Arlette E. Hesselink

Determinants of an incorrect inhalation technique in patients with asthma or COPD

Objective - To determine the prevalence of an incorrect inhalation technique and to examine its determinants among primary care patients with asthma or chronic obstructive pulmonary disease (COPD). Design - Cross-sectional study. Setting - 28 general practitioners in The Netherlands. Subjects - 558 asthma and COPD patients, aged 16-75 years. Main outcome measures - Inhalation technique was assessed using a standardised inhaler-specific checklist. Pulmonary function assessment and questionnaires were used to collect data about inhaler, patient and disease characteristics. Results - Overall, 24.2% of the patients made at least one essential mistake in their inhalation technique. The type of inhaler appeared to be the strongest independent determinant of an incorrect inhalation technique. Compared to patients using the Diskhaler, patients using the Rotahaler/Spinhaler, Turbuhaler, Metered Dose Inhaler (MDI) or Cyclohaler/Inhaler-Ingelheim were at significantly higher risk of making inhalation mistakes (odds ratios (OR) were 16.08, 13.17, 11.60 and 3.27, respectively). Other significant determinants of an incorrect inhalation technique were low emotional quality of life (OR =1.73) and being treated in a group practice (OR =2.26). Conclusions - An incorrect inhalation technique is common among pulmonary disease patients in primary care. Our study suggests that especially patients using the Rotahaler/Spinhaler, Turbuhaler or MDI, patients with emotional problems and patients in a group practice are at increased risk for an incorrect inhalation technique.OBJECTIVE To determine the prevalence of an incorrect inhalation technique and to examine its determinants among primary care patients with asthma or chronic obstructive pulmonary disease (COPD). DESIGN Cross-sectional study. SETTING 28 general practitioners in The Netherlands. SUBJECTS 558 asthma and COPD patients, aged 16-75 years. MAIN OUTCOME MEASURES Inhalation technique was assessed using a standardised inhaler-specific checklist. Pulmonary function assessment and questionnaires were used to collect data about inhaler, patient and disease characteristics. RESULTS Overall, 24.2% of the patients made at least one essential mistake in their inhalation technique. The type of inhaler appeared to be the strongest independent determinant of an incorrect inhalation technique. Compared to patients using the Diskhaler, patients using the Rotahaler/Spinhaler, Turbuhaler, Metered Dose Inhaler (MDI) or Cyclohaler/Inhaler-Ingelheim were at significantly higher risk of making inhalation mistakes (odds ratios (OR) were 16.08, 13.17, 11.60 and 3.27, respectively). Other significant determinants of an incorrect inhalation technique were low emotional quality of life (OR = 1.73) and being treated in a group practice (OR = 2.26). CONCLUSIONS An incorrect inhalation technique is common among pulmonary disease patients in primary care. Our study suggests that especially patients using the Rotahaler/Spinhaler, Turbuhaler or MDI, patients with emotional problems and patients in a group practice are at increased risk for an incorrect inhalation technique.

The role of coping resources and coping style in quality of life of patients with asthma or COPD

Objective: Sufficient psychosocial coping resources and an adequate coping style may have a beneficial influence on quality of life in patients with a chronic disease. Until now little research has been directed at these associations and particularly not among patients with asthma or chronic obstructive pulmonary disease (COPD). The objective of this study is to examine the association between psychosocial coping resources and coping style with HRQoL, for asthma and COPD separately. Methods: Fourteen general practitioners in the Netherlands recruited 273 adult patients with asthma (n = 220) or COPD (n = 53). Data were collected by a pulmonary function assessment, a face-to-face interview and validated questionnaires about psychosocial coping resources (self-efficacy, mastery, self-esteem, and social support), coping style (avoidant, rational and emotional), and health related quality of life (HRQoL). Results: A more emotional coping style (p < 0.01) was independently associated with poor HRQoL in both asthma and COPD patients. Furthermore, in asthma patients, less self-efficacy feelings (p < 0.01), less mastery feelings (p = 0.05), a more avoidant coping style (p = 0.04) and poor pulmonary function (p < 0.01) were independently associated with poor HRQoL. In COPD patients, a more rational coping style (p = 0.02) was independently associated with poor HRQoL. Conclusion: Our findings suggest that psychosocial coping resources and coping style are independently associated with HRQoL in patients with asthma or COPD. Further research should explore the possibilities of intervening on these factors, aiming to improve HRQoL in patients with asthma or COPD.

