Jildou Sijbrandij

Phenotype at diagnosis predicts recurrence rates in Crohn’s disease

Background: In Crohn’s disease (CD), studies associating phenotype at diagnosis and subsequent disease activity are important for patient counselling and health care planning. Aims: To calculate disease recurrence rates and to correlate these with phenotypic traits at diagnosis. Methods: A prospectively assembled uniformly diagnosed European population based inception cohort of CD patients was classified according to the Vienna classification for disease phenotype at diagnosis. Surgical and non-surgical recurrence rates throughout a 10 year follow up period were calculated. Multivariate analysis was performed to classify risk factors present at diagnosis for recurrent disease. Results: A total of 358 were classified for phenotype at diagnosis, of whom 262 (73.2%) had a first recurrence and 113 patients (31.6%) a first surgical recurrence during the first 10 years after diagnosis. Patients with upper gastrointestinal disease at diagnosis had an excess risk of recurrence (hazard ratio 1.54 (95% confidence interval (CI) 1.13–2.10)) whereas age ⩾40 years at diagnosis was protective (hazard ratio 0.82 (95% CI 0.70–0.97)). Colonic disease was a protective characteristic for resective surgery (hazard ratio 0.38 (95% CI 0.21–0.69)). More frequent resective surgical recurrences were reported from Copenhagen (hazard ratio 3.23 (95% CI 1.32–7.89)). Conclusions: A mild course of disease in terms of disease recurrence was observed in this European cohort. Phenotype at diagnosis had predictive value for disease recurrence with upper gastrointestinal disease being the most important positive predictor. A phenotypic North-South gradient in CD may be present, illustrated by higher surgery risks in some of the Northern European centres.

Crohn’s disease: increased mortality 10 years after diagnosis in a Europe-wide population based cohort

Background: No previous correlation between phenotype at diagnosis of Crohn’s disease (CD) and mortality has been performed. We assessed the predictive value of phenotype at diagnosis on overall and disease related mortality in a European cohort of CD patients. Methods: Overall and disease related mortality were recorded 10 years after diagnosis in a prospectively assembled, uniformly diagnosed European population based inception cohort of 380 CD patients diagnosed between 1991 and 1993. Standardised mortality ratios (SMRs) were calculated for geographic and phenotypic subgroups at diagnosis. Results: Thirty seven deaths were observed in the entire cohort whereas 21.5 deaths were expected (SMR 1.85 (95% CI 1.30–2.55)). Mortality risk was significantly increased in both females (SMR 1.93 (95% CI 1.10–3.14)) and males (SMR 1.79 (95% CI 1.11–2.73)). Patients from northern European centres had a significant overall increased mortality risk (SMR 2.04 (95% CI 1.32–3.01)) whereas a tendency towards increased overall mortality risk was also observed in the south (SMR 1.55 (95% CI 0.80–2.70)). Mortality risk was increased in patients with colonic disease location and with inflammatory disease behaviour at diagnosis. Mortality risk was also increased in the age group above 40 years at diagnosis for both total and CD related causes. Excess mortality was mainly due to gastrointestinal causes that were related to CD. Conclusions: This European multinational population based study revealed an increased overall mortality risk in CD patients 10 years after diagnosis, and age above 40 years at diagnosis was found to be the sole factor associated with increased mortality risk.

Disease outcome of inflammatory bowel disease patients: general outline of a Europe-wide population-based 10-year clinical follow-up study

Objective. To give a general outline of a 10-year clinical follow-up study of a population-based European cohort of inflammatory bowel disease (IBD) patients and to present the first results in terms of clinical outcome parameters and risk factors. Materials and methods. A population-based cohort of newly, prospectively, diagnosed cases was initiated between 1991 and 1993. The 2201 patients with IBD (706 had Crohns disease (CD), 1379 had ulcerative colitis (UC) and 116 had indeterminate colitis) originated from 20 different areas in 11 different European countries and Israel. For the 10-year follow-up of this cohort, electronic data-collecting instruments were made available through an Internet-based website. Data concerning vital status, disease activity, medication use, surgical events, cancer, pregnancy, fertility, quality of life and health-care costs were gathered. A blood sample was obtained from patients and controls to perform genotypic characterization. Results. Thirteen centres from eight European countries and Israel participated. In 958 (316 CD and 642 UC) out of a total of 1505 IBD patients (64%) from these 13 centres, a complete dataset was obtained at follow-up. Even though an increased mortality risk was observed in CD patients 10 years after diagnosis, a benign disease course was observed in this patient group in terms of disease recurrence. A correlation between ASCA and CARD15 variants in CD patients and complicated disease course was observed. A north–south gradient was observed regarding colectomy rates in UC patients. Direct costs were found to be highest in the first year after diagnosis and greater in CD patients than in UC patients, with marked differences between participating countries. Conclusions. This 10-year clinical follow-up study of a population-based European cohort of IBD patients provides updated information on disease outcome of these patient groups.

