Showing papers by "Geert-Jan Dinant published in 2006"

Risk of new clinical fractures within 2 years following a fracture

Abstract: Introduction:Clinical fractures are associated with an increased relative risk of future fractures, but the absolute risk and timing of new clinical fractures immediately after a clinical fracture have not been reported extensively. The study objective was to determine the absolute risk of subsequent clinical fractures within 2 years after a clinical fracture. Methods:We analyzed clinical fracture data from a university hospital recruiting all fractures in the area between January 1999 and December 2001. Subjects were 2,419 male and female patients aged 50 years and older, with a total of 2,575 fractures. There were 139 patients with more than one simultaneous fracture. Mean age was 66 years for males and 72 for females. Results:The cumulative incidence of patients with new clinical fractures over 2 years was 10.8% (262/2,419). In the 262 patients with subsequent fractures, we observed a higher mean age, more females and more often multiple baseline fractures compared with the 2,157 patients without subsequent fractures. Kaplan-Meier analysis indicated that age, gender and having multiple baseline fractures contributed significantly to cumulative new fracture incidence. Cox regression showed that these variables independently contributed to a higher subsequent fracture incidence. New fracture incidence was higher with increasing age ( p <0.001; hazard ratio [HR] 1.2 per decade; confidence interval [CI] 1.1–1.3). Females had a new fracture incidence of 12.2% compared with 7.4% in males ( p =0.015; HR 1.5; CI 1.1–2.0). Patients with multiple baseline fractures had a new fracture incidence of 17.3% compared with 10.4% for subjects with one baseline fracture ( p =0.006; HR 1.8; CI 1.2–2.7). Of all clinical fractures occurring within 2 years after a clinical fracture, 60% occurred during the first year and 40% during the second year ( p =0.005). The absolute risk to develop an incident clinical fracture within 2 years after any clinical fracture was 10.8%. Increased age, female gender and the presence of multiple simultaneous fractures at baseline each independently increased the risk of incident fracture. Significantly more fractures occurred in the first year following the index fracture than in the second year. Conclusion: Altogether, these data support the need for early prevention of future fracture among individuals with a fracture after age 50, using interventions which have been shown to have a rapid anti-fracture benefit.

Why do patients want to have their blood tested? A qualitative study of patient expectations in general practice

Abstract: General practitioners often take their impression of patients' expectations into account in their decision to have blood tests done. It is commonly recommended to involve patients in decision-making during consultations. The study aimed to obtain detailed information on patients' expectations about blood tests. Qualitative study among patients in waiting rooms of general practices. Each patient was presented with a short questionnaire about their preferences in terms of diagnostics. Patients who would like blood tests to be done were interviewed. Fifty-seven (26%) of the 224 respondents wanted blood tests. Twenty-two were interviewed. Patients overestimated the qualities of blood tests. Favourable test results were regarded as proof of good health. Patients regarded blood tests as a useful instrument to screen for serious disorders, and were confirmed in this belief by people in their social environment and by the media. Many patients expected their GP to take an active test ordering approach, though some indicated that they might be convinced if their GP proposed a wait-and-see policy. GPs' perceptions about patient expectations seem justified: patients appear to have high hopes for testing as a diagnostic tool. They expect diagnostic certainty without mistakes and a proof of good health. The question is whether it would be desirable to remove patients' misconceptions, allowing them to participate in policy decisions on the basis of sound information, or whether it would be better to leave the misconceptions uncontested, in order to retain the 'magic' of additional tests and reassure patients. We expect that clarifying the precise nature of patients' expectations by the GP may be helpful in creating a diagnostic strategy that satisfies both patients and GPs. GPs will have to balance the benefits of reassuring their patients by means of blood tests which may be unnecessary against the benefits of avoiding unnecessary tests. Further research is needed into the effects of different types of patient information and the effects of testing on satisfaction and anxiety.

