Search

Objective: Consistent evidence on the effects of specialist services in the primary care setting is lacking. Therefore, this study evaluated the effects of an in-house internist at a GP practice on the number of referrals to specialist care in the hospital setting. Additionally, the involved GPs and internist were asked to share their experiences with the intervention.Design: A retrospective interrupted times series study.Setting: Two multidisciplinary general practitioner (GP) practices.Intervention: An internist provided in-house patient consultations in two GP practices and participated in the multidisciplinary meetings.Subjects: The referral data extracted from the electronic medical record system of the GP practices, including all referral letters from the GPs to specialist care in the hospital setting.Main outcome measures: The number of referrals to internal medicine in the hospital setting. This study used an autoregressive integrated moving average model to estimate the effect of the intervention taking account of a time trend and autocorrelation among the observations, comparing the pre-intervention period with the intervention period.Results: It was found that the referrals to internal medicine did not statistically significant decrease during the intervention period.Conclusions: This small explorative study did not find any clues to support that an in-house internist at a primary care setting results in a decrease of referrals to internal medicine in the hospital setting.Key points:An in-house internist at a primary care setting did not result in a significant decrease of referrals to specialist care in the hospital setting. The GPs and internist experience a learning-effect, i.e. an increase of knowledge about internal medicine issues.

There is no consensus among physicians as to whether or not pectus excavatum can produce symptoms sometimes even severe enough to justify a surgical procedure.

Objectives. Doctors all over the world consider a pectus excavatum usually as an incidental finding. There is some evidence suggesting that a pectus excavatum may cause symptoms in the elderly. It is not known how often a pectus excavatum occurs and how strong the relation is with symptoms. Methods. In hospitals and general practice data, we searched for evidence of a connection between cardiac symptoms and the presence of a pectus excavatum in a retrospective survey among patients in whom a pectus excavatum was found in a chest X-ray. In radiology reports, we searched for “pectus excavat*” in almost 160000 chest X-rays. The identified X-rays were reviewed by 2 radiologists. Reported symptoms were combined to a severity sum score and the relation with pectus excavatum was assessed through logistic regression. Results. Pectus excavatum was found in 1 to 2 per 1000 chest X-rays. In 32% of patients (N=117), we found symptoms that might reflect the presence of symptomatic pectus excavatum. We found a significant relation between the SPES sum score and the radiological level of pectus excavatum. Conclusions. A pectus excavatum found when examining the patient should not be neglected and should be considered as a possible explanation for symptoms like dyspnoea, fatigue, or palpitations.

Scand J Caring Sci; 2013; 27; 253-259 Consumer satisfaction among patients and their general practitioners about involving nurse specialists in primary care for patients with urinary incontinence Background: Urinary incontinence (UI) is a very common problem, but existing guidelines on UI are not followed. To bring care in line with guidelines, we planned an intervention to involve nurse specialists on UI in primary care and assessed this in a randomised controlled trial. Alongside this intervention, we assessed consumer satisfaction among patients and general practitioners (GPs). Methods: Patients' satisfaction with the care provided by either nurse specialists (intervention group) or GPs (control group), respectively, was measured with a self-completed questionnaire. GPs' views on the involvement of nurse specialists were measured in a structured telephone interview. Results: The patient satisfaction score on the care offered by nurse specialists was 8.4 (scale 1-10), vs. 6.7 for care-as-usual by GPs. Over 85% of patients would recommend nurse specialist care to their best friends and 77% of the GPs considered the role of the nurse specialist to be beneficial, giving it a mean score of 7.2. Conclusions: Although the sample was relatively small and the stability of the results only provisionally established, substituting UI care from GP to nurse specialist appears to be welcomed by both patients and GPs. Small changes like giving additional UI-specific information and devoting more attention to UI (which had been given little attention before) would provide a simple instrument to stimulate patients to change their behaviour in the right direction.

Background: Urinary incontinence (UI) primary care management is substandard, offering care rather than cure despite the existence of guidelines that help to improve cure. Involving nurse specialists on incontinence in general practice could be a way to improve care for UI patients. Aims: We studied whether involving nurse specialists on UI in general practice reduced severity and impact of UI. Methods: Between 2005 and 2008 a pragmatic multicentre randomised controlled trial was performed comparing a 1-year intervention by trained nurse specialists with care-as-usual after initial diagnosis and assessment by general practitioners in adult patients with stress, urgency or mixed UI in four Dutch regions (Maastricht, Nijmegen, Helmond, The Hague). Simple randomisation was computer-generated with allocation concealment. Analysis was performed by intention-to-treat principles. Main outcome measure was the International Consultation on Incontinence Questionnaire Short Form (ICIQ-UI SF) severity sum score. Results: A total of 186 patients followed the intervention and 198 received care-as-usual. Patients in both study groups improved significantly in UI severity and impact on health-related quality of life. After correction for effect modifiers [type of UI, body mass index (BMI)], we found significant differences between groups in favour of the intervention group at 3 months (p = 0.04); no differences were found in the 1-year linear trend (p = 0.15). Patients in the intervention group without baseline anxiety/depression improved significantly better compared with care-as-usual after 1 year (p = 0.03). Conclusion: Involving nurse specialists in care for UI patients supplementary to general practitioners can improve severity and impact of UI, after correction for effect modifiers. This is also the case in specific situations such as anxiety/depression.

Houben PHH, Van der Weijden T, Winkens RAG, Grol RPTM. Laboratoriumonderzoek leidt tot minder cascade-effecten dan gedacht. Huisarts Wet 2010;53(12):662-6. Afwijkende laboratoriumuitslagen bij een lage pretestkans op ziekte kunnen leiden tot cascades van verdere onderzoeken en verwijzingen. Zo’n cascade heeft ongewenste gevolgen: ongerustheid bij de patient, extra risico’s bij invasieve procedures en extra kosten. Wij onderzochten wanneer zulke cascades optreden: hoe vaak gebeurt het, om welk soort cascades gaat het en welke factoren zijn daarop van invloed? In een prospectief cohortonderzoek registreerden wij zes maanden lang vervolgonderzoek en verwijzingen van huisartsen bij 256 patienten met normale (n = 129) en met afwijkende (n = 127) laboratoriumuitslagen. Vervolgens onderzochten wij in hoeverre dit beleid samenhing met de reden om het onderzoek aan te vragen, de interpretatie van de uitslag en de pretest- en posttestkans op ziekte. De huisartsen vroegen vervolgonderzoek aan voor 22 (17,3%) patienten met een afwijkende uitslag en voor 2 (1,6%) patienten met een normale uitslag (p < 0,001), en ze verwezen 12 (9,4%) patienten met een afwijkende uitslag en 8 (6,2%) patienten met een normale uitslag (p = 0,33). Slechts bij 7 (5,5%) patienten vroegen de huisartsen meer dan eenmaal vervolgonderzoek aan. De huisartsen kozen vaker voor verder onderzoek of verwijzing bij een afwijkende laboratoriumuitslag (p = 0,004) en als ze de posttestkans op ziekte hoog inschatten (p = 0,001). Cascades van onderzoek en verwijzing na een afwijkende laboratoriumuitslag komen slechts weinig voor. De bezorgdheid over dit medicaliserende effect van laboratoriumonderzoek lijkt daarom niet gerechtvaardigd.

