H. C. P. M. van Weert

Cost‐effectiveness of ruling out deep venous thrombosis in primary care versus care as usual

Summary.  Background: Referral for ultrasound testing in all patients suspected of DVT is inefficient, because 80–90% have no DVT. Objective: To assess the incremental cost‐effectiveness of a diagnostic strategy to select patients at first presentation in primary care based on a point of care D‐dimer test combined with a clinical decision rule (AMUSE strategy), compared with hospital‐based strategies. Patients/Methods: A Markov‐type cost‐effectiveness model with a societal perspective and a 5‐year time horizon was used to compare the AMUSE strategy with hospital‐based strategies. Data were derived from the AMUSE study (2005–2007), the literature, and a direct survey of costs (2005–2007). Results of base‐case analysis: Adherence to the AMUSE strategy on average results in savings of €138 (

The psychometric properties of the panic disorder module of the Patient Health Questionnaire (PHQ-PD) in high-risk groups in primary care.

185) per patient at the expense of a very small health loss (0.002 QALYs) compared with the best hospital strategy. The iCER is €55 753(

Rationale and design of the CAREFUL study : The yield of CARdiogenetic scrEening in First degree relatives of sudden cardiac and UnexpLained death victims <45 years

74 848). The cost‐effectiveness acceptability curves show that the AMUSE strategy has the highest probability of being cost‐effective. Results of sensitivity analysis: Results are sensitive to decreases in sensitivity of the diagnostic strategy, but are not sensitive to increase in age (range 30–80), the costs for health states, and events. Conclusion: A diagnostic management strategy based on a clinical decision rule and a point of care D‐dimer assay to exclude DVT in primary care is not only safe, but also cost‐effective as compared with hospital‐based strategies.

NHG-Standaard Slechthorendheid

AIMS To study the validity of detecting panic disorder (PD) using the Patient Health Questionnaire (PHQ) in a high-risk population in primary care and to test whether modified evaluation algorithms improve the operating characteristics of this questionnaire. Furthermore, the influence of psychiatric comorbidity on the test characteristics of the panic module was studied. METHODS The PHQ was administered in a primary care sample with patients at high-risk for psychiatric disorders. The total sample of 479 high-risk patients comprised 311 frequent attenders (FA), 39 patients with unexplained somatic complaints (USC) and 191 patients with mental health problems (MHP). The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID- I) was the reference standard for the presence of PD. Sensitivity, specificity, and predictive values were calculated. The conditional test characteristics were calculated based on the observed prevalence of PD in the three high-risk groups. RESULTS PD was diagnosed in 4.8% of the FAs, in 9.8% of the USCs and in 7.6% of the MHPs. The PHQ achieved moderate operating characteristics. Modified evaluation algorithms of the questionnaire led to an improvement of test characteristics, especially the screening question: sensitivity .71 and specificity .83. Psychiatric comorbidity increased sensitivity while decreasing specificity. CONCLUSION The original and modified algorithms of the PHQ-PD performed moderately in screening for panic disorder. Using only the first question of the PHQ-PD showed the best psychometric properties (sensitivity). For screening purposes requiring high sensitivity we endorse to use the screening question instead of the original algorithm.

Feasibility and accuracy of a rapid 'point-of-care' D-dimer test performed with a capillary blood sample.

Background. Sudden cardiac death (SCD) in the young (1-45 years) is a strong risk factor for the presence of inherited cardiac diseases in surviving first-degree relatives. Postmortem investigation of the victim and cardiogenetic evaluation of the first-degree relatives is indicated to detect inherited cardiac diseases and treat relatives at an early stage to prevent SCD. In the Netherlands, postmortem investigation is often not performed and relatives of SCD and sudden unexplained death (SUD) victims are rarely evaluated for inherited cardiac diseases. Methods. A prospective population-based follow-up study carried out in two intervention regions and two control regions. In the intervention regions a comprehensive intervention (stimulate autopsy and storage of victims DNA and the referral of first-degree relatives for cardiogenetic evaluation) is applied in a ‘top down’ and ‘bottom up’ mode. In each region, young sudden death victims are registered and for all cases performance of autopsy and evaluation of relatives in a cardiogenetics outpatient clinic will be determined. Expected results. The study will provide information on the incidence of sudden death in the young and the proportion of diagnosed inherited cardiac diseases. Moreover, the additional value of the introduction of two different preventive strategies directed at early detection of inherited cardiac diseases in first-degree relatives to usual care will be evaluated. Conclusion. The CAREFUL study will help to set a new standard of care in the evaluation of young sudden death victims and their relatives to identify the presence of inherited cardiac diseases, in order to prevent sudden death. (Neth Heart J 2010;18:286-90.)

