Henk E. P. Bosveld

Out-of-hours medical care for terminally ill patients: A survey of availability and preferences of general practitioners

Background: Continuity of care is one of the core values of good medical care for terminally ill patients. The availability of one’s own general practitioner (GP) out of hours is regarded as important for personal continuity. Few data are available about the extent of out-of-hours care given by GPs to their terminally ill patients. Aim: The objective of this study was to determine to which level GPs are available out of hours for their own terminally ill patients and to elicit what factors are relevant to this availability. Design and setting: The research questions were investigated using a cross-sectional study of Dutch GPs. A questionnaire was sent to a random sample of 691 Dutch GPs. Results: The response rate was 47% (n = 327). Of the respondents, 86% was willing to provide out-of-hours care for their own terminally ill patients. These figures are higher than reported in previous studies. This study shows that out-of-hours availability correlates most strongly with the GPs’ perception of duties of care. Availability is negatively influenced if the GP is in a salaried job, if he or she works in a city based practice, or if home is far from the practice. A correlation between age, sex, and experience of GPs and availability for out-of- hours care for their terminally ill patients was not confirmed. Conclusions: The reported out-of-hours availability of GPs for terminally ill patients is still high. GPs’ perception of their duty of care might change in the next generations, and the increasing number of salaried GPs, living far from their practice, might threaten out-of-hours availability for terminally ill patients. GPs’ perception of their duty of care might change in the next generations, and the increasing number of salaried GPs living far from their practice might threaten out-of-hours availability for terminally ill patients.

Knowledge and preferences regarding cardiopulmonary resuscitation: A survey among older patients

OBJECTIVE Survival rates following cardiopulmonary resuscitation (CPR) are low for older people, and are associated with a high risk of neurological damage. This study investigated the relationship between the preferences, knowledge of survival chances, and characteristics among older people regarding CPR. METHODS A cross-sectional, self-administrated survey was distributed by researchers to 600 patients aged at least 50 years. The 14-question survey tool was used to collect basic demographic data, knowledge about CPR, and preference for CPR. We performed binary logistic regression analysis to predict whether patients wanted to receive CPR or not. RESULTS The response rate was 48%. Most respondents (84%) predicted the estimated survival rate to be higher than the actual rate. Patients were significantly less likely to want to receive CPR if they correctly estimated the survival rate, had ever contemplated CPR, were older, or female. Discussing CPR with a doctor had no influence on patient preference for CPR. CONCLUSION Older patients choose to receive CPR based on incorrect knowledge. PRACTICE IMPLICATIONS Doctors should be aware of the impact of knowing the true chances of survival on patient preference for CPR. Knowledge and skills need to be updated to provide this information to patients.

COPD exacerbations in general practice: variability in oral prednisolone courses

BackgroundThe use of oral corticosteroids as treatment of COPD exacerbations in primary care is well established and evidence-based. However, the most appropriate dosage regimen has not been determined and remains controversial. Corticosteroid therapy is associated with a number of undesirable side effects, including hyperglycaemias, so differences in prescribing might be relevant. This study examines the differences between GPs in dosage and duration of prednisolone treatment in patients with a COPD exacerbation. It also investigates the number of general practitioners (GPs) who adjust their treatment according to the presence of diabetic co-morbidity.MethodsCross-sectional study among 219 GPs and 25 GPs in training, located in the Northern part of the Netherlands.ResultsThe response rate was 69%. Nearly every GP prescribed a continuous dose of prednisolone 30 mg per day. Among GPs there were substantial differences in treatment duration. GPs prescribed courses of five, seven, ten, or fourteen days. A course of seven days was most common. The duration of treatment depended on exacerbation and disease severity. A course of five days was especially prescribed in case of a less severe exacerbation. In a more severe exacerbation duration of seven to fourteen days was more common. Hardly any GP adjusted treatment to the presence of diabetic co-morbidity.ConclusionUnder normal conditions GPs prescribe prednisolone quite uniformly, within the range of the current Dutch guidelines. There is insufficient guidance regarding how to adjust corticosteroid treatment to exacerbation severity, disease severity and the presence of diabetic co-morbidity. Under these circumstances, there is a substantial variation in treatment duration.