Gender Differences in Health-Related Quality of Life Among Asthma Patients

Objective. To identify and explain differences between men and women with asthma regarding health-related quality of life (HRQoL). Methods. A cross-sectional study was performed among 967 asthma patients recruited from general practice. Data were collected by means of a pulmonary function assessment, a face-to-face interview, and a written questionnaire. Results. Women with asthma reported lower scores on HRQoL in the age groups 16–34 and 56–75 years but not in the age group 35–55 years. In all age groups, women reported more severe dyspnea but had higher levels of pulmonary function. The poorer HRQoL reported by women could be explained by a more severe dyspnea and a higher level of medication use in women. Conclusions. The finding that women with asthma aged 16–34 and 56–75 years report poorer HRQoL than men is not due to a more severe disease state in terms of pulmonary obstruction but does seem to be related to a more severe subjective disease state in women than in men.

Acculturation and use of health care services by Turkish and Moroccan migrants: a cross-sectional population-based study

BackgroundThere is insufficient empirical evidence which shows if and how there is an interrelation between acculturation and health care utilisation. The present study seeks to establish this evidence within first generation Turkish and Moroccan migrants, two of the largest migrant groups in present-day Western Europe.MethodsData were derived from the Amsterdam Health Monitor 2004, and were complete for 358 Turkish and 288 Moroccan foreign-born migrants. Use of health services (general practitioner, outpatient specialist and health care for mental health problems) was measured by means of self-report. Acculturation was measured by a structured questionnaire grading (i) ethnic self-identification, (ii) social interaction with ethnic Dutch, (iii) communication in Dutch within ones private social network, (iv) emancipation, and (v) cultural orientation towards the public domain.ResultsAcculturation was hardly associated with the use of general practitioner care. However, in case of higher adaptation to the host culture there was less uptake of outpatient specialist care among Turkish respondents (odds ratio [OR] = 0.90, 95% confidence interval [CI] = 0.82-0.99) and Moroccan male respondents (OR = 0.81, 95% CI = 0.71-0.93). Conversely, there was a higher uptake of mental health care among Turkish men (OR = 0.81, 95% CI = 0.71-0.93) and women (OR = 0.81, 95% CI = 0.71-0.93). Uptake of mental health care among Moroccan respondents again appeared lower (OR = 0.74, 95% CI = 0.55-0.99). Language ability appeared to play a central role in the uptake of health care.ConclusionSome results were in accordance with the popular view that an increased participation in the host society is concomitant to an increased use of health services. However, there was heterogeneity across ethnic and gender groups, and across the domains of acculturation. Language ability appeared to play a central role. Further research needs to explore this heterogeneity into more detail. Also, other cultural and/or contextual aspects that influence the use of health services require further identification.

What predicts change in pulmonary function and quality of life in asthma or COPD

Information about predictors of decline in pulmonary function (forced expiratory volume in 1 second [FEV1]) or health-related quality of life (HRQoL) in patients with asthma or (chronic obstructive pulmonary disease [COPD]) might help to determine those who need additional care. A 2-year prospective cohort study was conducted among 380 asthma and 120 COPD patients. In both asthma and COPD patients, a 2-year change in FEV1 was only weakly associated with a 2-year change in HRQoL (r =. 0.19 and 0.24, respectively). In both groups, older age, living in an urban environment, and a lower peak expiratory flow rate (PEFR) at baseline were associated with a decline in FEV1. Additional predictors of FEV1 decline were greater body weight, less chronic cough or sputum production, and less respiratory symptoms in asthma patients and current smoking in COPD patients. A decline in HRQoL was associated with older age, non-compliance with medication, more dyspnea, and a lower PEFR in asthma patients and with male gender, lower education, lower body weight, more dyspnea, and more respiratory symptoms in COPD patients. Our results show that FEV1 and HRQoL appear to represent different disease aspects influenced by different predictors.