Contains fulltext : 89474.pdf (Publisher’s version ) (Open Access) OBJECTIVE: Laboratory tests are ordered on a daily basis, even though disease probability is often very low. Abnormal results, especially mildly abnormal results, can be difficult to interpret in these circumstances. Further insights into the occurrence of abnormalities can help improve rational test ordering and test interpretation. The objective was therefore to examine the frequency of mildly and markedly abnormal results and their relationship with physicians' reasons for ordering tests. DESIGN: Prospective study. Participants. A total of 87 primary care physicians in the Netherlands collected data on 1775 patients. MAIN OUTCOME MEASURES: The physicians recorded the reason for ordering the tests, the most probable diagnosis and the pretest probability. The laboratories' reference values and specified "action limits" were used to assess the number of abnormal results and markedly abnormal results, respectively. RESULTS: Laboratory results were received for 1621 patients and 15,603 tests were reported (mean 9.6). The proportion of abnormal test results increased with increasing pretest probability (from 13.9% to 34.7%) and was 13.4% for tests ordered to reassure the patient and 13.3% for psychosocial diagnoses. The proportion of patients with at least one abnormal test result was high: 53.1% for tests ordered to reassure and 57.7% in patients with low pretest probability. Corresponding values for a marked abnormality were 11.1% and 12.4%, respectively. CONCLUSION: Abnormal laboratory test results were frequent, even when pretest probability was low. Physicians should therefore carefully consider when tests are necessary. Future research could explore physicians' interpretation of test results and its impact on diagnosis and management. 01 maart 2010

Derkx HP, Rethans JJ, Maiburg HJS, Winkens RAG, Muijtjens AM, Van Rooij HG, Knottnerus JA. Kwaliteit van telefonische triage op huisartsenposten in Nederland. Communicatieve vaardigheden en verslaglegging. Huisarts Wet 2009;52(9):455-61.

Derkx HP, Rethans JJ, Maiburg BH, Winkens RAG, Muijtjens AM, Van Rooij HG, Knottnerus JA. De kwaliteit van telefonische triage op huisartsenposten. Huisarts Wet 2009;52(7):326-31. Doel Om de kwaliteit en veiligheid van telefonische triage op een huisartsenpost te bepalen moeten we de kwaliteit van de verschillende fasen van dit zorgproces onderzoeken. Dit betekent dat we niet alleen moeten beoordelen of de triagist het juiste urgentieniveau heeft bepaald, maar ook dat we de kwaliteit van de medisch inhoudelijke vragen en de inhoud van een zelfzorg- en vangnetadvies moeten onderzoeken. Methode Voor de uitvoering van dit onderzoek belden twaalf telefonische simulatiepatienten (TSP’s) in de periode april 2006 tot juli 2007 naar zeventien verschillende huisartsenposten voor zeven medische problemen. De TSP’s belden iedere huisartsenpost voor iedere casus driemaal. Resultaten De triagisten stelden gemiddeld 21% van de verplichte vragen die in de standaarden waren vermeld. Gemiddeld 54% van alle gestelde vragen behoorde tot de categorie verplichte vragen. Niet altijd schatten de triagisten het belang van een antwoord op een vraag op de juiste wijze in. Triagisten bepaalden voor 58% van alle gesprekken de gewenste urgentie. Voor 41% was het urgentieniveau te laag en voor 1% te hoog ingeschat. De kwaliteit van de zelfzorg- en vangnetadviezen varieerde sterk per casus en was op alle huisartsenposten beperkt. Conclusie De triagisten formuleerden meestal een zorgadvies na het stellen van een zeer beperkt aantal verplichte vragen, waardoor ze een mogelijk gezondheidsrisico voor de patient niet tot het minimum beperkten. Als we de kwaliteit tijdens opeenvolgende fasen van het zorgproces van telefonische triage-onderzoeken, kunnen we vaststellen in hoeverre triagisten de juiste urgentie bepalen op basis van voldoende en juist geinterpreteerde informatie of dat het toeval daarbij een grote rol heeft gespeeld. Om de veiligheid van telefonische triage te bevorderen moeten triagisten niet alleen de juiste vragen stellen en de antwoorden correct inschatten, maar ook een volledig zelfzorg- en vangnetadvies geven.

The incidence and prevalence of dyspnea increases with age. Frequently, for the general practitioner with his limited diagnostic facilities, it is impossible to separate dyspnea from cardiac causes and non-cardiac causes. Without cardiac imaging it is also impossible to separate systolic dysfunction from diastolic dysfunction. After a thorough physical examination, initial screening of systolic and diastolic heart failure can be done by measurement of plasma NT-pro BNP or plasma BNP. Additionally a Chest X-Ray or ECG can be performed. To improve diagnostic performance an open access echocardiographic service can be initiated. Recent studies showed, that open access echocardiography can easily detect systolic and diastolic dysfunction in the community and can separate cardiac from non-cardiac dyspnea.

Context Many countries now use call centres as an integral part of out-of-hours primary care. Although some research has been carried out on safety issues pertaining to telephone consultations, there has been no published research on how to train and use standardised patients calling for medical advice or on the accuracy of their role-play. Objectives This study aimed to assess the feasibility and validity of using telephone incognito standardised patients (TISPs), the accuracy of their role-play and the rate of detection. Further objectives included exploring the experiences of TISPs and the difficulties encountered in self-recording calls. Methods Twelve TISPs were trained in role-play by presenting their problem to a general practitioner and a nurse. They were also trained in self-recording calls. Calls were made to 17 different out-of-hours centres (OOHCs) from home. Of the four or five calls made per evening, one call was assessed for accuracy of role play. Retrospectively, the OOHCs were asked whether they had detected any calls made by a TISP. The TISPs filled in a questionnaire concerning their training, the self-recording technique and their personal experiences. Results The TISPs made 375 calls over 84 evenings. The accuracy of role-play was close to 100%. A TISP was called back the same evening for additional information in 11 cases. Self-recording caused extra tension for some TISPs. All fictitious calls remained undetected. Conclusions Using the method described, TISPs can be valuable both for training and assessment of performance in telephone consultation carried out by doctors, trainees and other personnel involved in medical services.

