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Biomedical subjects

C van Weel

Publications and source records attributed to C van Weel.

At least 91 records · Page 5Linked to original sources
PubMed1998

[Recent disciplinary committee rulings foster defensive medicine].

Recent medicolegal rulings corrected practitioners for not applying all possible interventions in the care of acute rare conditions. The performance was judged negligent, not on the clinical information available at the time, but in the light of the later course of disease. This paper argues that quality assurance requires a system of critical self and peer assessment, superimposed on medicolegal judgement. In all instances performance should be set against (external) criteria, including guidelines. Guidelines, in particular for general practice, define optimal care, to entitle patients to what is relevant while at the same time protecting them from ill-advised interventions. The point is made that the medicolegal ruling must be based on the same criteria that govern self and peer group assessment, and not on whatever it might be possible to do (maximal criteria), to prevent quality assurance from leading to defensive practice.

Acute Disease↗
PubMed1998

No relevant seasonal influences on office and ambulatory blood pressure: data from a study in borderline hypertensive primary care patients.

Our objective was to study seasonal influences on office and ambulatory blood pressure. We therefore designed a prospective 7-month study of 47 borderline hypertensive patients in a primary care setting. We used no interventions. Our main outcome measures were the differences between summer and winter office and ambulatory blood pressures and 95% confidence intervals. Results showed that winter minus summer differences ranged from 0 to 3 mm Hg. Only one significant difference was found: ambulatory systolic daytime pressure was significantly higher (3 mm Hg) in winter than in summer. Our results do not confirm the data of earlier studies in hypertensives. In view of the small and clinically irrelevant winter-summer differences, it seems unnecessary to modify antihypertensive treatment of borderline hypertensives according to the season.

Adult↗
PubMed1998

Are anti-oxidant and anti-inflammatory treatments effective in different subgroups of COPD? A hypothesis.

The treatment of chronic obstructive pulmonary disease (COPD) with inhaled corticosteroids or anti-oxidants is still under debate and the identification of sub-groups of COPD patients who may benefit from either anti-inflammatory or anti-oxidant treatment is needed. We re-analysed data from an earlier study of inhaled beclomethasone therapy in COPD (n = 28) and asthma (n = 28) patients in order to determine patient characteristics that predict a favourable inhaled steroid treatment effect. A higher bronchodilatory response, a faster decline of FEV1 prior to the treatment period and a lower Tiffeneau index were significantly related to more beneficial treatment effects. Increased smoking tended to be related to less steroid treatment benefits, though it was not statistically significant. In this paper these findings are presented in light of the available literature on anti-inflammatory and anti-oxidant COPD treatment. On this basis the hypothesis is presented that anti-oxidant treatment might be relatively more effective among those COPD patients who respond less well to inhaled steroids (low reversibility and heavy smoking).

Anti-Inflammatory Agents↗
PubMed1998

Tailored outreach visits as a method for implementing guidelines and improving preventive care.

OBJECTIVES: Authors of successful outreach visit studies stress the importance of tailoring the intervention to the unique attributes and needs of each practice. For a better understanding of the outreach visit method, the tailoring mechanism is explored in this article. The variation among practices in preventive outreach visits to implement guidelines and characteristics that determine the variation (baseline adherence to organizational guidelines, practice and visitor characteristics) are described. We explored whether and how many visits were paid to practices that showed no increase in adherence to guidelines. SETTING AND STUDY PARTICIPANTS: For 18 months, six trained nurse visitors assisted 33 family practices in implementing a set of guidelines to organize a program for cardiovascular disease prevention. MEASURES: Visit and consultative action parameters (number and duration of visits, duration of training and of conferring) and increase in adherence to organizational guidelines after 18 months of assistance compared to baseline adherence. RESULTS: Practices differed considerably concerning the visit and consultative action parameters. Exploratory multiple regression analysis showed that baseline adherence to guidelines, and practice and visitor characteristics were related to the number of visits. Visitor characteristics were strongly related to the total time spent on visits, training, and conferring. DISCUSSION: Our findings confirm that, concerning the number of visits, assistance is primarily adapted to the unique attributes of each clinic. It may be useful, from the viewpoint of cost-effectiveness, to standardize the performance of visitors somewhat more with regard to the visit length. The tailoring mechanism resulted in time well spent in assisting practices. We hope that our results contribute to the further development of the outreach method.