De implementatie van de NDF Zorgstandaard Diabetes anno 2013

SamenvattingTijdens de looptijd van het Nationaal Actieprogramma Diabetes (NAD) zijn twee monitoronderzoeken (2010 en 2013) uitgezet onder zorgprofessionals en patiënten met (een verhoogd risico op) diabetes. Het hoofddoel van het huidige onderzoek was zicht krijgen op de mate van implementatie van de NDF Zorgstandaard Diabetes (hierna te noemen Zorgstandaard). Dit artikel beschrijft de stand van zaken in 2013 en vergelijkt de resultaten uit het onderzoek met die van het monitorondezoek uit 2010.Het cross-sectioneel vragenlijstonderzoek vond plaats tussen november 2012 en februari 2013 onder 2.423 zorgprofessionals en 5.650 patiënten.Van de zorgprofessionals was 43,7% in het bezit van de Zorgstandaard. De meerderheid van de zorgprofessionals (89,2%) gaf aan (grotendeels) conform de Zorgstandaard te werken en had een positieve houding ten aanzien van de Zorgstandaard en de bijdrage die deze levert aan het waarborgen van de kwaliteit van de diabeteszorg.Patiënten ervaren in hoge mate door de zorgverlener betrokken te worden in hun behandeling en rapporteren dat ze tevreden zijn over het contact met hun zorg verlener( s). Ongeveer 60% van de patiënten was bekend met de Zorgwijzer (de patiëntenversie van de Zorgstandaard) en een kleine minderheid (15,3%) had de Zorgwijzer in bezit.Terugkijkend op het NAD lijkt het erop dat de Zorgstandaard heeft gefungeerd als een vliegwiel om processen ter verbetering van de zorg voor chronisch zieken in Nederland vorm te geven. Een volgende stap zou kunnen zijn om de zorg op lokaal niveau te implementeren en in te bedden in een wijkgerichte aanpak, waarbij ook aandacht is voor de preventie van andere chronische aandoeningen.SummaryDuring the implementation period of the National Diabetes Action Program (NAD) two monitor studies (2010 and 2013) have been conducted among health care professionals and patients with (a high risk of) diabetes. The main aim of this study was to obtain insight in the implementation of the Dutch Diabetes Federation Health Care Standard for diabetes. This article describes the current situation in 2013 and makes a comparison with the results in 2010.A cross-sectional questionnaire study was conducted among 2423 health care professionals and 5650 patients between November 2012 and February 2013.The results showed that 43.7% of the health care professionals was in possession of the Care Standard. The majority of the professionals (89.2%) worked (largely) in accordance with the Care Standard and had a positive attitude towards the Care Standard and its contribution to ensuring the quality of diabetes care.Patients perceived a high degree of involvement in their treatment and were satisfied about the contact with their caregiver(s). Approximately 60% was familiar with the ‘Diabetes Zorgwijzer’ (patient version of the Standard) and a minority (15.3%) was in possession of the Zorgwijzer.Looking back on the NAD it seems that the Care Standard has functioned as flywheel in implementing processes to improve the care for chronic diseases in the Netherlands. A next step could be to implement the care on a local level, embedding it into a community approach, with possibilities for prevention of other chronic diseases as well.