Background Urinary incontinence is a common problem, affecting quality of life and leading to high costs. There is doubt about the use of clinical practice guidelines on urinary incontinence in primary care. Objective To assess adherence levels and reasons for (non)adherence to the Guideline on Urinary Incontinence of the Dutch College of General Practitioners. Design, setting and participants A postal survey among Dutch general practitioners (GPs). Main outcome measure Adherence of GPs to the guideline. Results We analysed 264 questionnaires. Almost all GPs adhered to the guideline when diagnosing the type of urinary incontinence. A bladder diary is not often used (35%). Adherence to therapeutic procedures was only high for mild/moderate stress urinary incontinence: most GPs (82.6%) used adequate advice on bladder retraining and pelvic floor muscle training. One out of four GPs agreed that adhering to the guideline is difficult, mainly owing to lack of time, staff, diagnostic tools, competences to provide this care and low motivation of patients. Conclusions Dutch GPs follow the guideline only partially: compliance with diagnostic advices is fairly good; compliance with treatment advices is low. Further research should focus on solutions how to support GPs to tackle major barriers to facilitate the adherence to guidelines (substitution of tasks to specialized nurses, reducing the threshold for referral and concentrating expertise in integrated continence care services).

BACKGROUND: Urinary incontinence (UI) is a widespread problem, affecting quality of life and leading to high costs, mainly caused by incontinence pads. It seems that, despite guidelines, many UI patients get pads from their general practitioner (GP) without adequate diagnostics or treatment. OBJECTIVES: To assess what further treatment UI patients receive from their GP next to pads and to measure patient satisfaction with care. METHODS: A postal survey among UI patients who started pad use in the past 12 months. MAIN OUTCOME: Satisfaction with UI care. Results: We analysed 208 questionnaires. 29.3% of pad users had no direct contact with their GP for a pad prescription. Of 147 UI patients who visited their GP 50.3% only got pads. 25% of patients was not satisfied with the information on UI received from their GP, especially younger patients, women, less healthy patients and patients with urgency UI. CONCLUSIONS: Dutch UI patients using pads experience suboptimal GP care and management. Factors identified through patient feedback should be used to improve quality of care for UI in primary care.

AB - GOALS OF WORK: In preterminal cancer patients, provision of palliative care in the patients' own environment is preferred. The aim of the present study was to evaluate patients' and caregivers' treatment adherence and patients' acceptance of home infusions with adenosine 5'-triphosphate (ATP). PATIENTS AND METHODS: Preterminal cancer patients (life expectancy

Cardiac disease is not easy to recognise in general practice. An echocardiogram is an excellent way to provide information about left ventricular mass and diastolic (dys)function and the presence of valvular heart disease. To improve diagnostic care of cardiac patients, an open access echocardiography service was established in the referral area of our hospital, where general practitioners were able to ask for an echocardiogram without referring the patient to the cardiologist. Between December 2002 and October 2006 echocardiograms were requested for 471 patients. Thirteen percent of the patients referred for dyspnoea and 3% of patients with a cardiac murmur had a left ventricular ejection fraction

OBJECTIVE: To determine the effect of an out-of-hours primary care physician (PCP) cooperative on the caseload at the emergency department (ED) and to study characteristics of patients utilizing out-of-hours care. DESIGN: A pre-post intervention design was used. During a 3-week period before and a 3-week period after establishing the PCP cooperative, all patient records with out-of-hours primary and emergency care were analyzed. SETTING: Primary care in Maastricht (the Netherlands) is delivered by 59 PCPs. Primary care physicians formerly organized out-of-hours care in small locum groups. In January 2000, out-of-hours primary care was reorganized, and a PCP cooperative was established. This cooperative is located at the ED of the University Hospital Maastricht, the city’s only hospital, which has no emergency medicine specialists. MAIN OUTCOME MEASURES: The number of patients utilizing out-of-hours care, their age and sex, diagnoses, post-ED care, and serious adverse events. RESULTS. After establishing the PCP cooperative, the proportion of patients utilizing emergency care decreased by 53%, and the proportion of patients utilizing primary care increased by 25%. The shift was the largest for patients with musculoskeletal disorders or skin problems. There were fewer hospital admissions, and fewer subsequent referrals to the patient’s own PCP and medical specialists. No substantial change in new outpatient visits at the hospital or in mortality occurred. CONCLUSIONS: In the city of Maastricht, the Netherlands, the PCP cooperative reduced the use of hospital emergency care during out-of-hours care.

Objective: To evaluate the use of an automated test ordering and feedback system (named GRIF) in daily practice. The system produces recommendations to general practitioners (GPs) to improve the application of accepted practice guidelines for test ordering. Methods: A randomised controlled trial with balanced block design was carried out in general practices in two regions of the Netherlands from August 2000 to July 2001. We implemented the GRIF system on the workstations at the offices of the participating GPs. The GPs ( n = 11) were asked to use GRIF during patient consultation instead of filling in the paper request form. The system displayed critical comments about their non-adherence to the guidelines as apparent from the request forms. Results: The median time of producing the comments plus the response time of the GP was 13s. Of the 2780 presented recommendations, 4.3% were accepted. Advice of the GRIF system that presents a concrete test to request in a particular situation is adhered to most frequently. Finally, there seems to be a decrease of accepted comments over the trial period. Conclusion: Computerised recommendations should contain, if possible, suggestions for alternative tests to improve the application of these recommendations. Furthermore, creative solutions must be developed to avoid that GPs get used to the recommendations of critiquing systems and to stimulate a better adherence to these recommendations.

Verstappen WHJM, ter Riet G, Dubois WI, Winkens R, Grol RPTM and van der Weijden T. Variation in test ordering behaviour of GPs: professional or context-related factors? Family Practice 2004; 21: 387‐395. Objective. The aim of this study was to describe GPs’ test ordering behaviour, and to establish professional and context-related determinants of GPs’ inclination to order tests. Methods. A cross-sectional analysis was carried out of 229 GPs in 40 local GP groups from five regions in The Netherlands of the combined number of 19 laboratory and eight imaging tests ordered by GPs, collected from five regional diagnostic centres. In a multivariable multilevel regression analysis, these data were linked with survey data on professional characteristics such as knowledge about and attitude towards test ordering, and with data on context-related factors such as practice type or experience with feedback on test ordering data. The main outcome measure was the percentage point differences associated with professional and context-related factors. Results. The total median number of tests per GP per year was 998 (interquartile range 663‐1500), with significant differences between the regions. The response to the survey was 97%. At the professional level, ‘individual involvement in developing guidelines’ (yes versus no), and at the context-related level ‘group practice’ (versus single-handed and two-person practices) and ‘more than 1 year of experience working with a problem-oriented laboratory order form’ (yes versus no) were associated with 27, 18 and 41% lower numbers of tests ordered, respectively. Conclusion. In addition to professional determinants, context-related factors appeared to be strongly associated with the numbers of tests ordered. Further studies on GPs’ test ordering behaviour should include local and regional factors.

