-
-
-
-
-
[show abstract]
[hide abstract]
ABSTRACT: Studies about reduced neonatal lung function and wheezing illnesses during childhood showed conflicting results. The aim of this study was to assess the association between resistance and compliance of the respiratory system (Rrs/Crs) by using the single occlusion technique (SOT) and prospectively collected wheezing illnesses during the first 5 years of life in a large birth cohort.SOT was performed during natural sleep before the age of 2 months. Information about wheezing illnesses was collected from the electronic patient file.549 infants had successful SOT measurement and complete medical records. Every kPa·l(-1)·s(-1) increase in Rrs was associated with 10% more consultations in the first 3 years of life. Every 10 mL·kPa(-1) increase in Crs was associated with a 14% reduction of consultations in the first 3 years of life, 27% in the 4(th)-5(th) year of life, and a lower probability of having asthma at the age of 5 (OR=0.66). Children with late-onset or persistent wheezing had significant lower Crs values than their peers.An increased neonatal resistance is associated with more wheezing illnesses during infancy, while a reduced neonatal compliance is associated with more wheezing illnesses during the first 5 years of life, a late-onset or persistent wheezing phenotype, and asthma.
European Respiratory Journal 11/2012; · 5.89 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Patients with acute rhinosinusitis are frequently encountered in primary care. Although corticosteroids are being increasingly used for symptom control, evidence supporting their use is inconclusive. We conducted a randomized controlled trial to examine the effectiveness of systemic corticosteroid monotherapy for clinically diagnosed, uncomplicated acute rhinosinusitis.
We conducted a block-randomized, double-blind, placebo-controlled clinical trial at 54 primary care practices (68 family physicians) in the Netherlands between Dec. 30, 2008, and Apr. 28, 2011. Adult patients with clinically diagnosed acute rhinosinusitis were randomly assigned to receive either prednisolone 30 mg/d or placebo for 7 days and asked to complete a symptom diary for 14 days. The primary outcome measure was the proportion of patients with resolution of facial pain or pressure on day 7.
Of the 185 patients included in the trial (93 in the treatment group, 92 in the placebo group), 2 withdrew from the study and 9 were excluded from the primary analysis because of incomplete symptom reporting. The remaining 174 patients (88 in the treatment group, 86 in the placebo group) were included in the intention-to-treat analysis. The proportions of patients with resolution of facial pain or pressure on day 7 were 62.5% (55/88) in the prednisolone group and 55.8% (48/86) in the placebo group (absolute risk difference 6.7%, 95% confidence interval -7.9% to 21.2%). The groups were similar with regard to the decrease over time in the proportion of patients with total symptoms (combined symptoms of runny nose, postnasal discharge, nasal congestion, cough and facial pain) and health-related quality of life. Adverse events were mild and did not differ significantly between the groups.
Systemic corticosteroid monotherapy had no clinically relevant beneficial effects among patients with clinically diagnosed acute rhinosinusitis. Netherlands Trial Register registration no. 1295 (www.trialregister.nl/trialreg/index.asp).
Canadian Medical Association Journal 08/2012; 184(14):E751-7. · 8.22 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: In absence of a gold standard for chronic obstructive pulmonary disease (COPD) it remains difficult to compare the true diagnostic characteristics of the forced expiratory volume in 1 second to the forced vital capacity (FEV(1)/FVC) <0.70 and < lower limit of normal (LLN). COPD is a clinical diagnosis, based on symptoms signs and lung function results combined, and an expert panel assessment would be an adequate reference standard. We compared the diagnostic properties of FEV(1)/FVC <LLN and <0.70 against this panel diagnosis: 342 participants, aged >50, consulting for persistent cough, but without physician-diagnosed COPD, were prospectively enrolled. All underwent extensive history taking, physical examination, spirometry and diffusion testing. An expert panel, including a board certified respiratory physician, assessed all diagnostic information to determine the presence or absence of COPD and served as reference standard. Then, 104 participants were diagnosed with COPD by the panel. The reproducibility of the panel diagnosis was high (kappa of 0.94). Sensitivity estimates of <0.70 were significantly higher than that of <LLN (0.73 and 0.47, respectively, p < 0.001). The fixed approach was less specific than the LLN (0.95 and 0.99, respectively, p < 0.001). There was no significant difference in diagnostic property when using pre- or post-bronchodilator FEV(1)/FVC (p = 0.615). In a symptomatic primary care population, the FEV(1)/FVC <0.70 was more accurate to detect COPD.