Adult↗
PubMed1998

Active detection of chronic obstructive pulmonary disease and asthma in the general population. Results and economic consequences of the DIMCA program.

The aim of this prospective study was to detect subjects in the general population with objective signs of chronic obstructive pulmonary disease (COPD) or asthma at an early stage. This was done by means of a two-stage protocol involving screening and a subsequent 2-yr monitoring of all subjects with positive results of screening. The study was done in 10 general practices located in the eastern part of the Netherlands. A random sample was taken from the general population aged 25 to 70 yr. All known COPD and asthma patients were excluded. A total of 1,749 subjects met the inclusion criteria: 1,155 subjects (66%) agreed to participate in the screening stage of the study. A total of 604 subjects (52.3%) showed symptoms or objective signs of COPD or asthma during the screening and were considered "positive." Of those with positive screening results, 384 subjects (64%) agreed to participate in the second, 2-yr monitoring stage of the study. The costs involved in detection were calculated for three different scenarios, as follows: (1) The detection of subjects with persistently decreased lung function or an increased level of bronchial hyperresponsiveness (BHR) during 6 mo of monitoring; (2) Scenario 1 plus the detection of subjects with a rapid decline in lung function with signs of BHR during 12 mo of monitoring; (3) Scenario 2 plus the detection of subjects with a moderate increase in the decline in lung function or signs of BHR during 24 mo of monitoring. The costs of lung function assessments, organization, transportation, and patient time were included. The costs were converted to United States dollars on the basis of purchasing power (1 United States dollar = 2.08 Netherlands guilders). During the second stage, 252 subjects were detected with objective signs of COPD or asthma at an early stage. Smoking status as a screening criterion was neither sensitive nor specific. Because there was no evidence of biased recruitment or selection during the program, the proportions of subjects found to have objective signs of COPD or asthma at an early stage could be extrapolated to the general population. Of the general population, 7.7% showed persistently reduced lung function or increased BHR. Another 12.5 % of the general population showed a rapid decline in lung function (> 80 ml/yr) in combination with signs of BHR, and a further 19.4% of the general population showed mild objective signs of COPD or asthma. The average costs per detected case varied from US$953 (Scenario 1) to US$469 (Scenario 3). In conclusion, detection of COPD or asthma at an early stage by means of a two-stage protocol was feasible at relatively little expense in comparison with other mass screening programs. Persistently decreased lung function or a rapid decline in lung function (Scenario 2) was observed in approximately 20% of the general adult population.

Adult↗
PubMed1998

Association between health-related quality of life and consultation for respiratory symptoms: results from the DIMCA programme.

In general practice, diagnosis of chronic obstructive pulmonary disease (COPD) is hampered by underpresentation. A substantial proportion of subjects experiencing respiratory complaints do not consult their general practitioner (GP). In this study, the relationship between disease-specific quality of life and presentation of respiratory symptoms to a GP is investigated. A random sample from the general population (undiagnosed subjects) was screened for symptoms and objective signs of COPD (n=1,155). The lung function of subjects with symptoms of COPD was monitored for 6 months. During this period, 48 new COPD patients with a persistently reduced lung function (forced expiratory volume in one second (FEV1) less than or equal to the predicted value minus 2 SD) were detected. A disease-specific quality-of-life questionnaire (chronic respiratory questionnaire (CRQ)) was administered and clinical and GP consultation data were collected. Multivariate analysis showed that quality-of-life impairments due to dyspnoea and fatigue and variability in lung function (bronchial hyperresponsiveness, reversibility and peak expiratory flow rate variability) were related to medical consultation. Only 31% of the newly detected patients reported that they had ever visited their GP for respiratory complaints. A similarly low percentage was found in the rest of the sample (26%). It is concluded that the mere presence of respiratory symptoms or a (gradually) reduced lung function is insufficient reason for patients to seek medical help. Subjects are more likely to consult their general practitioner once their quality of everyday life is affected or they experience variability in lung function.

Adult↗
PubMed1998

The role of "fear of corticosteroids" in nonparticipation in early intervention with inhaled corticosteroids in asthma and COPD in general practice.

