Wil van den Bosch

It can always happen: the impact of urinary incontinence on elderly men and women.

Objective. To determine the impact of urinary incontinence (UI) on the quality of life of the elderly in the general population and to identify factors with the greatest effect. Design. Qualitative and quantitative analyses of interview data. Setting. Patients from the nine family practices of the Nijmegen University Research Network. Subjects. Independently living patients aged 60 and over. Main outcome measures. All independently living patients aged 60 and over with uncomplicated UI were interviewed at home using the Incontinence Impact Questionnaire and open-ended questions. Results. In total, 56 men and 314 women were interviewed. A majority do not have such an impact. In the Incontinence Impact Questionnaire (IIQ) emotional well-being was most affected. Half to one-third of the patients felt nervous, embarrassed, or frustrated because of their incontinence. In the social domain “clothing” and “fear of odour” scored the highest impact. The most affected practical consequence in the IIQ was “going to places where you are not sure about the availability of a toilet” followed by “travelling longer than 20 minutes” and “entertainment”. Men reported higher impact scores than women, despite the fact that incontinence was less severe in men. The most important effect of incontinence reported in men was “being out of control” while most women considered “feeling impelled to take several precautions” to be the most important consequence of UI. Conclusion. UI affects nearly half of patients, particularly as regards their emotional well-being and in public activities. Men experienced more impact compared with women and experienced loss of control more often than women.

Measurement properties of questionnaires measuring continuity of care: a systematic review.

Background Continuity of care is widely acknowledged as a core value in family medicine. In this systematic review, we aimed to identify the instruments measuring continuity of care and to assess the quality of their measurement properties. Methods We did a systematic review using the PubMed, Embase and PsycINFO databases, with an extensive search strategy including ‘continuity of care’, ‘coordination of care’, ‘integration of care’, ‘patient centered care’, ‘case management’ and its linguistic variations. We searched from 1995 to October 2011 and included articles describing the development and/or evaluation of the measurement properties of instruments measuring one or more dimensions of continuity of care (1) care from the same provider who knows and follows the patient (personal continuity), (2) communication and cooperation between care providers in one care setting (team continuity), and (3) communication and cooperation between care providers in different care settings (cross-boundary continuity). We assessed the methodological quality of the measurement properties of each instrument using the COSMIN checklist. Results We included 24 articles describing the development and/or evaluation of 21 instruments. Ten instruments measured all three dimensions of continuity of care. Instruments were developed for different groups of patients or providers. For most instruments, three or four of the six measurement properties were assessed (mostly internal consistency, content validity, structural validity and construct validity). Six instruments scored positive on the quality of at least three of six measurement properties. Conclusions Most included instruments have problems with either the number or quality of its assessed measurement properties or the ability to measure all three dimensions of continuity of care. Based on the results of this review, we recommend the use of one of the four most promising instruments, depending on the target population Diabetes Continuity of Care Questionnaire, Alberta Continuity of Services Scale-Mental Health, Heart Continuity of Care Questionnaire, and Nijmegen Continuity Questionnaire.

Development of blood pressure and the incidence of hypertension in men and women over an 18-year period: results of the Nijmegen cohort study

The objective of this study was to determine the factors that influence diastolic blood pressure (DBP) and the incidence of hypertension. In 1977, DBP and cardiovascular risk factors were measured in 7092 men and women. In 1995, 2335 subjects participated at a second screening. Those patients already under hypertension treatment in 1977 were excluded. The DBP tracking was studied in subjects not under hypertension treatment during the study. Hypertension was defined on two ways in the analysis: under current hypertension treatment or a DBP > 95 mmHg measured at rescreening in 1995. Forty-seven percent of the subjects with a DBP < 75 mmHg in 1977 remained in the same category of DBP in 1995, and 7% had become hypertensive. Of the 75-84 mmHg group in 1977, 40% stayed in the same category in 1995 and 15% became hypertensive. Of the 85-94 mmHg category, 30% stayed in the same category and 30% became hypertensive in 1995. Of the highest category in 1977 (> 95 mmHg), 64% were still in that category in 1995. Baseline DBP in 1977 had the highest predictive value for future DBP. Weight gain over the years increased the risk for future hypertension: in contrast, there was no risk at a low DBP without weight gain. There is no need for regular check-ups for those patients with a low DBP who experience no weight gain. Borderline DBP (85-95 mmHg), together with weight gain, increases the risk of development of hypertension. The risk was especially high for men in the lower socioeconomic class.