COPD Journal of Chronic Obstructive Pulmonary Disease 04/2012; 9(4):338-43. · 1.79 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: BackgroundA revised primary care guideline on acute rhinosinusitis (ARS) has been introduced in the Netherlands in 2005, which advocates a more judicious use of antibiotics.ObjectiveTo investigate whether consultation and prescription rates for ARS in adults changed over recent years in order to provide information on family physicians' behaviour before and after introduction of the revised guideline.MethodsRetrospective cohort study. All adult patients within the computerized database of Utrecht Primary Care Research Network over the years 2000-09 were included. Clinical diagnoses of ARS were recorded according to the International Classification of Primary Care codes (R75 and/or R09) and drug prescriptions according to the Anatomical Therapeutic Chemical Classification System.ResultsARS consultation rates revealed a stable pattern, with an average consultation rate of 29 episodes per 1000 person-years. From 2000 to 2005, the antibiotic prescription rate increased from 56 to 62 prescriptions per 100 episodes (P value for time trend <0.05). From 2005 onwards, the antibiotic prescription rate decreased to 56 per 100 episodes in 2009 [rate difference (RD): -6, 95% confidence interval (CI): -10 to -1; P value for difference between 2000-05 and 2005-09 <0.05]. From 2005 to 2009, intranasal corticosteroid (INCS) prescription rate increased from 20 to 31 prescriptions per 100 episodes (RD: 11, 95% CI: 7 to 15; P value for difference between 2000-05 and 2005-09 <0.01). Oral corticosteroid prescription and referral rates remained low.ConclusionsDespite strong guideline recommendations to restrict the use of antibiotics and INCS, we found only a modest decrease in antibiotic prescription rates, whereas INCS prescription rates even increased.
Family Practice 03/2012; · 1.50 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: An individualised action plan (AP) is a potentially effective method of helping patients with chronic obstructive pulmonary disease (COPD) to recognise and anticipate early exacerbation symptoms. This multicentre randomised controlled trial evaluates the hypothesis that individualised APs reduce exacerbation recovery time.
Two hundred and thirty-three patients with COPD (age 65±10 years, forced expiratory volume in 1 s 56±21% predicted) were randomised to receive either an individualised AP (n=111) or care as usual (n=122). The AP provides individualised treatment prescriptions (pharmaceutical and non-pharmaceutical) related to a colour-coded symptom status to enhance an adequate response to periods of symptom deterioration (reinforced at 1 and 4 months). Exacerbation onset was defined using the Anthonisen symptom diary card algorithm. Every 3 days the Clinical COPD Questionnaire (CCQ) was assessed to evaluate the longitudinal course of health status. The primary outcome was health status recovery in the event of an exacerbation.
During the 6-month follow-up period there was no difference in exacerbation rates and healthcare utilisation between the two groups. Cox-adjusted survival analysis including frailty showed enhanced health status recovery (HR 1.58; 95% CI 0.96 to 2.60) and reduced length of the exacerbation (HR 1.30; 95% CI 0.92 to 1.84). The mean difference in symptom recovery time was -3.68 days (95% CI -7.32 to -0.04). Mixed model repeated measure analysis showed that an AP decreased the impact of exacerbations on health status both in the prodromal and early post-onset periods. Between-group differences in CCQ scores were above the minimal clinically relevant difference of 0.4 points (3.0±0.7 vs. 3.4±0.9; p≤0.01).