Changing relationships: attitudes and opinions of general practitioners and pharmacists regarding the role of the community pharmacist

Background: Relationship between general practitioners and pharmacists.Aim: To explore similarities and differences in opinions between general practitioners and pharmacists about the pharmacists role. To identify factors which determine the attitude of the general practitioner towards the role of the pharmacist as a care provider.Design: Cross‐sectional questionnaire survey. Setting: The Netherlands, 2001.Participants: 926 non‐dispensing general practitioners, 93 dispensing general practitioners and 328 community pharmacists.Methods: Statements about the pharmacists position in primary care were formulated. The attitude towards the pharmacists care‐providing function was determined by adding the scores to the statements. Data were collected on age, gender, professional experience, trainership, type and size of practice, electronic communication, urbanisation level, part‐time work, work pressure, postgraduate training, pharmacotherapy audit meetings (PTAMs), the mutual relationship and the desired role of the pharmacist in pharmacotherapy.Results: No significant differences in opinions were found between pharmacists and non‐dispending general practitioners with respect to a number of the pharmacists signalling tasks. Eighty‐six percent (CI 83–89) of non‐dispensing general practitioners and eighty‐two percent (CI 76–87) of pharmacists shared the opinion that pharmacists need to provide the general practitioner with feedback on prescription figures. Furthermore, 85% (CI 82–88) of the non‐dispensing general practitioners and 80% (CI 75–86) of the pharmacists believed that pharmacists should suggest items for the PTAM agenda, based on prescription patterns they notice in their pharmacy.The attitude of general practitioners towards the care‐providing function of the community pharmacist correlates significantly with the relationship between general practitioners and pharmacists (p < 0.001). There is also a significant difference (p < 0.001) in the attitude score between dispensing and non‐dispensing general practitioners: dispensing general practitioners scored lower on the attitude scale.Conclusion: Pharmacists and general practitioners largely agree on the pharmacotherapeutic signalling role that a pharmacist should fulfil. A good relationship benefits the attitude of general practitioners towards the pharmacists care‐providing function.

Pharmacists in primary care. Determinants of the care-providing function of Dutch community pharmacists in primary care.

Objective: To identify determinants of the care-providing function of the community pharmacists (CPs) to explain variations in professional practice.Setting: The Netherlands 2001.Participants: 328 CPs.Method: A cross-sectional questionnaire survey was performed. Questionnaires were used to collect data about the care provided in pharmacies. As dependent variables three partial constructs: ‘individual patient care’, ‘registration of the care’, and ‘cooperation with GPs’, and one total construct: ‘care function’ were formed. Independent variables were: gender, work experience, attitude to the care-providing function, tenure, relationship with GPs, pharmacist trainer, frequency of postgraduate training, workload, part-time working, frequency of contact with pharmaceutical representatives, presence of technicians with a specialised caring duty, size of the pharmacy, urbanisation, competition, franchise pharmacy, presence of sufficient personnel. A multiple-regression analysis was performed.Results: Respondents 71% of the respondents 29% never enquired about the patient’s experience when supplying a medication for the second time. The supply of self-care remedies was never registered by 11% of respondents. Ninety percent of pharmacists participate more than four times per year in Pharmacotherapy Audit Meetings. The attitude of the pharmacist, relationship with the GP, presence of specialised technicians, frequency of postgraduate training and the type of tenure are significantly positively correlated with a care-providing function. Being a pharmacist trainer is significantly positively related with ‘individual patient care’, the frequency of postgraduate training is significantly positively correlated with ‘registration of the care’ and the number of years in service is significantly negatively correlated with ‘cooperation with GPs’. There is a negative correlation between the cooperation with GPs and the number of years a pharmacist has been in service.Conclusion: Based on this survey, the development of programmes focused on optimal attitude, and cooperation between pharmacists and GPs is recommended.