Do clinical findings in lower respiratory tract infection help general practitioners prescribe antibiotics appropriately? An observational cohort study in general practice

Abstract: Background. Antibiotics are over-prescribed for lower respiratory tract infection (LRTI). The influence of clinicians' history and examination findings on antibiotic prescribing for LRTI has not been directly assessed, and the extent to which these clinical findings predict appropriate antibiotic prescribing is unknown. A clearer understanding is crucial to achieving evidence-based prescribing. Objectives. To directly assess the influence of general practitioners' history and examination findings on antibiotic prescribing for LRTI, and to explore the extent to which these clinical findings predict appropriate antibiotic prescribing. Methods. In this observational cohort study 25 GPs in The Netherlands were recruited during routine consultations and 247 adult patients with a clinical diagnosis of LRTI. The GPs recorded clinical information. Odds ratios (ORs) with 95% confidence intervals (CIs) for clinical variables predicting a prescription for an antibiotic were calculated. The relationship between antibiotic prescription and radiographic evidence of pneumonia was explored in order to gauge appropriateness of antibiotic prescribing. Results. Auscultation abnormalities (OR 11.5; 95% CI 5.4–24.7), and diarrhoea (OR > 11) were strongly associated with antibiotic prescribing. An antibiotic was prescribed for 195 (79%) patients. Assuming that an antibiotic definitely needs to be prescribed only for patients with pneumonia, antibiotics may have been inappropriately prescribed for 166/193 (86%) of the patients. Antibiotics were not prescribed for 5 of the 32 (16%) patients with a radiographic diagnosis of pneumonia. Conclusions. Abnormal findings on auscultation in patients with LRTI strongly predict antibiotic prescribing and this is probably inappropriate for most patients. These results should prompt GPs to consider the extent to which finding ‘crackles/rhonchi on auscultation’ influences their decisions to prescribe antibiotics for their patients with LRTI, and to consider the predictive value of individual clinical signs in reaching evidence-based prescribing decisions.

Cost-effectiveness of a graded exercise therapy program for patients with chronic shoulder complaints.

Abstract: OBJECTIVES: The present study evaluated the cost-effectiveness of a behavioral graded exercise therapy (GET) program compared with usual care (UC) in terms of the performance of daily activities by patients with chronic shoulder complaints in primary care. METHODS: A total of 176 patients were randomly assigned either to GET (n=87) or to UC (n=89). Clinical outcomes (main complaints, shoulder disability [SDQ] and generic health-related quality of life [EQ-5D], and costs [intervention costs, direct health care costs, direct non-health-related costs, and indirect costs]) were assessed during the 12-week treatment period and at 52 weeks of follow-up. RESULTS: Results showed that GET was more effective than UC in restoring daily activities as assessed by the main complaints instrument after the 12-week treatment period (p = .049; mean difference, 7.5; confidence interval [CI], 0.0-15.0). These effects lasted for at least 52 weeks (p = .025; mean difference 9.2; CI, 1.2-17.3). No statistically significant differences were found on the SDQ or EQ5D. GET significantly reduced direct health care costs (p = .000) and direct non-health care costs (p = .029). Nevertheless, total costs during the 1-year follow-up period were significantly higher (p = .001; GET = Euro 530 versus UC = Euro 377) due to the higher costs of the intervention. Incremental cost-effectiveness ratios for the main complaints (0-100), SDQ (0-100), and EQ-5D (-1.0-1.0) were Euro 7, Euro 74, and Euro 5278 per unit of improvement, respectively. CONCLUSIONS: GET proved to be more effective in the short- and long-term and reduces direct health care costs and direct non-health care costs but is associated with higher costs of the intervention itself.