Huisartsopleiders over omgaan met evidence-based medicine

SamenvattingRaghoebar-Krieger H, Bosveld H, Winters J. Huisartsopleiders over evidence-based medicine. Huisarts Wet 2017;60(11):560-3.Doel In het kader van een nascholing in evidence-based medicine (EBM) voor huisartsopleiders onderzochten wij of en hoe huisartsopleiders wetenschappelijke informatiebronnen gebruiken, hoeveel kennis zij hebben van onderzoeksbegrippen, of zij behoefte hebben aan nascholing terzake en in hoeverre zij betrokken zijn bij de PICO-CAT van hun aios.Methode Op een nascholingsdag voor huisartsopleiders in november 2014 vroegen we alle aanwezige opleiders een vragenlijst in te vullen.Resultaten We ontvingen 107 vragenlijsten (96%) ingevuld retour. Als bron van wetenschappelijke informatie gebruikten de respondenten vooral NHG-standaarden (89%) en Google (67%), veel minder vaak websites zoals PubMed (7%) en Clinical Evidence (5%). Het kennisniveau van onderzoeksbegrippen varieert sterk: 91% wist wat incidentie betekent, slechts 2% wat een ROC-curve is. Hun vermogen om deze begrippen aan aios uit te leggen was gemiddeld 10-20% lager dan hun kennisniveau, maar slechts ongeveer de helft had behoefte aan EBM-nascholing. De helft wist over welk onderwerp zijn of haar laatste aios een CAT schreef, maar slechts 20% wist waar die afkorting voor staat.Conclusie EBM werd 25 jaar geleden geïntroduceerd, maar nog steeds schieten de kennis en vaardigheden van onze huisartsopleiders tekort om adequaat EBM-onderwijs aan aios te geven. Daarbij komt dat veel huisartsopleiders, ongeacht hun kennisniveau, geen behoefte zeggen te hebben aan EBM-scholing. Huisartsopleidingen moeten op zoek naar een manier om huisartsopleiders te overtuigen van de waarde van EBM.

COPD: vergrote kans op exacerbatie bij bètablokker?

SamenvattingVraagstelling Op het spreekuur kwam een 64-jarige man met in de voorgeschiedenis COPD en NYHA-klasse II hartfalen. De cardioloog had bij hem onlangs de bètablokker gestaakt, omdat bètablokkergebruik de kans op een COPD-exacerbatie zou vergroten.

Physician-assisted death is less frequently performed among women with a lower education: a survey among general practitioners.

In the Netherlands, since its legalization (2002) the number of physician-assisted deaths (PAD; i.e. euthanasia and physician-assisted suicide) has increased from 2120 to 3695 per year, whereas the profile of the patients (age, gender, and diagnosis) concerned has not changed. The number of cases of PAD is higher than that reported (reporting rate 77%).1 Of all registered deaths, 2.8% were the result of euthanasia and 0.1% of physician-assisted suicide. Annually, over 80% of PAD was performed by general practitioners (GPs). It has been shown that the majority (55%) of the requests does not lead to PAD, especially in elderly patients and patients with diagnoses other than cancer.1 Of these cases, 44% of the patients were deceased before PAD could be performed; in 35%, the statutory criteria were not met. This concerned mostly the criteria “unbearable suffering” and “well-considered request.” Although concerns were raised that PAD might, in particular, affect people with a low educational status, there is no evidence of an elevated risk for this group.2 Earlier research showed that higher educated older people are more confident that their request for PAD will be granted.3 The question arises whether any barriers exist for patients with a lower education level to receive PAD.

Maagzuurremmers bij urticaria

SamenvattingVraagstelling Urticaria zijn vaak moeilijk te behandelen en soms zelfs invaliderend. Klassieke antihistaminica werken vaak onvoldoende. Er zijn aanwijzingen dat toevoeging van maagzuurremmers (H2-receptorantagonist/H2RA), zoals cimetidine of ranitidine een gunstig effect hebben.