This study shows that an individualised AP, including ongoing support by a case manager, decreases the impact of exacerbations on health status and tends to accelerate recovery. APs can be considered a key component of self-management programmes in patients with COPD.
Thorax 07/2011; 66(11):977-84. · 6.84 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: There is an inherent tension between allowing trainees in general practice (GP) to feel comfortable to report and learn from errors in a blame-free environment while still assuring high-quality and safe patient care. Unfortunately, little is known about the types and potential severity of incidents that may confront GP trainees. Furthermore, incident reporting by resident trainees is hindered by their concern that such transparency might result in more negative performance evaluations.
To explore the number and nature of incidents that were reported by GP trainees and to determine whether there were differences between the reporters and non-reporters based on their performance evaluations.
Prospective cohort study.
Confidential and voluntary incident reporting was implemented in GP vocational training of the University Medical Center Utrecht, the Netherlands. Seventy-nine GP trainees were asked to report incidents over 6 months. Mixed methods were used to analyse the data.
24 trainees reported a total of 44 incidents. 23 incidents concerned the work process and 17 concerned problems with diagnosis or therapy. Three-quarters (34/44) of incidents were determined to be not specifically related to the inexperience of the GP trainees. While actual patient harm was determined to be minimal or absent in two-thirds of incidents (29/44), the potential for moderate, major, or catastrophic harm was 89% (39/44). Trainees performing best on their performance assessment in the domain of clinical expertise reported incidents more often (43% vs 18%, p<0.03) than those who performed at a lower level.
GP trainees rated highly by their faculty voluntarily reported incidents in the delivery of clinical care when given a safe, blame-free, and confidential reporting process. Most incidents were not found to be directly related to the inexperience of the trainee, but were caused by failing organisational processes in the healthcare delivery system. Moreover, the trainees who tended to report these incidents were those whose performance was highly evaluated in the domain of clinical expertise.
BMJ quality & safety 05/2011; 20(10):857-62.
-
[show abstract]
[hide abstract]
ABSTRACT: Background: In 2007, ESAC (http://www.esac.ua.ac.be) published a set of 12 valid drug-specific quality indicators for outpatient antibiotic use in Europe. In this study, the authors aimed to develop evidence-based disease-specific quality indicators for outpatient antibiotic prescribing in Europe. Methods: Two meetings were convened to produce a list of disease-specific quality indicators for outpatient antibiotic prescribing which conform to internationally agreed recommendations, building on a similar development of drug-specific quality indicators, and in collaboration with CHAMP and HAPPY AUDIT. 62 experts were asked to complete two scoring rounds of the proposed indicators on seven dimensions: their relevance to (1) reducing antimicrobial resistance, (2) patient health benefit, (3) cost-effectiveness, (4) policy makers, (5) individual prescribers, (6) their evidence base and (7) their range of acceptable use, using a scale ranging from 1 (completely disagree) to 9 (completely agree). Scores were judged according to the UCLA-RAND appropriateness method. Results: For the six main indications for antibiotic prescribing (acute otitis media, acute upper-respiratory infection, acute/chronic sinusitis, acute tonsillitis, acute bronchitis/bronchiolitis, cystitis/other urinary infection) and for pneumonia, three quality indicators were proposed, the percentage prescribed (a) antibiotics; (b) recommended antibiotics; (c) quinolones. This set was scored by 40 experts from 25 countries. After one scoring round, all indicators were already rated as relevant on all dimensions, except one. Conclusion: All proposed disease-specific quality indicators for outpatient antibiotic prescribing have face validity and are potentially applicable. They could be used to better describe antibiotic use and assess the quality of antibiotic prescribing patterns in ambulatory care.
BMJ quality & safety 03/2011; 20(9):764-772.
-
[show abstract]
[hide abstract]
ABSTRACT: To evaluate the feasibility of a locally implemented incident-reporting procedure (IRP) in primary healthcare centres after 1 year.
Five primary healthcare centres caring for more than 43000 patients in The Netherlands. GPs, medical nurses, physiotherapists, pharmacists, pharmacist assistants and trainees reported incidents (a total of 117 employees).