Timing and risk factors for clinical fractures among postmenopausal women: a 5-year prospective study

Abstract: Many risk factors for fractures have been documented, including low bone-mineral density (BMD) and a history of fractures. However, little is known about the short-term absolute risk (AR) of fractures and the timing of clinical fractures. Therefore, we assessed the risk and timing of incident clinical fractures, expressed as 5-year AR, in postmenopausal women. In total, 10 general practice centres participated in this population-based prospective study. Five years after a baseline assessment, which included clinical risk factor evaluation and BMD measurement, 759 postmenopausal women aged between 50 and 80 years, were re-examined, including undergoing an evaluation of clinical fractures after menopause. Risk factors for incident fractures at baseline that were significant in univariate analyses were included in a multivariate Cox survival regression analysis. The significant determinants were used to construct algorithms. In the total group, 12.5% (95% confidence interval (CI) 10.1–14.9) of the women experienced a new clinical fracture. A previous clinical fracture after menopause and a low BMD (T-score <-1.0) were retained as significant predictors with significant interaction. Women with a recent previous fracture (during the past 5 years) had an AR of 50.1% (95% CI 42.0–58.1) versus 21.2% (95% CI 20.7–21.6) if the previous fracture had occurred earlier. In women without a fracture history, the AR was 13.8% (95% CI 10.9–16.6) if BMD was low and 7.0% (95% CI 5.5–8.5) if BMD was normal. In postmenopausal women, clinical fractures cluster in time. One in two women with a recent clinical fracture had a new clinical fracture within 5 years, regardless of BMD. The 5-year AR for a first clinical fracture was much lower and depended on BMD.

The prevalence of intellectual disability in Limburg, the Netherlands.

Abstract: Department of General Practice, Maastricht University, Maastricht, the NetherlandsAbstractBackground Current changes in care philosophy and diversity in care arrangements caused the need for a new estimate of the number of people with intellec-tual disability (ID), based on recent data. Previous estimates were based on client registrations, which was thought unreliable at this time. This manuscript studies the question how many people with ID can be found in (part of) the Netherlands.Methods Identification of people with ID through a combination of general practice (GP) data bases and service registrations in the province of Limburg.Results The prevalence of people with ID appeared to be between 0.64% and 0.70%. About 0.21–0.27% were living with family or on their own; 55% of them did not use common ID services.Conclusion Results are based on a combination of identification methods. Thirteen per cent of uncer-tain cases led to minimum and maximum estimates of the population. Limitations of the method and alternative ways of data collection are discussed.Keywords general practice data bases, intellectual disability, prevalence, service registrations

Comparison of two recruitment strategies for patients with chronic shoulder complaints

Abstract: Background Recruiting adequate numbers of participants represents a major problem to the completion of randomised clinical trials in primary care. Information on different recruitment strategies applied in one trial is scarce. Aim To evaluate the application of two recruitment strategies in one trial. Design of study The study was performed within the framework of a randomised clinical trial on the effectiveness of a behavioural treatment for patients with chronic shoulder complaints. Setting Thirty-two general practices in the Netherlands. Method Patients recruited during a consultation with their GP for chronic shoulder complaints were compared with patients recruited by advertisement in a local newspaper as regards baseline characteristics, withdrawals (drop-outs and losses to follow-up) and post-treatment clinical outcomes. Results Patients recruited by the GPs ( n = 83) were similar to those recruited by advertisement ( n = 83) in terms of demographic characteristics and clinical outcome measures at baseline, but differed slightly in disease characteristics and treatment preferences. Recruitment strategy was not related to reasons for or numbers of withdrawals. Improvements on outcome measures were greater in patients recruited by the GPs, irrespective of allocated treatment. Results on the clinical effectiveness of treatments at the end of the treatment period or during follow-up were neither modified by recruitment strategy, nor by differences between the two strategy groups in patient characteristics found at baseline. Conclusion Using two recruitment strategies did not influence the outcomes on clinical effectiveness in this trial. However, recruitment strategy should be considered as a putative modifying factor in the design of a study.

Prognostic factors and clinical outcome in acute lower respiratory tract infections: a prospective study in general practice.

