with guidelines is predominantly caused by adding tests. We conclude that noncompliance with a guideline seems to be partly caused by practitioners applying new medical insight before it is incorporated in a revision of that guideline.