Treatment of chronic airflow obstruction with inhaled corticosteroids at an early stage has been shown to preserve the lung function. We tested the hypothesis that "fear of corticosteroids" may be an important reason for nonparticipation in the Detection, early Intervention and Monitoring programme on Chronic obstruction pulmonary disease (COPD) and Asthma ("DIMCA") project. One thousand seven hundred and forty nine adult subjects from 10 general practices were invited to participate in the several parts of the "DIMCA" programme. Refusers were questioned about the reason(s) for nonparticipation. Together the screening, monitoring and three drug interventions of the study showed on average 25-35% refusers. The most frequent reasons for nonparticipation were absence of pulmonary symptoms and lack of time. For those invited to take part in one of the three drug interventions, "dislike of medication" was the most important reason for nonparticipation (33, 45 and 67% of the refusers). "Fear of corticosteroids" specifically was the reason for nonparticipation in 8% of the refusers on the basis of "dislike of medication". We concluded that a specific fear of corticosteroids was not a major obstacle for early intervention with inhaled corticosteroids.

Administration, Inhalation↗
PubMed1998

How to avoid underdiagnosed asthma/chronic obstructive pulmonary disease?

The prevalence of asthma and chronic obstructive pulmonary disease (COPD) is rising in most countries, including The Netherlands. It has been suggested that a majority of these cases of (self-reported) symptoms related to asthma/COPD are not diagnosed in general practice. We compared a population screening for underdiagnosed asthma/COPD with a high-risk approach by a questionnaire form with specified questions about asthma/COPD-related symptoms. A case-controlled study including a record review was performed of cases and controls. The results of a population screening were used to classify patients as (a) asthma/COPD, (b) at risk for asthma/COPD, or (c) no asthma/COPD. Eleven hundred fifty-five patients were screened. One hundred fifty-five patients reported previous asthma/COPD-related care (cases). The difference between number of cases and controls in asthma/COPD diagnosis was chosen as main outcome measure. The population screening revealed 85 subjects with a diagnosis of asthma/COPD and 154 subjects with an increased risk. Nineteen diagnoses could be made in cases, and eight diagnoses in controls. The chart review showed that only seven cases and two controls were known to the general practitioner. From this study it can be concluded that in order to reduce the number of un- and underdiagnosed patients, all listed patients in general practice should be screened. However, if screening of all patients is not feasible, active case finding by asking a few questions about shortness of breath or wheezing to all patients in the group of listed individuals is recommended.

Adult↗
PubMed1998

Long-term effect of treatment of female incontinence in general practice.

BACKGROUND: Urinary incontinence in women can be treated successfully by the general practitioner. However, little is known about the long-term effects of conservative treatment. AIM: To evaluate the long-term effect of treatment of female incontinence by the general practitioner (pelvic floor exercises, and bladder training) in female urinary incontinence. METHOD: A total of 88 women, aged between 20 and 65, who had participated in a controlled trial between 1987 and 1990, were contacted to participate in a five-year follow-up study. Stress incontinence and urge incontinence were treated by means of pelvic floor exercises and bladder training respectively, while a mixed incontinence was treated by bladder training followed by pelvic floor exercises. The outcome measures were a constructed scale for the severity of the incontinence, a seven-day bladder chart, and a questionnaire concerning patients' opinions. All patients were evaluated by an independent researcher. RESULTS: Compared with the one-year follow-up, the number of continent women remained the same, but a significantly greater number of patients worsened. Forty per cent of the women stayed in the same category of severity, while 45% moved into the contiguous categories. The weekly frequency of wet episodes increased significantly, with a mean increase of 2.65 episodes. Women with mixed incontinence were especially prone to relapse in the long-term. Compliance with the exercises had a positive influence on the outcomes, with 67% of the women expressing satisfaction with the results. CONCLUSIONS: Despite a decline in the effect of conservative treatment in the long-term, the majority of the women are satisfied with their treatment. Patient compliance is the key to long-term success.

Adult↗
PubMed1998

Control group characteristics and study outcomes: empirical data from a study on mortality of patients with type 2 diabetes mellitus in Dutch general practice.