An IRP was implemented in which participants were encouraged to report all incidents. In addition, dedicated 'reporting weeks' were introduced that emphasised reporting of minor incidents and near misses. In every centre, an IRP committee analysed the reported incidents in order to initiate improvements when necessary.
Frequency and nature of reported incidents, number of incidents analysed by the IRP committees and number of improvements implemented. In addition, the authors studied the actual implementation of the IRP and the acceptability as experienced by participants.
A total of 476 incidents were reported during a 9-month reporting period. Of all incidents, 62% were reported in a reporting week, and most were process-related. Possible harm for patients was none or small in 87% of the reported incidents. IRP committees analysed 84 incidents and found 230 root causes. All participating centres had initiated improvement projects as a result of reported incidents. Most interviewees considered the IRP feasible, but several practical, professional and personal barriers to implementation of the IRP were identified.
The implementation of a centre-based IRP in primary care is feasible. Reporting weeks enhance the willingness to report.
BMJ quality & safety 02/2011; 20(2):121-7.
-
[show abstract]
[hide abstract]
ABSTRACT: Little is known about factors that determine prescribing of asthma therapy in infancy.
To describe factors related to the initiation and refill of asthma therapy in infancy.
This study included 1202 infants who participated in a prospective birth cohort study: the 'Wheezing Illnesses Study Leidsche Rijn (WHISTLER)'. Outcomes, asthma therapy initiation and refill, were assessed using prescription data. Logistic regression analysis was used to study determinants of therapy initiation in two groups: total population and infants with a respiratory system symptom diagnosis. In addition, determinants of refilling prescriptions were studied in infants who started therapy in their first year of life.
Fifteen per cent of all infants started asthma therapy in their first year of life. Respiratory symptoms were an important driver of both initiation and refill of prescriptions. In the total population, therapy initiation was associated with male gender [odds ratio (OR): 1.6, 95% confidence interval (CI): 1.1-2.6], day-care attendance (OR: 1.6, 95% CI: 1.0-2.5) and breastfeeding (OR: 0.6, 95% CI: 0.3-1.0). For infants with a respiratory system symptom diagnosis, day-care attendance was associated with an increased chance of therapy initiation (OR: 5.3, 95% CI: 1.8-16.2) and breastfeeding was associated with a lower chance of starting therapy (OR: 0.4, 95% CI: 0.1-1.1). Dutch children had a higher chance of refilling prescriptions in infancy (OR: 5.3, 95% CI: 1.1-26.8).
Apart from other factors involved, the principal reason for initiation and refill of asthma therapy in infancy was the presence of respiratory symptoms. This appeared the only reason to prescribe medication and physicians are not distracted by other factors.
Family Practice 02/2011; 28(4):377-84. · 1.50 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Several studies have shown that the occurrence of wheezing illnesses during the first year of life is associated with lower levels of lung function shortly after birth and before any respiratory illness. It has been suggested that reduced lung function early in life predisposes infants to wheezing during viral respiratory infections, but the association between neonatal lung function and subsequent confirmed viral infections has never been investigated.
To study the influence between neonatal lung function and the occurrence of human rhinovirus (HRV)-associated wheeze.
In a prospective birth cohort study, infants were followed from birth through the first year of life with daily questionnaires about respiratory symptoms. Neonatal lung function was performed within the first 2 months of life. Nose and throat swabs were collected during episodes with respiratory symptoms. Polymerase chain reaction was used to detect single HRV infections.
In 176 of the 202 infants (87%) with a single HRV infection, valid lung function measurements were obtained. The risk of wheeze was 1.49 times higher for each SD increase of airway resistance. The adjusted risk (corrected for possible important confounders) for wheeze was 1.77 (95% confidence interval, 1.16-2.69; P = 0.01) times higher for each SD increase of airway resistance. Maternal smoking during pregnancy was independently associated with wheeze (odds ratio 4.42; 95% confidence interval, 1.27-15.5; P = 0.02).
