Marijke M. Kuyvenhoven

Effectiveness of a co-ordinated nation-wide programme to improve influenza immunisation rates in The Netherlands

OBJECTIVE To assess t he effectiveness of a nation-widemultifaceted intervention programme involving general practitioners (GPs) on influenza immunisation practice. DESIGN Pragmatic before-after trial using pre- and post-measurement questionnaires. SETTING AND SUBJECTS Random sample of Dutch general practices. INTERVENTION During a 2.5-year period (1995-1997) a variety of methods was implemented to enhance physician adoption of the immunisation guideline, including employment of facilitators, information-based methods, small-group consensus meetings, individual instructions and introduction of supportive computer software. MAIN OUTCOME MEASURES Influenza immunisation practice and influenza vaccine uptake. RESULTS In 988 practices all influenza vaccination characteristics markedly improved from 1995 to 1997. The most significant changes were found in computerised marking of high-risk patients (from 54% to 82% of practices), computerised selection (41% to 77%) and sending personal reminders (40% to 77%). Vaccine uptake increased from 9% to 16% of the practice population (78% increase, p < 0.001). Uptake was most prominent in urban and single-handed practices and in those with more patients insured through the National Health Service, low GP workload and low baseline uptake. CONCLUSION Our data suggest that a co-ordinated approach involving primary care physicians can succeed in enlarging the public health impact of a population-based preventive measure.

Antibiotics for respiratory, ear and urinary tract disorders and consistency among GPs

OBJECTIVES To describe specific diagnoses for which systemic antibiotics are prescribed, to assess adherence of antibiotic choice to national guidelines and to assess consistency among general practitioners (GPs) in prescribed volumes of antibiotics for respiratory, ear and urinary tract disorders. METHODS The cross-sectional study included 174 GPs from 89 general practices. Data were derived from the Second Dutch National Survey of General Practice (DNSGP-2) in 2001. Outcome measures were the antibiotic prescriptions for respiratory, ear and urinary tract disorders defined according to the International Classification of Primary Care codes, the percentage of first-choice antibiotics complying with national guidelines and the number of antibiotic prescriptions per 1000 patients per GP per year. RESULTS The most antibiotics for respiratory tract infection (RTI) were prescribed for acute bronchitis (25%), sinusitis (22%) and acute upper RTI (14%). The most antibiotics were prescribed for acute otitis media (77% of ear disorders) and cystitis (95% of urinary tract disorders). First-choice antibiotics were prescribed in approximately 75% of the cases, whereas macrolides and amoxicillin/clavulanate (second-choice antibiotics) were prescribed in approximately 25%, especially in lower RTIs. The correlations (Spearman rho) between prescribed volumes for the three main groups of disorders varied from 0.39 to 0.67. CONCLUSIONS GPs were consistent in prescribing antibiotics for the three groups of diseases. Improvement strategies should focus on the management of acute upper RTIs and acute bronchitis and also on the use of amoxicillin/clavulanate and macrolides, these being mostly second-choice antibiotics in national guidelines.

Health care utilisation by older people with non-traumatic foot complaints What makes the difference?

OBJECTIVES To determine the factors associated with the type of health care chosen by elderly people suffering from non-traumatic foot complaints. DESIGN Cross-sectional mailed survey. SETTING Population-based random sample of 7200 people aged > or = 65 years in The Netherlands. SUBJECTS 1130 people > or = 65 years with non-traumatic foot complaints for 4 weeks or more. MAIN OUTCOME MEASURES Use of non-(para)medical care (i.e. no care at all, self-care and chiropodial care) versus (para)medical care (i.e. care given by paramedical personnel, general practitioners and medical specialists). RESULTS Six of every 10 respondents sought (para)medical care, half of these visited the GP. Factors associated with the use of (para)medical care were foot-related limitations (adj OR 3.18; 95% CI 2.26-4.46), painful feet (adj OR 1.55; 1.09-2.23), and foot osteoarthritis (adj OR 1.88; 1.32-2.68). (Para)medical care was sought less often than non-(para)medical care for forefoot complaints (adj OR 0.56; 0.41-0.76). CONCLUSIONS Elderly people with non-traumatic foot complaints did not seem to underreport their problems to (para)medical care providers. Furthermore, they appeared to select the appropriate type of care. Future studies will have to assess the effectiveness of the care provided.Objectives - To determine the factors associated with the type of health care chosen by elderly people suffering from non-traumatic foot complaints. Design - Cross-sectional mailed survey. Setting