Contains fulltext : 57502.pdf (Publisher’s version ) (Closed access) BACKGROUND AND OBJECTIVE: To evaluate the value of balanced incomplete block designs in quality improvement research, and their capacity to control for the Hawthorne effect. METHODS: General practitioners teams were randomized into three arms and received an intervention on test ordering, relating to tests for two groups of clinical problems (A tests and B tests). In the two trials within the block design, we tried to control for the Hawthorne effect by comparing the complete intervention in both arms on either the A (arm I) or B tests (arm II); the arms acted as blind controls for each other. In the classical trial, the complete intervention on B tests (arm II) was compared with a control arm without any intervention on B tests (arm III). RESULTS: The trials with the block design yielded statistically significant changes in the numbers of A tests ordered (P=.013), but not in the numbers of B tests ordered (P=.29). In the classical design, the complete intervention reached a marginally significant change in the B tests (P=.068). The Hawthorne effect was the same for both arms of the block design. In the classical design, the effect could to some extent be attributed to the Hawthorne effect. CONCLUSION: Our block design allowed us to control for the Hawthorne effect. Suitable use of block designs may further our knowledge of nonspecific effects in quality improvement research.

OBJECTIVE: The GRIF automated feedback system produces real-time comments on the appropriateness of diagnostic tests ordered by general practitioners (GPs) based on recommendations from accepted national and regional practice guidelines. We investigated the experiences of GPs with this system and, more specifically, with the recommendations produced by the system as well as their views on using this system in daily practice. SETTING: We tested the GRIF system in an experiment in a laboratory setting and in a daily practice trial. STUDY PARTICIPANTS: General practitioners. INTERVENTION: In the laboratory experiment, GPs used the GRIF system to assess the appropriateness of 30 request forms. Each of the GPs was confronted with requests they had submitted to the diagnostic unit of the hospital in the past. In the field trial, the GRIF system was applied during patient consultations for 1 year. MAIN OUTCOME MEASURES: We measured GPs' satisfaction with the system using a questionnaire, and also conducted group discussions (in the laboratory experiment) and in-depth interviews (in the field trial) to elicit GPs' opinions of and experiences with the system. In addition, we explored GPs' reasons for not accepting the comments offered by the GRIF system. RESULTS: The results show that the GPs in the laboratory experiment had more positive attitudes towards the system compared with participants in the field trial. All discussion groups and most of the GPs in the field trial regarded receiving the immediate feedback during the test ordering process as an important advantage. The most frequently mentioned reason to reject the recommendation was disagreement with the content and/or the recommendations in the practice guidelines. CONCLUSION: Apart from securing agreement on guideline content, a prerequisite for using GRIF in daily practice on a large scale is that more attention is paid to promotion of the guidelines and their adoption, and stimulation of a positive attitude towards the practice guidelines among the users

Berghmans LCM, IJland M, Van Koeveringe GA, Winkens R, Van Kerrebroeck PhEV. Bekkenfysiotherapie bij onvrijwillig urineverlies. Huisarts Wet 2003;46(3):148-52.

Despite a poor reliability, peer assessment is the traditional method to assess the appropriateness of health care activities. This article describes the reliability of the human assessment of the appropriateness of diagnostic tests requests. The authors used a random selection of 1217 tests from 253 request forms submitted by general practitioners in the Maastricht region of the Netherlands. Three reviewers independently assessed the appropriateness of each requested test. Interrater kappa values ranged from 0.33 to 0.42, and kappa values of intrarater agreement ranged from 0.48 to 0.68. The joint reliability coefficient of the 3 reviewers was 0.66. This reliability is sufficient to review test ordering over a series of cases but is not sufficient to make case-by-case assessments. Sixteen reviewers are needed to obtain a joint reliability of 0.95. The authors conclude that there is substantial variation in assessment concerning what is an appropriately requested diagnostic test and that this feedback method is not reliable enough to make a case-by-case assessment. Computer support may be beneficial to support and make the process of peer review more uniform.

In this article we describe a real-time automated reminder system that has been developed to change Family Physicians' (FP) test ordering behavior. The system focuses on the appropriateness of test requests. We aim at using the system as a substitute for written feedback by human experts. The reminder system consists of a knowledge base, an order entry system and modules to provide passive and active support in the form of reminders to FPs. The system generates critical comments about the rationality of the test requests at the moment the FP orders a test that is not in line with national or regional guidelines. For the first validation of the knowledge base we compared the comments of a human expert to the comments of the reminder system on three random samples of test requests. The overall agreement in the subsequent validation rounds was 46, 60 and 69%. The corrections made in the knowledge base after each validation round resulted in a reminder system with 149 reminders concerning various medical problems. Due to the corrections in the knowledge base the reminder system reacts better over the subsequent validation rounds.

The purpose of this case report is to describe a rare case of a patient with a phaeochromocytoma with several cardiovascular complications, which can be attributed to the tumour. Detection of a phaeochromocytoma sometimes needs a 'Sherlock Holmes spirit' or simply time.

Due to possible methodological and practical problems, many researchers refrain from using a randomized controlled trial design to evaluate procedures already embedded in routine health care. We performed a randomized controlled trial on the effects of routine individual feedback on test ordering behavior of family physicians. The trial started after 4 years of feedback and lasted for 2.5 years. With some adaptations a randomized trial proved to be possible. In evaluating health-care procedures that cannot be blinded in a traditional way, asking full and study-specific informed consent may conflict with the validity of the design. In such studies, an alternative procedure is to be considered. Our trial, with doctors as study subjects, was held on an already accepted routine procedure (feedback). This made it possible to refrain from obtaining study-specific informed consent. Consequently, a Hawthorne effect and contamination of the trial arms through information leakage could be avoided. Justification and general criteria for not obtaining full and study-specific informed consent are worked out. In health-care research on the performance of doctors or on interventions into the quality of care, obtaining a general informed consent in advance is an acceptable alternative approach.

Introduction: Premature ventricular contractions (PVCs) are among the most prevalent arrhythmias. PVCs lead to haemodynamically insufficient heartbeats. Their presence is considered rather insignificant, but this widespread assumption is not supported by research evidence.Cases: We present three cases of patients commonly seen in daily general practice, with a range of presentations, varying from incidental (harmless) PVCs to frequent and potentially symptomatic PVCs.Discussion: In more frequent PVCs (> 10% heart beats) fatigue and exertional dyspnoea may occur. When > 20% of heart beats are PVCs, patients may develop cardiomyopathy and heart failure. Incidental PVCs are harmless. Anti-arrhythmic drug treatment should be considered in case of frequent PVCs but also catheter ablation appears an effective treatment option.Conclusion: Altogether, PVCs may not be harmless, depending on their occurrence rate. Research data from primary care settings on epidemiology and natural course is needed.

