Showing papers by "Geert-Jan Dinant published in 2002"

Understanding laboratory testing in diagnostic uncertainty: a qualitative study in general practice.

Abstract: BACKGROUND: Better knowledge of the professional's motives for ordering laboratory tests in the case of diagnostic uncertainty may lead to interventions directed at reducing unnecessary testing. AIM: To gain insight into the general practitioner's (GP's) motives for ordering laboratory tests for patients presenting with unexplained complaints. DESIGN OF STUDY: Semi-structured interviews based on surgery observations. SETTING: Twenty-one general practices in rural and urban areas of The Netherlands. METHOD: Investigation of the GP's perception of determinants of test-ordering behaviour in the situation of diagnostic uncertainty. The interviews were structured by evaluating the consultations and test-ordering performance of that day. RESULTS: Dutch GPs vary considerably in their motives for ordering tests. Numerous motives emerged from the data. Some examples of important themes include: personal routines; tolerance of diagnostic uncertainty; time pressure; and tactical motives for test ordering. Complying with the perceived needs of the patient for reassurance through testing is seen as an easy, cost- and time-effective strategy. A clear hierarchy in the determinants was not found. CONCLUSION: The decision to request laboratory testing is the result of a complex interaction of considerations that are often conflicting. Designers of interventions meant to improve the ordering of tests should be aware of the numerous determinants, and take contextual variables into account.

Evidence base of clinical diagnosis: Rational, cost effective use of investigations in clinical practice.

Abstract: Investigations such as blood tests and radiography are important tools for the making correct diagnoses. The use of diagnostic resources is growing steadily—in the Netherlands, for example, nationwide expenditure on diagnostic tests is growing at the rate of 7% a year. Unfortunately, health status is not improving similarly, which suggests that investigations are being overused. The ordering of tests seems not to be influenced by the fact that their diagnostic accuracy is often disappointing. Considerations other than strict scientific indications seem to be involved, and we may ask whether new knowledge and research findings are adequately reflected in daily practice. Several factors may be responsible for the increasing use of investigations, such as the increasing demand for care (due to ageing of the population and increasing numbers of chronically ill people); the fact that they are available, which in itself leads to ordering; and the urge to make use of new technology. Once an abnormal test result is found, doctors may order further investigations, not realising that on average 5% of test results are outside their reference ranges, and a cascade of testing may result. Furthermore, higher standards of care, the guidelines for which often recommend additional testing, and defensive behaviour have led to more investigations. Unfortunately, when guidelines on selective and rational ordering of investigations are introduced, numerous motives for ignoring evidence based recommendations, such as fear of litigation, or procrastination on the part of the doctor, come into play in daily practice and are difficult to influence. Overuse of investigations—and there is reason to believe that some requests are illogical—leads to overloading of the diagnostic services and overexpenditure: more efficient usage is therefore needed. Interventions focusing on overt examples of inappropriate testing might reduce costs while simultaneously improving quality of care. #### Summary points Intervention is needed to reduce the often …

Relationship between smoking habits and low-density lipoprotein-cholesterol, high-density lipoprotein-cholesterol, and triglycerides in a hypercholesterolemic adult cohort, in relation to gender and age.

Abstract: Elevated total cholesterol, the related low-density lipoprotein-cholesterol, high-density lipoprotein-cholesterol, triglycerides, and smoking habits are risk factors for cardiovascular disease. The objective of this study was to investigate the influence of habitual smoking on these parameters in 492 hypercholesterolemic men and women, aged between 26 and 66 years. Relative differences between smokers and non-smokers in the mean values of total cholesterol, low-density and hig-density lipoprotein-cholesterol, and triglycerides were 2.2%, 5.5%, -8.1%, and 13.7%, respectively. These differences were statistically significant (P or = 50 years (P=0.026). In conclusion, smoking has an adverse effect on low-density and high-density lipoprotein-cholesterol, and triglycerides in a hypercholesterolemic population of men and women, regardless of age.

Is roxithromycin better than amoxicillin in the treatment of acute lower respiratory tract infections in primary care? A double-blind randomized controlled trial.

Abstract: Objective To assess the efficacy of roxithromycin relative to amoxicillin. Study design We conducted a double-blind randomized controlled trial of oral 500 mg amoxicillin 3 times per day vs oral 300 mg roxithromycin once a day for 10 days. Population We included 196 adults who had presented to a general practitioner with lower respiratory tract infection (LRTI) and, in the physician's opinion, needed antibiotic treatment. Outcomes measured We measured clinical response after 10 and 28 days, defined in 4 ways: (1) decrease in LRTI symptoms; (2) complete absence of symptoms; (3) decrease in signs; and (4) complete absence of signs. Self-reported response included the decrease in symptoms and the time until resumption of impaired or abandoned daily activities on days 1 through 10, 21, and 27. Results Clinical cure rates after the completion of antibiotic treatment (10 days) were not significantly different for the 2 groups. After 28 days, the roxithromycin group showed no increase in cure rate as evidenced by the decrease in symptoms, indicating a significantly lower cure rate. However, this difference did not alter physicians' overall conclusion after complete follow-up that 90% of patients, regardless of age, had been effectively treated with either amoxicillin or roxithromycin. Conclusions The surplus value of roxithromycin was not confirmed. Amoxicillin remains a reliable first-choice antibiotic in the treatment of LRTI in general practice.

Traumatic events in a general practice population: the patient's perspective

Abstract: OBJECTIVES The aim of the present study was to describe the patient's perspective on the GP's care after violent events: which role is the GP assigned; and how is the care appreciated. Events studied were serious accidents, burglary, robbery, physical and sexual abuse, disasters and war. METHOD A postal questionnaire was sent to a random sample of 2997 patients (> or =20 years) from the practice population of 32 GPs (67 500 patients). RESULTS The response was 50%. Forty-two per cent of the respondents had experienced one or more events. Twenty-eight per cent of the victims desired some kind of professional help; more than half of them desired that care from their GP, three-quarters actually seeking it. Most frequently sought care was sympathy, "a number of good talks", and care for physical complaints. Overall, contentment with the GP's contribution was high; patients especially appreciate sympathy and support, as well as initiative on the GP's part in commencing and pursuing care. Of those who felt no need for professional help, 88% found that they could cope with the traumatic event well enough, with or without the help of family and friends. For those who did not seek help, although they did desire it, the main reasons were that they considered their problems insufficiently medical or felt that their GP lacked the time. In the case of physical and sexual abuse, feelings of guilt and issues of patient confidentiality played a role for some patients. CONCLUSIONS The number of events experienced by our respondents is lower than in previous studies for burglary, robbery, physical and sexual abuse (adults and children); the occurrence of accidents is similar. The majority of the people who experience traumatic events cope with them well enough without professional help. For those seeking help, the GP plays an important role. Care could be improved as follows: the GP should make it clear to patients that he/she can play a role in caring for them in the aftermath of a traumatic event and stress the confidential nature of the consultation. On the whole, GPs should be more supportive and attentive when being consulted about this topic; also patients would like their doctors to be more active in raising the subject, as well as in initiating follow-up.