Intervention with educational outreach at large scale to reduce antibiotics for respiratory tract infections: a controlled before and after study

BACKGROUND A multiple intervention targeted to reduce antibiotic prescribing with an educational outreach programme had proven to be effective in a randomized controlled trial in 12 peer review groups, demonstrating 12% less prescriptions for respiratory tract infections. OBJECTIVE To assess the effectiveness of a multiple intervention in primary care at a large scale. METHODS A controlled before and after study in 2006 and 2007 was designed. Participants were from general practices within a geographically defined area in the middle region of The Netherlands. Participants were GPs in 141 practices in 25 peer review groups. A control group of GP practices from the same region, matched for type of practice and mean volume of antibiotic prescribing. The multiple intervention consisted of the following elements: (i) group education meeting and communication training; (ii) monitoring and feedback on prescribing behaviour; (iii) group education for GPs and pharmacists assistants and (iv) patient education material. The main outcome measures are as follows: (i) number of antibiotic prescriptions per 1000 patients per GP and (ii) number of second-choice antibiotics, obtained from claims data from the regional health insurance company. The associations between predictors and outcome measurements were assessed by means of a multiple regression analyses. RESULTS At baseline, the number of antibiotic prescriptions per 1000 patients was slightly higher in the intervention group than in the control group (184 versus 176). In 2007, the number of prescriptions had increased to 232 and 227, respectively, and not differed between intervention and control group. CONCLUSIONS The implementation of an already proven effective multiple intervention strategy at a larger scale showed no reduction of antibiotic prescription rates. The failure might be attributed to a less tight monitoring of intervention and audit. Inserting practical tools in the intervention might be more successful and should be studied.

Improving antibiotic prescribing quality by an intervention embedded in the primary care practice accreditation: the ARTI4 randomized trial

OBJECTIVES Antibiotic overprescribing is a significant problem. Multifaceted interventions improved antibiotic prescribing quality; their implementation and sustainability, however, have proved difficult. We analysed the effectiveness of an intervention embedded in the quality cycle of primary care practice accreditation on quantity and quality of antibiotic prescribing for respiratory tract and ear infections (RTIs). METHODS This was a pragmatic, cluster-randomized intervention trial in 88 Dutch primary care practices. The intervention (physician education and audit/feedback on antibiotic prescribing quantity and quality) was integrated in practice accreditation by defining an improvement plan with respect to antibiotic prescribing for RTIs. Numbers and types of dispensed antibiotics were analysed from 1 year prior to the intervention to 2 years after the intervention (pharmacy data). Overprescribing, underprescribing and non-first-choice prescribing for RTIs were analysed at baseline and 1 year later (self-registration). RESULTS There were significant differences between intervention and control practices in the changes in dispensed antibiotics/1000 registered patients (first year: -7.6% versus -0.4%, P = 0.002; second year: -4.3% versus +2%, P = 0.015), which was more pronounced for macrolides and amoxicillin/clavulanate (first year: -12.7% versus +2.9%, P = 0.001; second year: -7.8% versus +6.7%, P = 0.005). Overprescribing for RTIs decreased from 44% of prescriptions to 28% (P < 0.001). Most general practitioners (GPs) envisaged practice accreditation as a tool for guideline implementation. CONCLUSIONS GP education and an audited improvement plan around antibiotics for RTIs as part of primary care practice accreditation sustainably improved antibiotic prescribing. Tools should be sought to further integrate and facilitate education and audit/feedback in practice accreditation.

Variation in outpatient antibiotic use in three European countries: exploration of possible determinants

Introduction Most antibiotics in primary care are for respiratory tract infections, while the vast majority of these infections are self-limiting. This over-prescribing of antibiotics wastes money, unnecessarily exposes patients to risk of side effects, encourages re-consulting for similar problems and causes antimicrobial resistance. Several studies have reported a large international variation in out-patient antibiotic use in Europe. The international trend to prescribe more broad-spectrum, newer and more expensive chemotherapeutics 4,5 and the growing antibiotic resistance problems emphasize the need of implementing guidelines advocating a restrictive antibiotic policy. An awareness of possible determinants of international differences in antibiotic prescribing could help in designing interventions.