Abstract: Objectives. We aimed to identify clinical factors that may predict a prolonged clinical course or poor outcome for patients with LRTI and to provide an evidence-based account of duration of an LRTI and the impact of the illness on daily activities in patients consulting in general practice. Methods. A prospective cohort study of 247 adult patients with a clinical diagnosis of LRTI presenting to 25 GPs in The Netherlands was carried out. Multivariable Cox regression analysis was used to identify baseline clinical and infection parameters that predicted the time taken for symptoms to resolve. A Kaplan–Meier curve was used to analyse time-to-symptom resolution. Clinical cure was recorded by the GPs at 28 days after the initial consultation and by the patients at 27 days. Results. Co-morbidity of asthma was a statistically significant predictor of delayed symptom resolution, whereas the presence of fever, perspiring and the prescription of an antibiotic weakly predicted enhanced symptom resolution. The GPs considered 89% of the patients clinically cured at 28 days, but 43% of these nevertheless reported ongoing symptoms. Patientreported cure was much lower (51%), and usual daily activities were limited in 73% of the patients at baseline, and 19% at final follow-up. Conclusions. The course of LRTI was generally uncomplicated, but the morbidity of this illness was considerable with a longer duration than generally reported, especially for patients with co-existent asthma. These results underline once again the importance of providing GPs with an evidence-based account of outcomes to share with patients in order to set realistic expectations and of enhancing their communication skills within the consultation.

The added value of C-reactive protein to clinical signs and symptoms in patients with obstructive airway disease: results of a diagnostic study in primary care

Abstract: To evaluate the diagnostic accuracy of clinical signs and symptoms, C-reactive protein (CRP) and spirometric parameters and determine their interrelation in patients suspected to have an obstructive airway disease (OAD) in primary care. In a cross sectional diagnostic study, 60 adult patients coming to the general practitioner (GP) for the first-time with complaints suspicious for obstructive airway disease (OAD) underwent spirometry. Peak expiratory flow (PEF)-variability within two weeks was determined in patients with inconspicuous spirometry. Structured medical histories were documented and CRP was measured. The reference standard was the Tiffeneau ratio (FEV1/VC) in spirometry and the PEF-variability. OAD was diagnosed when FEV1/VC ≤ 70% or PEF-variability > 20%. 37 (62%) patients had OAD. The best cut-off value for CRP was found at 2 mg/l with a diagnostic odds ratio (OR) of 4.4 (95% CI 1.4–13.8). Self-reported wheezing was significantly related with OAD (OR 3.4; CI 1.1–10.3), whereas coughing was inversely related (OR 0.2; CI 0.1–0.7). The diagnostic OR of CRP increased when combined with dyspnea (OR 8.5; 95% CI 1.7–42.3) or smoking history (OR 8.4; 95% CI 1.5–48.9). CRP (p = 0.004), FEV1 (p = 0.001) and FIV1 (p = 0.023) were related with the severity of dyspnea. CRP increased with the number of cigarettes, expressed in pack years (p = 0.001). The diagnostic accuracy of clinical signs and symptoms was low. The diagnostic accuracy of CRP improved in combination with dyspnea and smoking history. Due to their coherence with the severity of dyspnea and number of cigarettes respectively, CRP and spirometry might allow risk stratification of patients with OAD in primary care. Further studies need to be done to confirm these findings.

Blood test ordering for unexplained complaints in general practice: the VAMPIRE randomised clinical trial protocol. [ISRCTN55755886]

Abstract: General practitioners (GPs) frequently order blood tests when they see patients presenting with unexplained complaints. Due to the low prevalence of serious pathology in general practice, the risk of false-positive test results is relatively high. This may result in unnecessary further testing, leading to unfavourable effects such as patient anxiety, high costs, somatisation and morbidity. A policy of watchful waiting is expected to lower both the number of patients to be tested and the risk of false-positive test results, without missing serious pathology. However, many general practitioners experience barriers when trying to postpone blood testing by watchful waiting. The objectives of this study are (1) to determine the accuracy of blood tests in patients presenting with unexplained complaints in terms of detecting pathology, (2) to determine the accuracy of a watchful waiting strategy and (3) to determine the effects of a quality improvement strategy to promote the postponement of blood test ordering by GPs for patients with unexplained complaints. General practices are randomised over three groups. Group 1 is instructed to order blood tests immediately, group 2 to apply a watchful waiting policy and group 3 also to postpone testing, but supported by our quality improvement strategy. The trial consists of two sub-studies: a diagnostic study at patient level (group 1 versus groups 2 and 3) and a quality improvement study at GP level (group 2 versus group 3). The diagnostic strategy to be used involves of both customary and innovative tests. The quality improvement strategy consists of two small-group meetings and a practice outreach visit. Patient follow-up ends at 12 months after the initial consultation. Primary outcome measures are the accuracy and added value of blood tests for detecting pathology, the effect of a 4-week postponement of test ordering on the blood test characteristics and the quantity of tests ordered. Secondary outcome measures are the course of complaints, quality of life, satisfaction with care, anxiety of patients and practitioners, determinants of physicians' behaviour, health care utilisation and costs. The innovative aspect of this trial is that it combines a clinical-epidemiological study and a quality of care study.