De helft van de astmapatiënten heeft onvoldoende ziektecontrole

SamenvattingWijnhoven HAH, Kriegsman DMW, Hesselink AE, Van der Windt DAWM. De Haan M, Stalman WAB. De helft van de astmapatiënten heeft onvoldoende ziektecontrole.. Huisarts Wet 2006;49(8):398-403. Doel In dit onderzoek gingen wij de ziektecontrole van astmapatiënten in Nederlandse huisartsenpraktijken na. Wij vergeleken de ziektecontrole met het niveau van de medicamenteuze behandeling om een indruk te krijgen van het percentage patiënten met een suboptimale ziektecontrole bij wie wellicht een betere controle behaald zou kunnen worden. Daarnaast onderzochten wij welke kenmerken van astmapatiënten samenhangen met een suboptimale ziektecontrole.Methoden Wij onderzochten 661 volwassen astmapatiënten uit 25 Nederlandse huisartsenpraktijken en definieerden ziektecontrole aan de hand van de frequentie van luchtwegklachten, het FEV1%-voorspeld, piekstroomvariabiliteit en het gebruik van luchtwegverwijders. Wij gebruikten richtlijnen voor de stapsgewijze behandeling van astmapatiënten van de NHG-Standaard uit 1997 om het niveau van de medicamenteuze behandeling in te delen.Resultaten De ziektecontrole bleek suboptimaal bij de helft van de astmapatiënten. Bij een groot deel van de patiënten (41% van totale populatie) zou aanpassing van het niveau van medicamenteuze behandeling wellicht kunnen leiden tot een beter resultaat. Slechts 1% werd al maximaal behandeld. Een suboptimale ziektecontrole bleek samen te hangen met hogere leeftijd, lagere opleiding, sputumproductie, jongere leeftijd bij begin van de luchtwegklachten, ernstiger dyspnoe en een lagere kwaliteit van leven.Conclusie De helft van de astmapatiënten uit de Nederlandse huisartsenpraktijk heeft een suboptimale ziektecontrole. Aangezien niet al deze patiënten maximaal behandeld worden, lijkt een aanpassing van de medicamenteuze behandeling bij een deel van deze patiënten noodzakelijk om een betere ziektecontrole te bereiken.

Competentiegericht astma-onderwijs aan huisartsenin-opleiding: door onderwijs ondersteunde kwaliteitszorg en de effecten op de klinische toestand van de begeleide patiënten

Inleiding: Om de competenties van huisartsen-in-opleiding (HAIO’s) bij astma te ontwikkelen, is bij het Vrije Universiteit Medisch Centrum (VUmc) een keuzemodule uitgevoerd, waarbij HAIO’s slecht ingestelde astmapatienten in de stage-huisartspraktijk begeleidden. De consulten werden gefaciliteerd door onderwijsbijeenkomsten, die wat betreft inhoud en planning in de tijd afgestemd waren op de consulten in de praktijk.

An education programme for asthma and COPD patients conducted by a general practice assistant; a randomised controlled trial

To improve disease control and thereby health related quality of life (HRQoL) in patients with asthma or chronic obstructive pulmonary disease (COPD) in general practice, we developed and evaluated an education program conducted by a practice assistant. Methods: 272 Asthma and COPD patients were stratified by age and randomly assigned to the intervention (n=139) or control group (n=137). The intervention program consisted of training regarding inhalation technique, and patient centred information about the disease, medication, hyperreactivity, and coping with their disease. The control group received usual care. Measurements took place before randomisation and after one and two years. Outcome measures included HRQoL and disease symptoms. Furthermore, process measures included compliance, inhalation technique, coping and self-efficacy. 209 patients (77 %) completed at least one year follow-up. No differences regarding HRQoL and disease symptoms were observed between the intervention and the usual-care group. In addition, no differences were observed in compliance, coping, and self-efficacy. However, after one and two years the inhalation technique improved significantly (p<0.05) in the intervention group (adequate technique in respectively 62% and 71%) compared to the control group (respectively 42% and 59%). Our results show that an education by a practice assistant may result in an important improvement of inhalation technique in patients with asthma or COPD. However, no effects were found on HRQoL or disease symptoms.