The authors assessed the economic consequences of routine individual feedback on test requests provided to 85 family physicians in a region with 187,000 inhabitants. In a retrospective study as part of a quasi-experiment, cost trends in a region where feedback was provided over a seven-year period were compared with cost trends elsewhere in The Netherlands without feedback. Data on variable costs were obtained for 400 individual tests that accounted for 90% of all requests. Differences in request trends thus were transformed to savings in costs of diagnostic testing, taking account of the extra costs of providing the feedback. Expenditures for diagnostic testing de clined after the start of the feedback, despite the costs of providing the feedback. The savings increased as the feedback continued. Compared with the trend elsewhere without feedback, over seven years a total net sum of 1.4 million U.S. dollars was saved. Routine individual feedback is therefore economically worthwhile. Key words: economic evaluation; feedback; diagnostic testing; quality assurance; cost contain ment. (Med Decis Making 1996;16:309-314)

Feedback can be described as a way to provide information on doctors' performance to enable changes in future behaviour. Feedback is used with the aim of changing test-ordering behaviour. It can lead to reductions in test usage and cost savings. It is not sufficiently clear, however, whether feedback leads to more appropriate test use. Since 1985, the Diagnostic Coordinating Center Maastricht has been giving feedback on diagnostic tests as a routine health care activity to all family doctors in its region. Both quantity and quality of requests are discussed. In a randomised, controlled trial over 2.5 years, discussion of tests not included previously was added to the existing routine feedback. One group of family doctors (n = 39) received feedback on test-group A (electrocardiography, endoscopy, cervical smears, and allergy tests), the other (n = 40) on test-group B (radiographic and ultrasonographic tests). Thus, each group of doctors acted as a control group for the other. Changes in volume and rationality of requests were analysed. The number of requests decreased during the trial (p = 0.036). Request numbers decreased particularly for test-group A (p = 0.04). The proportion of requests that were non-rational decreased more in the intervention than in the control groups (p = 0.009). Rationality improved predominantly for test-group B (p = 0.043). Thus, routine feedback can change the quantity and quality of requests.

For urinary tract infections (UTI), diagnostic testing appears to be reliable and simple to perform. This particularly seems to hold true for test strips. In studies the validity of several urine tests proved to be high. These studies were, however, performed under optimal and standardized conditions. Their results therefore do not reflect daily practice. In this study the validity of urine tests for UTI is deterined under daily practice conditions, without the use of a protocol. The results show a validity considerably lower than under optimal conditions. Specificity in particular was lower, even for simple tests like the nitrite reaction. Under daily practice conditions, UTI can neither be confirmed nor excluded sufficiently on the outcome of a urinary sediment or test strip.

So far, the validity of urine dipslides has been studied only under optimal conditions, which may not reflect the situation in daily practice.We studied the validity of the urine dipslide as performed under daily practice conditions and assessed the influence of the incubation period (24 h versus 48 h) on validity.Fresh urine samples of patients with signs/symptoms of a possible urinary tract infection (UTI) were examined in general practice via a nitrite test, a urine sediment and a dipslide. A second dipslide was inoculated and sent to the hospital microbiology laboratory for culture. This culture acted as gold standard. We calculated the sensitivity and specificity of the tests performed.Of the 273 patient episodes included, 62% had a UTI (166 of 268 cultures). The sensitivity of the dipslide performed in daily general practice was 73% and the specificity was 94%.The validity of the dipslide read under practice conditions is lower than under optimal conditions. Actions to improve performance are needed. Nonetheless, using the dipslide instead of the sediment as a second step after the nitrite test would improve the diagnostic work-up of UTI.

Urinary incontinence (UI) is a very common problem, but existing guidelines on UI are not followed. To bring care in line with guidelines, we planned an intervention to involve nurse specialists on UI in primary care and assessed this in a randomised controlled trial. Alongside this intervention, we assessed consumer satisfaction among patients and general practitioners (GPs).Patients' satisfaction with the care provided by either nurse specialists (intervention group) or GPs (control group), respectively, was measured with a self-completed questionnaire. GPs' views on the involvement of nurse specialists were measured in a structured telephone interview.The patient satisfaction score on the care offered by nurse specialists was 8.4 (scale 1-10), vs. 6.7 for care-as-usual by GPs. Over 85% of patients would recommend nurse specialist care to their best friends and 77% of the GPs considered the role of the nurse specialist to be beneficial, giving it a mean score of 7.2.Although the sample was relatively small and the stability of the results only provisionally established, substituting UI care from GP to nurse specialist appears to be welcomed by both patients and GPs. Small changes like giving additional UI-specific information and devoting more attention to UI (which had been given little attention before) would provide a simple instrument to stimulate patients to change their behaviour in the right direction.

Investigations such as blood tests and radiography are important tools for the making correct diagnoses. The use of diagnostic resources is growing steadily—in the Netherlands, for example, nationwide expenditure on diagnostic tests is growing at the rate of 7% a year. Unfortunately, health status is not improving similarly, which suggests that investigations are being overused. The ordering of tests seems not to be influenced by the fact that their diagnostic accuracy is often disappointing. Considerations other than strict scientific indications seem to be involved, and we may ask whether new knowledge and research findings are adequately reflected in daily practice. Several factors may be responsible for the increasing use of investigations, such as the increasing demand for care (due to ageing of the population and increasing numbers of chronically ill people); the fact that they are available, which in itself leads to ordering; and the urge to make use of new technology. Once an abnormal test result is found, doctors may order further investigations, not realising that on average 5% of test results are outside their reference ranges, and a cascade of testing may result. Furthermore, higher standards of care, the guidelines for which often recommend additional testing, and defensive behaviour have led to more investigations. Unfortunately, when guidelines on selective and rational ordering of investigations are introduced, numerous motives for ignoring evidence based recommendations, such as fear of litigation, or procrastination on the part of the doctor, come into play in daily practice and are difficult to influence. Overuse of investigations—and there is reason to believe that some requests are illogical—leads to overloading of the diagnostic services and overexpenditure: more efficient usage is therefore needed. Interventions focusing on overt examples of inappropriate testing might reduce costs while simultaneously improving quality of care. #### Summary points Intervention is needed to reduce the often …

Pectus excavatum is usually considered meaningless and without clinical significance. The following case may put a different complexion on the matter. A healthy 59-year-old male patient complained of progressive heart palpitations, fatigue and postural dyspnoea; bending over caused a clear increase of dyspnoea. At repeated examinations no overt abnormality or explanation was found, except a supraventricular arrhythmia and a nodal tachycardia. In the years to follow the symptoms led to considerable physical impairments. Finally, the patient himself, after searching the web, came up with a possible cause: his pectus excavatum. A lateral chest x-ray with the patient bending over and a lateral computed tomography of the thorax revealed an impression of the heart by the sternum. Ten years after the patient’s signs and symptoms first appeared, a modified Ravitch procedure was carried out, after which the physical condition of the patient improved rapidly.