Pulse oximetry in family practice: indications and clinical observations in patients with COPD

PURPOSE To establish situations in which family physicians (FPs) consider pulse oximetry a valuable addition to their clinical patient assessment; to explore pulse oximetry results (SpO(2)) when used by FPs in patients with chronic obstructive pulmonary disease (COPD); to explore associations between SpO(2) and other markers of COPD severity. METHODS We performed three separate studies: (i) interviews plus a Delphi consensus procedure with FPs experienced in using pulse oximetry to elucidate indications for pulse oximetry; (ii) analysis of SpO(2) and clinical data in COPD patients who presented to FPs with deteriorating symptoms and (iii) analysis of SpO(2), spirometry and clinical data in patients with stable COPD. RESULTS Interviewed FPs (n = 11) used their pulse oximeter for a range of acute (14) and non-acute (11) indications but valued it highest in acute (worsening of) dyspnoea, in suspected respiratory insufficiency/failure and in patients with COPD. In 88 patients with deteriorating COPD, 22% showed SpO(2) <or=92%. Correlation between baseline forced expiratory volume in 1 second % predicted and SpO(2) in patients presenting with acute COPD exacerbations was r = 0.55 (P = 0.001). In 207 patients with stable COPD, 6.3% showed SpO(2) values <or=92%. SpO(2) values were associated with Medical Research Council dyspnoea scores (P = 0.019). CONCLUSIONS FPs report a wide range of indications for pulse oximetry in acute as well as non-acute situations. In COPD, pulse oximetry appears to be especially useful in patients with severe disease and worsening of symptoms. Pulse oximetry may have a role in the monitoring of patients with COPD with exercise-related dyspnoea.

Trends in COPD prevalence and exacerbation rates in Dutch primary care

BACKGROUND Changes in the burden of chronic obstructive pulmonary disease (COPD) and its exacerbations on primary health care are not well studied. AIM To identify trends in the prevalence of physician-diagnosed COPD and exacerbation rates by age, sex, and socioeconomic status in a general practice population. DESIGN OF STUDY Trend analysis of COPD data from a 27-year prospective cohort of a dynamic general practice population. SETTING Data were taken from the Continuous Morbidity Registration Nijmegen. METHOD For the period 1980-2006, COPD and COPD exacerbation data were extracted for patients aged ≥40 years. Data were standardised for the composition of the Continuous Morbidity Registration population in the year 2000. Regression coefficients for trends were estimated by sex, age, and socioeconomic status. Rate ratios were calculated for prevalence differences in different demographic subgroups. RESULTS During the study period, the overall COPD prevalence decreased from 72.7 to 54.5 per 1000 patients per year. The exacerbation rate decreased from 44.1 to 31.5 per 100 patients, and the percentage of patients with COPD who had exacerbations declined from 27.6% to 21.0%. The prevalence of COPD increased significantly in women, in particular those aged ≥65 years with low socioeconomic status. Decreases in exacerbation rates and percentages of patients with exacerbations were independent of sex, age, and socioeconomic status. CONCLUSION The decline in COPD prevalence and exacerbation rates suggests a reduction of the burden on Dutch primary care. The increase of the prevalence in women indicates a need to focus on this particular subgroup in COPD management and research.

Treatment of heart failure in Dutch general practice

BackgroundTo study the relation between the prescription rates of selected cardiovascular drugs (ACE-inhibitors and Angiotensin receptor blockers, beta-blockers, diuretics, and combinations), sociodemographic factors (age, gender and socioeconomic class) and concomitant diseases (hypertension, coronary heart disease, cerebrovascular accident, heart valve disease, atrial fibrillation, diabetes mellitus and asthma/COPD) among patients with heart failure cared for in general practice.MethodsData from the second Dutch National Survey in General Practice, conducted mainly in 2001. In this study the data of 96 practices with a registered patient population of 374.000 were used.Data included diagnosis made during one year by general practitioners, derived from the electronic medical records, prescriptions for medication and sociodemographic characteristics collected via a postal questionnary (response 76%)ResultsA diagnosis of HF was found with 2771 patients (7.1 in 1000). Their mean age was 77.7 years, 68% was 75 years or older, 55% of the patients were women. Overall prescription rates for RAAS-I, beta-blockers and diuretics were 50%, 32%, 86%, respectively, whereas a combination of these three drugs was prescribed in 18%. Variations in prescription rates were mainly related to age and concomitant diseases.ConclusionPrescription is not influenced by gender, to a small degree influenced by socioeconomic status and to a large degree by age and concomitant diseases.

Hoe urgent is de gepresenteerde morbiditeit op de Centrale Huisartsenpost

SamenvattingGiesen PHJ, Mokkink HGA, Ophey G, Drijver CR, Grol RPTM, Van den Bosch WJHM. Hoe urgent is de gepresenteerde morbiditeit op de Centrale Huisartsenpost? Huisarts Wet 2005;48(5):207-10.Doel Explorerend onderzoek naar de mate van urgentie en de aard van de hulpvragen waarmee patiënten bij een huisartsenpost komen.Methoden Dwarsdoorsnedenonderzoek waarbij in de computer geregistreerde gegevens over patiëntencontacten van een huisartsenpost werden ingedeeld naar ICPC-code en mate van urgentie (U1-4).Resultaten Van de 20.471 patiëntencontacten werd 0,7% van de gevallen als levensbedreigend (U1) en 76,9% als niet-urgent (U4) ingeschat. Indien er sprake was van urgente klachten (U1-3), dan bleek de urgentie zoals ingeschat op basis van de diagnose (E-regel) 29% lager uit te vallen dan de urgentie-inschatting op basis van de klacht (S-regel). Problemen in de hoogste urgentiecategorieën werden vooral bepaald door hart-, luchtweg- en bewustzijnsstoornissen; bij de niet-urgente klachten ging het vooral om infecties en klachten van het bewegingsapparaat.Conclusie Het aantal als urgent ingeschatte patiëntencontacten op deze huisartsenpost is klein. Het grootste deel van de klachten wordt als niet-urgent beoordeeld.