This study showed that total lung resistance is clearly associated with HRV-associated wheeze. Moreover, HRV-associated wheeze might be the first sign to recognize infants with reduced neonatal lung function.
American Journal of Respiratory and Critical Care Medicine 01/2011; 183(2):262-7. · 11.08 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: A supportive patient safety culture is considered to be an essential condition for improving patient safety. Assessing the current safety culture in general practice may be a first step to target improvements. To that end, we studied internal consistency and construct validity of a safety culture questionnaire for general practice (SCOPE) which was derived from a comparable questionnaire for hospitals (Dutch-HSOPS).
The survey was conducted among caregivers of Dutch general practice as part of an ongoing quality accreditation process using a 46 item questionnaire. We conducted factor analyses and studied validity by calculating correlations between the subscales and testing the hypothesis that respondents' patient safety grade of their practices correlated with their scores on the questionnaire.
Of 72 practices 294 respondents completed the questionnaire. Eight factors were identified concerning handover and teamwork, support and fellowship, communication openness, feedback and learning from error, intention to report events, adequate procedures and staffing, overall perceptions of patient safety and expectations and actions of managers. Cronbach's alpha of the factors rated between 0.64 and 0.85. The subscales intercorrelated moderately, except for the factor about intention to report events. Respondents who graded patient safety highly scored significantly higher on the questionnaire than those who did not.
The SCOPE questionnaire seems an appropriate instrument to assess patient safety culture in general practice. The clinimetric properties of the SCOPE are promising, but future research should confirm the factor structure and construct of the SCOPE and delineate its responsiveness to changes in safety culture over time.
BMC Family Practice 01/2011; 12:117. · 1.80 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Unlike most other drugs that only affect individual patients if used incorrectly for self-medication, misused antibiotics add to the global risk of increased spread of bacterial resistance. This review focuses on self-medication with antibiotics in Europe and its determinants. High prevalence of self-medication with antibiotics has been repeatedly found in Southern and Eastern European countries that also report high levels of antibiotic resistance. Despite being illegal, over the counter dispensation of systemic antibiotics occurs in several European Union Member States. A second major source of self-medication is the availability of "leftover" antibiotics which results from either patient non-compliance or dispensation of a larger number of tablets than needed for one single course. The potentially modifiable factors associated with self-medication are: availability of antibiotics without prescription, pack-based antibiotic dispensing system, misconceptions of the general public about the efficacy of antibiotics for minor illnesses and prescribing of antibiotics for minor ailments by physicians. Measures that may reduce and prevent self-medication include dispensation of exact tablet quantities in pharmacies as already implemented e.g. in the UK, Netherlands, the Czech Republic and the United States, and enforcement of existing laws prohibiting over-the-counter sales of antibiotics. Such measures should be embedded in a general policy to change the culture of antibiotic use by improving awareness of the general public and professionals about antibiotics and the risks associated with their use as well as reducing misconceptions about the need for antibiotics for minor ailments.
Current drug safety. 10/2010; 5(4):329-32.
-
[show abstract]
[hide abstract]
ABSTRACT: Different expectations and demands of non-western immigrants may prompt physicians to deviate from their routine clinical management strategies resulting in more diagnostic tests and higher prescription rates. Antibiotic prescription is of specific importance, since overuse of antibiotics is a major public health concern. No data are available about possible differences in antibiotic prescription rates between natives and non-western immigrants in Europe.
To determine whether ethnic origin is an independent determinant for the frequency of antibiotic treatment and additional diagnostic tests in primary care patients with infectious diseases.
In this cross-sectional study, 1015 non-western immigrants were compared to 995 native Dutch, all selected from the Utrecht Health Project database. Data were analysed using multiple logistic regression analyses. Antibiotics most frequently used in Dutch primary care were included in the analyses. For the analyses of additional diagnostic tests, only respiratory tract infections were included, since these are the most common infectious diseases for which general practitioners are contacted.