Treatment inferred disease severity in Crohn's disease: Evidence for a European gradient of disease course

Objective. Geographic differences in disease course of Crohns disease (CD) might possibly be related to differences in genetic and environmental factors encountered in different parts of the world. The aim of this study was to assess differences in treatment regimens within a European cohort of CD patients as a reflection of disease course, and to identify associated phenotypic risk factors at diagnosis. Material and methods. A prospective European population-based inception cohort of 380 CD patients was studied. The patients were classified for phenotype according to the Vienna classification. Differences between Northern and Southern European centres in treatment over the first 10 years of disease were analysed using a competing risks survival analysis method. Results. Patients in the North were more likely to have had surgery (p<0.01), whereas patients in the South were more likely to have been treated medically (p<0.01). Phenotype at diagnosis was not predictive of differences in treatment regimens between North and South. Conclusions. In this study, a difference in management of CD was observed between Northern and Southern European centres. This suggests that there may be a North–South disease severity gradient across Europe. Phenotypic differences between patients in the North and South did not explain this observed difference.

Insurance problems among inflammatory bowel disease patients: results of a Dutch population based study

Background and aims: The majority of patients with inflammatory bowel disease (IBD) have a normal life expectancy and therefore should not be weighted when applying for life assurance. There is scant literature on this topic. In this study our aim was to document and compare the incidence of difficulties in application for life and medical insurance in a population based cohort of IBD patients and matched population controls. Methods: A population based case control study of 1126 IBD patients and 1723 controls. Based on a detailed questionnaire, the frequency and type of difficulties encountered when applying for life and medical insurance in matched IBD and control populations were appraised. Results: In comparison with controls, IBD patients had an 87-fold increased risk of encountering difficulties when applying for life assurance (odds ratio (OR) 87 (95% confidence interval (CI) 31–246)), with a heavily weighted premium being the most common problem. Patients of high educational status, with continuous disease activity, and who smoked had the highest odds of encountering such problems. Medical insurance difficulties were fivefold more common in IBD patients compared with controls (OR 5.4 (95% CI 2.3–13)) although no specific disease or patient characteristics were identified as associated with such difficulties. Conclusions: This is the first detailed case control study that has investigated insurance difficulties among IBD patients. Acquiring life and medical insurance constituted a major problem for IBD patients in this study. These results are likely to be more widely representative given that most insurance companies use international guidelines for risk assessment. In view of the recent advances in therapy and promising survival data on IBD patients, evidence based guidelines for risk assessment of IBD patients by insurance companies should be drawn up to prevent possible discriminatory practices.

Pharmaceutical care and its relationship to prescribing behaviour of general practitioners.

ObjectiveTo study the correlation between pharmaceutical care and prescribing routines of general practitioners (GPs).MethodsCross-sectional study; 201 pharmacies, 408 general practices, The Netherlands, 2000/2001. The variation in prescribing behaviour was characterised using 20 validated prescribing indicators based on general practice guidelines. The general construct ‘adherence to guidelines’ served as the dependent variable and was formed by summing the scores of the prescribing indicators. Four possible determinants of the variation were determined on the basis of survey questions: the construct ‘the pharmacist’s attitude towards pharmaceutical care’, and three partial constructs derived from the pharmacist’s care-providing function: the care for the individual patient, the cooperation with general practitioners and the registration of the care provided. A multiple linear regression analysis was then performed.Main outcome measureThe weighted score for the prescribing indicators.ResultsThe weighted average score for the prescribing indicators was 65% (SD 3.7). The response rate to the survey was 71%. The pharmacist’s attitude to pharmaceutical care, as well as the degree to which the pharmacist provided care for the individual patient, the degree to which he cooperated with the general practitioner and the degree to which he registered the care provided were not correlated with the ‘adherence to guidelines’ by the general practitioner with whom the pharmacist frequently cooperated.ConclusionVariations between general practitioners in the quality of prescribing, as measured by their adherence to guidelines, were not correlated with pharmaceutical care by the pharmacist with whom they cooperated on a day-to-day basis.