Morbidity in early childhood, sex differences, birth order and social class.

STUDY OBJECTIVE The aim of the study was to investigate the relationship between morbidity in early childhood and gender, birth order, and social class. DESIGN The study used data collected in the Nijmegen Continuous Morbidity Registration. All presented morbidity and a number of personal data were available. SETTING The survey population was regional; four general practices in the east of The Netherlands. PARTICIPANTS The study population included all children born in the four practices from 1971 to 1984. They were followed up till the age of five (1537 children). MEASUREMENTS AND MAIN RESULTS Morbidity of children in the first five years was allocated to three degrees of seriousness and to 14 diagnosis groups. The morbidity of all children was analysed for boys and girls, first-born, second-born, and later-born children, and low, middle, and high social class. Boys presented more morbidity than girls; in particular, nervous disorders, lower respiratory tract infections, and accidents. First-born children presented more morbidity than later-born children; in particular, non-serious diseases, nervous disorders, and colds. Lower social class children presented more moderately serious and non-serious morbidity, colds, lower respiratory tract infections, and skin diseases. Logistic regression analysis showed that high social class, being the first-born child, and male gender were the most important factors related to presented morbidity in general practice. CONCLUSIONS High social class, low social class, gender, and being the first-born child were, in this sequence, related to morbidity in early childhood presented to the general practitioner in this study population.

All in the Family: Headaches and Abdominal Pain as Indicators for Consultation Patterns in Families

PURPOSE Headaches and abdominal pain are examples of minor ailments that are generally self-limiting. We examined the extent to which patterns of visits to family physicians for minor ailments, such as headaches or abdominal pain, cluster within families. METHODS Using information from the Second Dutch National Survey of General Practice for 96 family practices, we analyzed the visits of families with at least 1 child aged 12 years or younger during a period of 12 months. RESULTS Family patterns were clearest in the visits of mothers and children. A large part of the similarity in the frequencies of contact by mothers and daughters could be attributed to shared family factors. This finding was especially true for families with a child who had a headache or abdominal pain as the presenting symptom, rather than physical trauma or chronic disease. Within families, we did not find any specific patterns of diagnoses. Diagnoses were recorded by family physicians. In the case of young children, family similarity may have been overestimated because parents initiated the visits and put their child’s health problem into words. CONCLUSIONS Visits to family physicians for headaches or abdominal pain can be seen as indicators of consultation patterns in families. Family patterns related to minor ailments are likely to be a result of socialization. Family consultation patterns might point toward specific needs of families and consequently at a different approach to treatment.

Heart failure patients’ experiences with continuity of care and its relation to medication adherence: a cross-sectional study

BackgroundA growing number of health care providers are nowadays involved in heart failure care. This could lead to discontinuity and fragmentation of care, thus reducing trust and hence poorer medication adherence. This study aims to explore heart failure patients’ experiences with continuity of care, and its relation to medication adherence.MethodsWe collected data from 327 primary care patients with chronic heart failure. Experienced continuity of care was measured using a patient questionnaire and by reviewing patients’ medical records. Continuity of care was defined as a multidimensional concept including personal continuity (seeing the same doctor every time), team continuity (collaboration between care providers in general practice) and cross-boundary continuity (collaboration between general practice and hospital). Medication adherence was measured using a validated patient questionnaire. The relation between continuity of care and medication adherence was analysed by using chi-square tests.ResultsIn total, 53% of patients stated not seeing any care provider in general practice in the last year concerning their heart failure. Of the patients who did contact a care provider in general practice, 46% contacted two or more care providers. Respectively 38% and 51% of patients experienced the highest levels of team and cross-boundary continuity. In total, 14% experienced low levels of team continuity and 11% experienced low levels of cross-boundary continuity. Higher scores on personal continuity were significantly related to better medication adherence (p < 0.01). No clear relation was found between team- or cross-boundary continuity and medication adherence.ConclusionsA small majority of patients that contacted a care provider in general practice for their heart failure, contacted only one care provider. Most heart failure patients experienced high levels of collaboration between care providers in general practice and between GP and cardiologist. However, in a considerable number of patients, continuity of care could still be improved. Efforts to improve personal continuity may lead to better medication adherence.