Welke gezondheidsproblemen zien huisartsen in opleiding

Deze standaard is inhoudelijk verouderd. Kijk op de site van het NHG ( http://nhg.artsennet.nl/kenniscentrum/k_richtlijnen/k_nhgstandaarden.htm ) voor de meest recente versie.

Qualitative point-of-care D-dimer testing compared with quantitative D-dimer testing in excluding pulmonary embolism in primary care

1 Souto JC, Almasy L, Borrell M, Garı́ M, Martı́nez E, Mateo J, Stone WH, Blangero J, Fontcuberta J. Genetic determinants of hemostasis phenotypes in Spanish families. Circulation 2000; 101: 1546–51. 2 Ariëns RA, de Lange M, Snieder H, Boothby M, Spector TD, Grant PJ. Activation markers of coagulation and fibrinolysis in twins: heritability of the prethrombotic state. Lancet 2002; 359: 667–71. 3 Vossen CY, Hasstedt SJ, Rosendaal FR, Callas PW, Bauer KA, Broze GJ, Hoogendoorn H, Long GL, Scott BT, Bovill EG. Heritability of plasma concentrations of clotting factors and measures of a prethrombotic state in a protein C-deficient family. J Thromb Haemost 2004; 2: 242–7. 4 Buil A, Soria JM, Souto JC, Almasy L, Lathrop M, Blangero J, Fontcuberta J. Protein C levels are regulated by a quantitative trait locus on chromosome 16: results from the Genetic Analysis of Idiopathic Thrombophilia (GAIT) Project. Arterioscler Thromb Vasc Biol 2004; 24: 1321–5. 5 Souto JC, Almasy L, Soria JM, Buil A, Stone W, Lathrop M, Blangero J, Fontcuberta J. Genome-wide linkage analysis of von Willebrand factor plasma levels: results from the GAIT project. Thromb Haemost 2003; 89: 468–74. 6 Bovill EG, Bauer KA, Dickerman JD, Callas P, West B. The clinical spectrum of heterozygous protein C deficiency in a large New England kindred. Blood 1989; 73: 712–17. 7 Hasstedt SJ, Scott BT, Callas PW, Vossen CY, Rosendaal FR, Long GL, Bovill EG. Genome scan of venous thrombosis in a pedigree with protein C deficiency. J Thromb Haemost 2004; 2: 868–73. 8 Heath SC. Markov chain Monte Carlo segregation and linkage analysis for oligogenic models. Am J Hum Genet 1997; 61: 748–60. 9 Nickerson D. NHLBI Program for Genomic Applications, UWFHCRC, Seattle, WA: http://pga.gs.washington.edu/data/f7; accessed 10 April 2007. 10 Livak KJ. Allelic discrimination using fluorogenic probes and the 5¢ nuclease assay. Genet Anal 1999; 14: 143–9. 11 Almasy L, Blangero J.Multipoint quantitative-trait linkage analysis in general pedigrees. Am J Hum Genet 1998; 62: 1198–211. 12 Soria JM, Almasy L, Souto JC, Sabater-Lleal M, Fontcuberta J, Blangero J. The F7 gene and clotting factor VII levels: dissection of a human quantitative trait locus. Hum Biol 2005; 77: 561–75. 13 Santacroce R, Cappucci F, Di Perna P, Sessa F, Margaglione M. Protein Z gene polymorphisms are associated with protein Z plasma levels. J Thromb Haemost 2004; 2: 1197–9. 14 Lichy C, Kropp S, Dong-Si T, Genius J, Dolan T, Hampe T, Stoll F, Reuner K, Grond-Ginsbach C, Grau A. A common polymorphism of the protein Z gene is associated with protein Z plasma levels and with risk of cerebral ischemia in the young. Stroke 2004; 35: 40–5. 15 Humphries S, Temple A, Lane A, Green F, Cooper J, Miller G. Low plasma levels of factor VIIc and antigen are more strongly associated with the 10 base pair promoter (-323) insertion than the glutamine 353 variant. Thromb Haemost 1996; 75: 567–72. 16 Hunault M, Arbini AA, Lopaciuk S, Carew JA, Bauer KA. The Arg353Gln polymorphism reduces the level of coagulation factor VII. In vivo and in vitro studies. Arterioscler Thromb Vasc Biol 1997; 17: 2825–9.