Transient Ischemic Attacks and the General Practitioner: Diagnosis and Management

We studied the question whether the decision of general practitioners (GPs) to refer patients with transient ischemic attacks (TIAs) to hospital departments of neurology is influenced by certain chara

Selection for Dutch postgraduate GP training; time for improvement

Background: In the Netherlands we select candidates for the postgraduate GP training by assessing personal qualities in interviews. Because of differences in the ratio of number of candidates and number of vacancies between the eight departments of GP training we questioned whether the risk of being rejected diverged amongst them. Objective: The research question of this study was to which degree department of choice, candidates’ characteristics and qualities assessed during interviews explain admission into GP training. Methods: A nationwide observational study was conducted of all candidates who applied for postgraduate GP training in 2009/ 2010. Application ratio per department, candidates’ characteristics (gender, age, region of medical school and times of application) and qualities (motivation, orientation on the job, personal attributes and learning needs) were collected. Outcome measures were admission to interview and admission to GP training. Results: The study population addressed 542 candidates. Sixty three candidates were rejected on application letter (11.6%). So 479 candidates were admitted to the interview, of which 340 were admitted to the GP training (71%). Gender and region of medical school outside North West Europe were associated with admission to the interview. Department of choice had a strong association with admission in both stages (RR: 0.30 to 0.74; 0.20 to 0.79 respectively), while candidates’ qualities explained admission (RR: 1.09– 1.25) as well. Conclusion:The influence of department of choice yields doubts about fairness of the procedure. So advantages and disadvantages of a national procedure are discussed as well as those of a competency based procedure.

Diagnostic Styles of General Practitioners Confronted with Ambiguous Symptoms: An Exploratory Study

This study explores the diagnostic process of general practitioners confronted with ill-defined and ambiguous complaints, which eventually appeared to be caused by a malignancy. Three aspects were rated: (a) the adequacy of the initial problem definition; (b) the carefulness of further diagnostic methods; and (c) how the suspicion of malignancy originated. These three aspects, which were strongly connected, seem to be parts of a diagnostic approach with two polar extrems: a critical style and a biased style. Characteristic of a critical style is full awareness of detail, careful observations, consideration of ambiguous symptoms, and consciousness that the correct diagnosis is often other than the one initially judged most likely. The opposite, the biased style, is characterized by little alertness for detail, less careful observations, and overinterpretation of facts supporting the initial hypotheses.

Management of acute cough: Comparisons between Belgian and Dutch GPs

Objectives: In Europe there are large variations in overall outpatient antibiotic use, even between two neighbouring countries as Belgium and the Netherlands. We aimed to compare the management of acute cough between Belgian and Dutch general practitioners (GPs). Methods: In cross-sectional studies in Belgium and the Netherlands, 71 Belgian and 84 Dutch GPs included adult patients consulting for acute cough. Differences in antibiotic prescription rates, the percentage of first-choice antibiotics (i.e. tetracyclines and broad-spectrum penicillins) and bronchodilator prescription rates were assessed by using Generalised Estimating Equations to adjust for clustering of patients within GPs. Results: In Belgium 324/810 patients (40%) were prescribed an antibiotic compared with 101/309 (33%) in the Netherlands (adjusted OR (95% CI) 1.28 (0.91–1.83)). Belgian GPs prescribed fewer first-choice antibiotics compared with Dutch GPs: 124/324 (38%) versus 67/101 (66%) (adjusted OR (95% CI) 0.39 (0.22–0.72)). In both countries, 17% of the patients were prescribed a bronchodilator. Conclusions: Antibiotic prescription rates for adult patients with acute cough were not significantly higher in Belgian than in Dutch general practice at the 5 % significance level. Dutch GPs’ antibiotic prescriptions were more in line with national guidelines. Bronchodilator prescription rates were similar. Because Dutch GPs probably encountered more severe cases of acute cough compared with their Belgian colleagues, the observed prescribing differences might be underestimated.