Stepwise diagnostic workup in general practice as a consequence of the Bayesian reasoning

Abstract: The dependency of the predictive values of tests on the prevalence of diseases is an escrow issue of clinical diagnostics. The relation between pre-test probability and post-test probability is well explained by Bayes' theorem, and the relation between prevalence and false diagnoses can be described well by modifying this theorem. In cases of low prevalence the positive predictive value (PPV) is lower and the false-positive predictive value (FPPV) higher. These aspects mainly depend on the test specificity. But basically, in cases of low prevalence there is a higher negative predictive value (NPV) and a lower false negative predictive value (FNVP). Depending on the sensitivity and specificity, NPV and FNPV vary only slightly in low prevalence ranges. These statistical relations are able to explain the typical mode of operation of general practitioners with their unselected patients. In order to increase PPV and decrease FPPV in the diagnostic workup, the GP must use his clinical experience, time and stepwise diagnostic procedures. More diagnostic studies are necessary to improve the diagnostic workup in patient care.

Vegemite and chocolate sprinkles : Dutch medical students in rural Australia

Abstract: • The Primary Health Care (PHC) working group of the Department of General Practice of Maastricht University in the Netherlands was founded in 1998 specifically to introduce students to patient care, research and education in primary health care settings outside the Netherlands. • Rural health care in Australia is appealing to international medical students because of its unique setting. • In the past 5 years, 42 medical students from Maastricht University have pursued a medical elective in rural Australia, supervised by the PHC working group. • Doctors and coordinators in primary care clinics across Australia have welcomed and supervised students from Maastricht and exposed them to the reality of rural health care. • Future collaboration with other Australian primary care clinics is welcomed.

Whooping cough in general practice.