Survey of the management of deep vein thrombosis in general practice in the Netherlands.

Abstract Vintges M, Van Weert HC, Van der Wiele E, Mohrs J, Brouwer HJ, Wigersma L. Welke gezondheidsproblemen zien huisartsen in opleiding? Diagnosen uit het elektronisch medisch dossier vergeleken met de eindtermen van de beroepsopleiding. Huisarts Wet 2001;44(11): 485-9.Doel In het rapport Eindtermen huisartsopleiding 2000 worden de gezondheidsproblemen beschreven waarmee huisartsen aan het einde van hun huisartsopleiding bekend moeten zijn. Een kwantitatieve onderbouwing ontbreekt. Het doel van dit onderzoek is om via het HIS na te gaan hoeveel en welk soort patiëntencontacten huisartsen in opleiding (haio’s) hebben gedurende hun stagejaren in de huisartspraktijk.Methode De diagnosen van de reguliere consulten en visites die gedurende acht maanden verricht werden door acht haio’s en hun opleiders werden uit het HIS geëxtraheerd, waarbij het ging om de ICPC-code van de E-regels van deelcontacten. De resultaten werden omgerekend naar een periode van twee volledige stagejaren.Resultaten De database bevatte ruim 25.000 ICPC-gecodeerde diagnosen. De haio’s hadden gemiddeld bij 42% van de 122 gezondheidsproblemen uit het Eindtermenrapport minder dan vijf deelcontacten in de twee stagejaren tezamen. Als de in het rapport gehanteerde ruime definiëring van de gezondheidsproblemen werd gebruikt waarbij ook de verwante klachten en ziekten werden geïncludeerd, dan was dat bij 14% van de gezondheidsproblemen het geval. De complete tabel van de aandoeningen uit het Eindtermenrapport met van elk de aantallen deelcontacten is in te zien via de website www.artsennet/henw.nl.Conclusie Het bleek mogelijk om met behulp van de routinematig in het EMD geregistreerde gegevens inzicht te krijgen in de aard en kwantiteit van patiëntencontacten van haio’s. Deze gegevens zouden een rol kunnen vervullen bij de sturing van haio’s in hun praktisch leerproces en bij de karakterisering van huisartspraktijken ten behoeve van de opleiding.

Hielpijn bij kinderen

General practitioners can safely exclude pulmonary embolism (PE) by using the Wells PE rule combined with D‐dimer testing.

Diagnosis of conjunctivitis in primary care: comparison of two different culture procedures.

BACKGROUND To investigate the management of (suspected) deep vein thrombosis in general practice. METHODS Self completing postal questionnaire among a random sample of 692 general practitioners in the Netherlands. RESULTS The overall response rate was 58%. Eighty-nine percent of the respondents initiated objective evaluation. Less than 3% usually make the diagnosis on clinical grounds only. Ninety-two percent initiated adequate treatment for the last patient with deep vein thrombosis. No more than 4% usually treat patients with acenocoumarol alone. Respondents frequently referred a patient to a specialist, 41% to confirm the diagnosis and 85% for treatment. Already 44% feel that management of deep vein thrombosis is a mandate of the general practitioner. For those who do not, the availability of diagnostic and therapeutic facilities are the main obstacles. CONCLUSION In general practice objective diagnostic methods to evaluate suspected deep vein thrombosis are routinely used and patients receive adequate treatment. Although patients are frequently referred to the hospital many general practitioners feel that they should be able to take care of these patients themselves. (See Editorial p. 133)