Objective To assess the quality of the content of reports of telephone consultations at out-of-hours centres and to investigate to what extent the reports reflect the actual telephone consultation. Design and setting Cross-sectional qualitative study; 17 out-of-hours centres in The Netherlands. Method To assess the quality of the content of reports, a focus group developed the Reason for calling, Information gathered, Care advice given, Evaluation of the care advice with the patient (RICE) report rating instrument. Telephone Incognito Standardised Patients presented seven different clinical problems three times to 17 out-of-hours centres. All calls were recorded and transcribed. The out-of-hours centres being called were asked for a copy of the report of the call. The authors assessed the quality of the content of the reports and compared this with the transcripts. Results The out-of-hours centres returned a report for 78% of the 357 calls. For the remaining 22% of the calls, no report was written. Reports contained almost always information about the medical reason for calling but little information about details of the clinical history. Patients' expectation, personal situation or perception of the care advice was seldom documented. In all but one out-of-hours centre, answers to obligatory questions were reported by triagists, although they had not been asked, varying between 1% and 54% of all questions entered. Triagists entered a subjective evaluation of a patients' condition in 12% of the reports. Conclusion Reports of telephone consultations of out-of-hours centres contained little information on patients' clinical and personal condition. This could potentially endanger patients' continuity of care and might pose legal consequences for the triagist.

Contains fulltext : 88080.pdf (Publisher’s version ) (Closed access) OBJECTIVES: (1) To investigate the frequency of cascades of further diagnostic investigations and referrals after abnormal laboratory results in situations of low disease probability; (2) to investigate pretest and posttest determinants; and (3) to describe the cascades that occur. STUDY DESIGN AND SETTING: Prospective cohort study in primary care in The Netherlands. Numbers of investigations/referrals were recorded during 6 months of follow-up for 256 patients with normal and abnormal laboratory results. The influences of the reason for ordering tests, interpretation of results, and pretest/posttest disease probability were examined. RESULTS: After receiving the laboratory results, the physicians ordered further investigations for 22 (17.3%) patients with abnormal results and for two (1.6%) patients with normal results (P

Background The use of guidelines in general practice is not optimal. Although evidence-based methods to improve guideline adherence are available, variation in physician adherence to general practice guidelines remains relatively high. The objective for this study is to transfer a quality improvement strategy based on audit, feedback, educational materials, and peer group discussion moderated by local opinion leaders to the field. The research questions are: is the multifaceted strategy implemented on a large scale as planned?; what is the effect on general practitioners' (GPs) test ordering and prescribing behaviour?; and what are the costs of implementing the strategy? Methods In order to evaluate the effects, costs and feasibility of this new strategy we plan a multi-centre cluster randomized controlled trial (RCT) with a balanced incomplete block design. Local GP groups in the south of the Netherlands already taking part in pharmacotherapeutic audit meeting groups, will be recruited by regional health officers. Approximately 50 groups of GPs will be randomly allocated to two arms. These GPs will be offered two different balanced sets of clinical topics. Each GP within a group will receive comparative feedback on test ordering and prescribing performance. The feedback will be discussed in the group and working agreements will be created after discussion of the guidelines and barriers to change. The data for the feedback will be collected from existing and newly formed databases, both at baseline and after one year. Discussion We are not aware of published studies on successes and failures of attempts to transfer to the stakeholders in the field a multifaceted strategy aimed at GPs' test ordering and prescribing behaviour. This pragmatic study will focus on compatibility with existing infrastructure, while permitting a certain degree of adaptation to local needs and routines. Trial registration Nederlands Trial Register ISRCTN40008171

The primary care specialist interface is a key organisational feature of many health care systems. Patients are referred to specialist care when investigation or therapeutic options are exhausted in primary care and more specialised care is needed. Referral has considerable implications for patients, the health care system and health care costs. There is considerable evidence that the referral processes can be improved.To estimate the effectiveness and efficiency of interventions to change outpatient referral rates or improve outpatient referral appropriateness.We conducted electronic searches of the Cochrane Effective Practice and Organisation of Care (EPOC) group specialised register (developed through extensive searches of MEDLINE, EMBASE, Healthstar and the Cochrane Library) (February 2002) and the National Research Register. Updated searches were conducted in MEDLINE and the EPOC specialised register up to October 2007.Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series of interventions to change or improve outpatient referrals. Participants were primary care physicians. The outcomes were objectively measured provider performance or health outcomes.A minimum of two reviewers independently extracted data and assessed study quality.Seventeen studies involving 23 separate comparisons were included. Nine studies (14 comparisons) evaluated professional educational interventions. Ineffective strategies included: passive dissemination of local referral guidelines (two studies), feedback of referral rates (one study) and discussion with an independent medical adviser (one study). Generally effective strategies included dissemination of guidelines with structured referral sheets (four out of five studies) and involvement of consultants in educational activities (two out of three studies). Four studies evaluated organisational interventions (patient management by family physicians compared to general internists, attachment of a physiotherapist to general practices, a new slot system for referrals and requiring a second 'in-house' opinion prior to referral), all of which were effective. Four studies (five comparisons) evaluated financial interventions. One study evaluating change from a capitation based to mixed capitation and fee-for-service system and from a fee-for-service to a capitation based system (with an element of risk sharing for secondary care services) observed a reduction in referral rates. Modest reductions in referral rates of uncertain significance were observed following the introduction of the general practice fundholding scheme in the United Kingdom (UK). One study evaluating the effect of providing access to private specialists demonstrated an increase in the proportion of patients referred to specialist services but no overall effect on referral rates.There are a limited number of rigorous evaluations to base policy on. Active local educational interventions involving secondary care specialists and structured referral sheets are the only interventions shown to impact on referral rates based on current evidence. The effects of 'in-house' second opinion and other intermediate primary care based alternatives to outpatient referral appear promising.