First generation non-western immigrants were more likely to undergo diagnostic tests and received more antibiotics than native Dutch (respectively OR: 2.08; 95% CI: 1.64-2.63; and OR: 1.31; 95% CI: 1.04-1.65). No differences were found for the second generation immigrants. The results found were independent of potential confounders.
The highest rates of antibiotic prescription and diagnostic tests concern first generation non-western immigrants. In order to promote a rational and restricted use of antibiotics in outpatients first generation immigrants should be a prioritized target group.
The European journal of general practice 09/2010; 16(3):143-7.
-
[show abstract]
[hide abstract]
ABSTRACT: Chronic obstructive pulmonary disease (COPD) and asthma are underdiagnosed in primary care.
To determine how often COPD or asthma are present in middle-aged and older patients who consult their GP for persistent cough. Design of study: A cross-sectional study in 353 patients older than 50 years, visiting their GP for persistent cough and not known to have COPD or asthma.
General practice in the Netherlands.
All participants underwent extensive diagnostic work-up, including symptoms, signs, spirometry, and body plethysmography. All results were studied by an expert panel to diagnose or exclude COPD and/or asthma. The reproducibility of the panel diagnosis was assessed by calculation of Cohen's kappa statistic in a sample of 41 participants.
Of the 353 participants, 102 (29%, 95% confidence interval [CI] = 24 to 34%) were diagnosed with COPD. In 14 of these 102 participants, both COPD and asthma were diagnosed (4%, 95% CI = 2 to 7%). Asthma (without COPD) was diagnosed in 23 (7%, 95% CI = 4 to 10%) participants. Mean duration of cough was 93 days (median 40 days). The reproducibility of the expert panel was good (Cohen's kappa = 0.90).
In patients aged over 50 years who consult their GP for persistent cough, undetected COPD or asthma is frequently present.
British Journal of General Practice 07/2010; 60(576):489-94. · 1.83 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: In this evidence-based case report we studied the clinical question: Does intranasal corticosteroid (INCS) monotherapy reduce time to recovery in adults with acute noncomplicated rhinosinusitis? The search yielded 490 papers, of which only two were relevant and had a high validity regarding our clinical question.
Otolaryngology Head and Neck Surgery 06/2010; 142(6):783-8. · 1.72 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Early treatment of COPD exacerbations has shown to be important. Despite a non-negligible negative impact on health related quality of life, a large proportion of these episodes is not reported (no change in treatment). Little is known whether (low burden) strategies are able to capture these unreported exacerbations.
The Clinical COPD Questionnaire (CCQ) is a short questionnaire with great evaluative properties in measuring health status. The current explorative study evaluates the discriminative properties of weekly CCQ assessment in detecting exacerbations.
In a multicentre prospective cohort study, 121 patients, age 67.4 ± 10.5 years, FEV1 47.7 ± 18.5% pred were followed for 6 weeks by daily diary card recording and weekly CCQ assessment. Weeks were retrospectively labeled as stable or exacerbation (onset) weeks using the Anthonisen symptom diary-card algorithm. Change in CCQ total scores are significantly higher in exacerbation-onset weeks, 0.35 ± 0.69 compared to -0.04 ± 0.37 in stable weeks (p < 0.001). Performance of the Δ CCQ total score discriminating between stable and exacerbation onset weeks was sufficient (area under the ROC curve 0.75). At a cut off point of 0.2, sensitivity was 62.5 (50.3-73.4), specificity 82.0 (79.3-84.4), and a positive and negative predictive value of 43.5 (35.0-51.0) and 90.8 (87.8-93.5), respectively. Using this cut off point, 22 (out of 38) unreported exacerbations were detected while 39 stable patients would have been false positively 'contacted'.
Weekly CCQ assessment is a promising, low burden method to detect unreported exacerbations. Further research is needed to validate discriminative performance and practical implications of the CCQ in detecting exacerbations in daily care.
Health and Quality of Life Outcomes 01/2010; 8:102. · 2.11 Impact Factor