Abstract: General practitioners seldom diagnose, or even consider, pertussis in older children who present with ongoing cough as a main symptom. Should this change in the light of new information in a paper by Harnden and colleagues in this week's issue (p 174)?1 They found that nearly 40% of a cohort of children aged 5-16 years presenting in UK general practice with a cough lasting 14 days or more had serological evidence of recent pertussis infection. This figure is perhaps even double that expected from previous research.2,3 The authors conclude that GPs should make a “secure diagnosis of whooping cough” to prevent inappropriate worry and treatment and demand for further tests. GPs are likely to follow this disease focused approach only if they feel that diagnosing whooping cough more often is both feasible and clinically important. The problem is that most of the currently available approaches to laboratory diagnosis either do not perform adequately in general practice or are unacceptably invasive in all but the most troubling cases. And even if a diagnosis is made, there is no evidence that treatment reduces the severity of symptoms, the duration of the illness, or transmission.4 The illness model, however, suggests that identifying a precise cause is generally unnecessary for achieving the authors' aims. Indeed, instead of reassurance, making a secure diagnosis of whooping cough might transform the experience of those children at the milder end of the spectrum into something altogether more fearful. Exploring and responding to patients' ideas, fears, and expectations about the likely effect of time, and the pros and cons of testing and treatment, may be more effective in reducing anxiety and avoiding inappropriate intervention than establishing a cause would be. GPs now know that although acute cough lasts longer than previously thought, almost all preschool children will have recovered without investigations, and largely irrespective of treatment, within one month after consulting.5 The information on prognosis from this study will therefore be of most immediate help to clinicians and patients. A clear, evidence based account of what to expect is rare in consultations for respiratory tract infection in children,6 and the evidence provided by this study will help set realistic expectations about the duration of cough. The authors found that the children at greatest risk of a prolonged clinical course whooped, vomited, and produced sputum the most often. Carers and children with a combination of symptoms could be targeted for additional communication and monitoring. In the few children who continue to cough after one month, clinicians should consider testing for evidence of pertussis and possibly other infections that commonly cause post-infective cough. Certainly, children with non-resolving cough should neither undergo x ray examination nor be prescribed inhalers without careful further thought.7,8 As pertussis is diagnosed more often among coughing older children, adolescents, and adults,9,10 many pressing questions arise. For example, what is the relation between pertussis infection and subsequent asthma? Do the study's findings apply to other countries—and, as none of the subjects received a pre-school booster dose of the pertussis vaccine, will the findings still apply in the UK now that the preschool booster has been introduced? Do the findings represent a “flow” in a cycle of pertussis incidence that will “ebb” on its own? How robust is the authors' approach of using a single serum sample for diagnosing recent or active Bordetella pertussis infection in general practice? How will new, non-invasive salivary tests perform, and how will they perform relative to clinical prognostic instruments, given the opportunity cost of new tests amid the relentless rise in requests for laboratory tests from general practice? And how will increased testing affect help-seeking behaviour? Consultations for common infections have fallen dramatically in recent years,11 making room for general practices to contribute more effectively to the management of chronic and complex diseases. Poorly targeted testing may encourage people with a cough to consult in the belief that a test is necessary for its optimal management, thus undermining trends towards greater self care. Perhaps even more importantly, older people with pertussis act as a reservoir for infection among the very young, and it is in the first months of life that the illness takes its greatest toll; 60-70% of infected babies are admitted to hospital, 12% develop pneumonia, 1% have seizures, and just under 1% die.9,12 Is the Bordetella organism evolving to escape the protection afforded by existing immunisation schedules? Should the UK follow the US and provide adolescents with a booster, and what effect will this have on pertussis in babies? Whatever the immediate implications for practice, this study focuses the agenda on pertussis as a major clinical and research issue for general practice. Keeping pertussis well to the back of our minds is no longer an option.

Post-traumatic stress after non-traumatic events

Abstract: Authors’ reply: We thank Ben-Ezra & Aluf (2005) for their letter, in which they broadly support our findings (Mol et al, 2005) that life events may cause as many symptoms of post-traumatic stress disorder (PTSD) as traumatic events classified according to the A1 criterion of the DSM–IV. However, they also have some criticisms. Ben-Ezra & Aluf argue that ‘serious illness (self)’ – classified as a life event in our study – can be considered a traumatic event. We decided against this classification as many respondents had experienced an illness that was chronic but not life-threatening in the short term. However, when we re-analysed the data with ‘serious illness (self)’ as a traumatic event the PTSD scores of the traumatic and life events groups still did not differ (total log PTSD score 0.68 in both groups). As suggested by Ben-Ezra & Aluf we have also excluded accidents and sudden deaths from the trauma events group, since this might be a heterogeneous group regarding the magnitude of the event. This resulted in a mean total log PTSD score of 0.76 (v. 0.71), which is not an essential change compared with the original difference. Ben-Ezra & Aluf argue that the magnitude (severity) of an event is related to the likelihood of developing PTSD, and that we should have allotted events to either of our two groups on the basis of their severity. We agree that symptoms are related to severity but we found a striking overlap in PTSD symptomatology after life events and traumatic events (Tables 2 and 4) and similar mean symptom levels (Table 3). The severity of an event can be assessed objectively and subjectively. Ben-Ezra & Aluf allude to the objective assessment but the subjective appraisal of an experience also plays an important role (McNally et al, 2003). It is likely that objective and subjective severity are associated with PTSD symptoms after both traumatic and life events.