Objective To assess the quality of telephone triage by following the consecutive phases of its care process and the quality of the clinical questions asked about the patient’s clinical condition, of the triage outcome, of the content of the home management advice, and of the safety net advice given at out of hours centres. Design Cross sectional national study using telephone incognito standardised patients. Setting The Netherlands. Participants 17 out of hours centres. Main outcome measures Percentages of clinical obligatory questions asked and items within home management and safety net advice, both in relation to pre-agreed standards, and of care advice given in relation to the required care advice. Results The telephone incognito standardised patients presented seven clinical cases three times each over a period of 12 months, making a total of 357 calls. The mean percentage of obligatory questions asked compared with the standard was 21%. Answers to questions about the clinical condition were not always correctly evaluated from a clinical viewpoint, either by triagists or by general practitioners. The quality of information on home management and safety net advice varied, but it was consistently poor for all cases and for all out of hours centres. Triagists achieved the appropriate triage outcome in 58% of calls. Conclusion In determining the outcome of the care process, triagists often reached a conclusion after asking a minimal number of questions. By analysing the quality of different phases within the process of telephone triage, evaluation of whether an appropriate triage outcome has been arrived at by means of good clinical reasoning or by an educated guess is possible. In terms of enhancing the overall clinical safety of telephone triage, apart from obtaining an appropriate clinical history, adequate home management and safety net advice must also be given.

Urinary incontinence is a common problem, affecting quality of life and leading to high costs. There is doubt about the use of clinical practice guidelines on urinary incontinence in primary care.To assess adherence levels and reasons for (non)adherence to the Guideline on Urinary Incontinence of the Dutch College of General Practitioners. Design, setting and participants A postal survey among Dutch general practitioners (GPs).Adherence of GPs to the guideline.We analysed 264 questionnaires. Almost all GPs adhered to the guideline when diagnosing the type of urinary incontinence. A bladder diary is not often used (35%). Adherence to therapeutic procedures was only high for mild/moderate stress urinary incontinence: most GPs (82.6%) used adequate advice on bladder retraining and pelvic floor muscle training. One out of four GPs agreed that adhering to the guideline is difficult, mainly owing to lack of time, staff, diagnostic tools, competences to provide this care and low motivation of patients.Dutch GPs follow the guideline only partially: compliance with diagnostic advices is fairly good; compliance with treatment advices is low. Further research should focus on solutions how to support GPs to tackle major barriers to facilitate the adherence to guidelines (substitution of tasks to specialized nurses, reducing the threshold for referral and concentrating expertise in integrated continence care services).

Objective To assess the quality of communication skills of triagists, working at out-of-hours (OOH) centres, and to determine the correlation between the communication score and the duration of the telephone consultation. Methods Telephone incognito standardised patients (TISPs) called 17 OOH centres presenting different clinical cases. The assessment of communication skills was carried out using the RICE-communication rating list. The duration of each telephone consultation was determined. Results The mean overall score for communication skills was 35% of the maximum feasible. Triagists usually asked questions about the clinical situation correctly and little about the patients’ personal situation, perception of the problem or expectation. Advice about the outcome of triage and self-care advice was usually given without checking for patients’ understanding and acceptance of the advice. Calls were often handled in an unstructured way, without summarizing or clarifying the different steps within the consultation. There was a positive correlation of 0.86 ( p Conclusion Assessment of communication skills of triagists revealed specific shortcomings and learning points to improve the quality of communication skills during telephone triage. Practice implications Training in telephone consultation should focus more on patient-centred communication with active listening, active advising and structuring the call. Apart from adequate communication skills, triagists need sufficient time for telephone consultation to enable high quality performance.

Item does not contain fulltext OBJECTIVE: To evaluate the feasibility and acceptability of a computer reminder system (CRS) to improve prescribing behaviour in general practice and to explore the strengths and weaknesses of a reminder system. One group of GPs received reminders on cholesterol lowering drugs, the other group on antibiotics, asthma and COPD drugs. METHODS: Process evaluation of the computer reminder system being used by 53 GPs in 20 practices, by means of an analysis of the research database of the CRS. In addition, a questionnaire and semi-structured face-to-face interview were conducted with all GP practices, two project leaders, and one technical consultant. RESULTS: The strategy was largely carried out as planned, although the development period for the CRS had to be extended. Nine percent of the GPs dropped out. We found a significant learning curve without extinguishing effect (p=0.03) for the antibiotics reminders. The questionnaire showed that, in general, GPs were satisfied with the user-friendliness and the content of the different types of reminders, but less satisfied with certain specific technical performance issues of the system. The GPs reported mixed feelings towards the CRS in the interviews. They were generally positive about the guidelines themselves, but negative regarding to the organisational context and the method of implementing the CRS. GPs stated that they sometimes manipulated the system to bypass reminders. Interviews with the project leaders and technical consultant revealed barriers to cooperation and miscommunication between the different parties, and technical problems with multiple updates of the GP information system and the operating system. CONCLUSIONS: This process evaluation demonstrated that the implementation of the CRS was mainly carried out as planned, but the subjective experience of working with the CRS was not only positive. Participating GPs had mixed feelings, and quite a number of barriers need to be addressed to facilitate large-scale implementation of the CRS. Costs cannot be neglected, so it is important to analyse the balance between costs and effects.

Contains fulltext : 70765.pdf ( ) (Open Access) BACKGROUND: Urinary incontinence affects approximately 5% (800.000) of the Dutch population. Guidelines recommend pelvic floor muscle/bladder training for most patients. Unfortunately, general practitioners use this training only incidentally, but prescribe incontinence pads. Over 50% of patients get such pads, costing 160 million euros each year. Due to ageing of the population a further increase of expenses is expected. Several national reports recommend to involve nurse specialists to support general practitioners and improve patient care. The main objective of our study is to investigate the effectiveness and cost-effectiveness of involving nurse specialists in primary care for urinary incontinence. This paper describes the study protocol. METHODS/DESIGN: In a pragmatic prospective multi centre two-armed randomized controlled trial in the Netherlands the availability and involvement for the general practitioners of a nurse specialist will be compared with usual care. All consecutive patients consulting their general practitioner within 1 year for urinary incontinence and patients already diagnosed with urinary incontinence are eligible. Included patients will be followed for 12 months.Primary outcome is severity of urinary incontinence (measured with the International Consultation on Incontinence Questionnaire Short Form (ICIQ-UI SF)). Based on ICIQ-UI SF outcome data the number of patients needed to include is 350. For the economic evaluation quality of life and costs will be measured alongside the clinical trial. For the longer term extrapolation of the economic evaluation a Markov modelling approach will be used. DISCUSSION/CONCLUSION: This is, to our knowledge, the first trial on care for patients with urinary incontinence in primary care that includes a full economic evaluation and cost-effectiveness modelling exercise from the societal perspective. If this intervention proves to be effective and cost-effective, implementation of this intervention is considered and anticipated. TRIAL REGISTRATION: Current Controlled Trials ISRCTN62722772.

Background Palliative care in cancer aims at alleviating the suffering of patients. A previous study in patients with advanced non-small-cell lung cancer showed that adenosine 5'-triphosphate (ATP) infusions had a favourable effect on fatigue, appetite, body weight, muscle strength, functional status and quality of life. The present study was designed 1. To evaluate whether ATP has favourable effects in terminally ill cancer patients, 2. To evaluate whether ATP infusions may reduce family caregiver burden and reduce the use of professional health care services, and 3. To test the feasibility of application of ATP infusions in a home care setting. Methods/Design The study can be characterized as an open-labelled randomized controlled trial with two parallel groups. The intervention group received usual palliative care, two visits by an experienced dietician for advice, and regular ATP infusions over a period of 8 weeks. The control group received palliative care as usual and dietetic advice, but no ATP. This paper gives a description of the study design, selection of patients, interventions and outcome measures. Discussion From April 2002 through October 2006, a total of 100 patients have been randomized. Follow-up of patients will be completed in December 2006. At the time of writing, five patients are still in follow up. Of the 95 patients who have completed the study, 69 (73%) have completed four weeks of follow-up, and 53 (56%) have completed the full eight-week study period. The first results are expected in 2007.

Objective It is difficult to control drug-prescribing behaviour in general practice, despite the development and distribution of guidelines. The purpose of this study was to assess the effect on drug-prescribing behaviour of implementing prescribing guidelines by means of a reactive computer reminder system (CRS). Design Cluster-randomised controlled trial with an incomplete block design in the south of the Netherlands: 25 GPs (7 GP practices) received reminders about antibiotics and asthma/COPD prescriptions, 28 GPs (7 GP practices) received reminders about cholesterol prescriptions. Prescription guidelines were integrated into the computerised GP information system. Measurements Both performance indicators and prescription volumes were calculated as the main outcome measures. Next to individual volume measure, sum scores were constructed on the volume measures per drug group (antibiotics, asthma/COPD and cholesterol). Results Variation between GPs turned out to be larger and more skewed than expected. No differences between groups were found for indicators and volumes related to recommendations advocating certain drugs. Although there was a tendency towards clinically relevant results for prescription volumes that were supposed to drop, the difference in sum score between the groups was not significant. For antibiotic prescriptions that were supposed to drop, the sum score for the intervention group was 28.2 (95% CI: 20.8–44.5) prescriptions per 1000 patients per GP, while this was 39.7 (95% CI: 29.7–64.1) for the control group ( p 0.2). For prescriptions asthma/COPD that were supposed to drop, the sum score for the intervention group was 1.1 (95% CI: 0.6–2.6) prescriptions per 1000 patients per GP, while this was 2.2 (95% CI: 1.4–4.3) for the control group ( p 0.1). On three specific recommendations (on quinolones for cystitis, corticosteroids for CPOD, and antibiotics for acute sore throat) significant differences were found. Conclusions This study turned out to be underpowered due to high inter doctor variation in prescribing behaviour. Nevertheless, computerised reminders sometimes have a favourable effect on restricting certain drugs that are not or no longer indicated in general practice.

Objective To evaluate the concordance of General Practitioners (GPs) with advice for treatment after a multidisciplinary psychogeriatric assessment by the Diagnostic Observation Centre for PsychoGeriatric patients (DOC-PG). Method Concordance checklists, listing the recommendations from the multidisciplinary team, were sent to the GPs in order to establish GP concordance. Regression models were used to study the associations between various patient and GP characteristics and level of concordance. Furthermore, results of a questionnaire (to identify the level of satisfaction regarding the services provided by the DOC-PG) were compared with the level of GP concordance. Results Based on 530 recommendations, the overall GP concordance rate amounted to 71%. The most common types of advice pertained to medication, GP follow-up/advice and referral. GP concordance with advice regarding admissions was the highest, followed by advice concerning the arrangement of daycare, home care and the adaptation of medication. GP concordance was lowest for referral recommendations to other specialties and recommendations regarding psychoeducation. Concordance was higher for patients who lived alone, for patients with fewer cognitive problems, when the number of recommendations did not exceed six and in group practices. Concordance was dependent on the type of advice. Satisfaction with DOC-PG did not correlate with the level of concordance. Conclusions In general, GPs showed a high level of concordance with advice from the DOC-PG. Enhancement of GP concordance can be achieved by limiting the number of recommendations, giving detailed explanations about the purpose of recommendations and educating GPs by doing. Copyright © 2006 John Wiley & Sons, Ltd.

Heart failure has a low incidence in general practice but is not easy to recognize in this setting. Frequently a normal electrocardiogram and a normal level of brain natriuretic peptide can exclude heart failure as a cause for dyspnea. Unfortunately the positive predictive value of both techniques is low. Imaging with echocardiography can then give the clue to the correct diagnosis. Also correct diagnosis of cardiac murmurs is not easy in general practice. Therefore an open access echocardiographic service was established in the south of the Netherlands. According to the existing services in the United Kingdom general practicioners in this area were able to ask for an echocardiogram without referring the patient to the cardiologist. During a period of 19 months 131 patients were referred to the Centre of Medical Diagnostics for an echocardiogram. In 12% of the patients referred for dyspnea a left ventricular ejection fraction lower than 40% was found. Fourty nine percent of the patients had diastolic dysfunction. In 33% heart failure could be excluded. In 62% of the patients referred for a cardiac murmur cardiac pathology could be found. In 38% of the patients the cardiac murmur could be established as a functional murmur. The service was found to improve practice by most of the general practicioners.

Background In recent years, Dutch general practitioner (GP) out-of-hours service has been reorganised into large-scale GP cooperatives. Until now little is known about GPs' experiences with working at these cooperatives for out-of-hours care. The purpose of this study is to gain insight into GPs' satisfaction with working at GP cooperatives for out-of-hours care in separated and integrated cooperatives. Methods A GP cooperative separate from the hospital Accident and Emergency (A&E) department, and a GP cooperative integrated within the A&E department of another hospital. Both cooperatives are situated in adjacent geographic regions in the South of the Netherlands. One hundred GPs were interviewed by telephone; fifty GPs working at the separated GP cooperative and fifty GPs from the integrated GP cooperative. Opinions on different aspects of GP cooperatives for out-of-hours care were measured, and regression analysis was performed to investigate if these could be related to GP satisfaction with out-of-hours care organisation. Results GPs from the separated model were more satisfied with the organisation of out-of-hours care than GPs from the integrated model (70 vs. 60 on a scale score from 0 to 100; P = 0.020). Satisfaction about out-of-hours care organisation was related to opinions on workload, guarantee of gatekeeper function, and attitude towards out-of-hours care as being an essential part of general practice. Cooperation with medical specialists was much more appreciated at the integrated model (77 vs. 48; P < 0.001) versus the separated model. Conclusion GPs in this study appear to be generally satisfied with the organisation of GP cooperatives for out-of-hours care. Furthermore, GPs working at the separated cooperative seem to be more satisfied compared to GPs working at the integrated cooperative.