STUDY OBJECTIVE: Control group characteristics as comorbidity and chronic psychosocial problems may play an important part in study outcomes. A primary care data base was used to quantify the effects of varying the case mix of participants. DESIGN: Historical cohort study. SETTING: Data were collected from 1967-1996 in four Dutch general practices performing the Continuous Morbidity Registration Nijmegen. PATIENTS AND CONTROLS: All newly diagnosed type 2 diabetic patients in the period 1967-1989 fulfilling the WHO criteria (n = 265); for each type 2 diabetic patient a control was matched for practice, sex, age, and social class; from these controls subgroups were selected based on the absence of different types of morbidity; these subgroups were also matched for practice, sex, age, and social class. MAIN RESULTS: The relative risk of mortality in type 2 diabetic patients in comparison with various subsets of controls ranged from 1.33 (95% CI 0.97, 1.81) to 2.16 (95% CI 1.46, 3.20). CONCLUSION: Control group characteristics as comorbidity and chronic psychosocial problems turned out to influence the risk estimation in a cohort study. General practice data enhance the study of these aspects.

Cardiovascular Diseases↗
PubMed1997

[Prevalence of chronic fatigue syndrome and primary fibromyalgia syndrome in The Netherlands].

OBJECTIVE: To determine the prevalence of chronic fatigue syndrome (CFS) and of primary fibromyalgia syndrome (PFS) in the Netherlands. DESIGN: Questionnaire. SETTING: Department of Medical Psychology, University Hospital Nijmegen, the Netherlands. METHOD: A questionnaire was mailed to all the 6657 general practitioners in the Netherlands in order to inform them of the existence of CFS and to ask them if they had any CFS or PFS patients in their practices. RESULTS: Sixty percent (n = 4027) of the general practitioners returned the questionnaire. Of all the general practitioners, 27% said they had no CFS patients, 23% said they had 1 CFS patient, while 21% had 2 CFS patients, and 29% said they had 3 or more CFS patients in their practice. Concerning PFS the results were 17% (no PFS patients), 18%, 18% and 47%, respectively. With a mean practice of 2486 patients per general practice, the estimated prevalence of CFS was 112 per 100,000 and that of PFS 157 per 100,000 persons. Of the CFS patients 81% were women and 55% were 25-44 years old; for PFS these figures were 87% and 48% respectively. CONCLUSION: Extrapolation of the study results indicates that there are at least 17,000 CFS patients and 24,000 PFS patients in the Netherlands. The found prevalence is probably an under-estimation.

Adult↗
PubMed1997

Symptoms and duration of the prodromal phase in Parkinson's disease.

To investigate the duration of a prodromal phase before the onset of the classic symptoms of idiopathic Parkinson's disease, the authors conducted a retrospective case-control study of 60 patients with Parkinson's disease and 58 age- and sex-matched control subjects, covering the decade preceding the onset of classic Parkinson's disease. The symptoms were derived from files of the patients' general practitioners. Compared with control subjects, patients pre-Parkinson's disease had more central nervous system, psychologic, musculoskeletal, and cardiovascular (i.e., autonomic) symptoms. Patients pre-Parkinson's disease also made more visits to general practitioners and medical specialists. The results indicate that the onset of classic parkinsonism is frequently preceded by a prodromal phase lasting from 4-6 years.

Adult↗
PubMed1997

Does the health status of chronically ill patients predict their judgements of the quality of general practice care?

Patients' health status as well as patients' judgements of care are used for assessing patients' perspectives, but the relation between those two concepts is unclear. In this study we explored whether health status predicts patients' judgements of the quality of general practice care. Hand-distributed and mailed surveys were performed by 28 general practitioners in The Netherlands. Chronically ill patients were approached when visiting the general practice or drawn from the practice registers. Health status was measured by WONCA/COOP charts, and patients' judgements by the CEP, a previously validated questionnaire. The response rate was 63% (n = 762). When controlled for other patient characteristics, a poor overall health predicted less positive judgements of medical care, information, counselling, relation and communication, continuity of care and the organization of appointments (p < 0.01). Poor mental well-being predicted less positive judgements of the cooperation between care providers and a stronger need for more care (p < 0.001). The four other aspects of health status did not predict the patients' judgements. Judgements about the premises and the availability for emergencies were not predicted by health status. It can be concluded that a multidimensional approach should be used for interpreting the relations between patients' health status and their judgements of general practice care.

Adult↗
PubMed1997

The influence of cuff size on blood pressure measurement.

The objective of the study was to determine the effect of the use of cuffs with different bladder sizes on the outcome of blood pressure (BP) measurements. Two sizes of bladders previously in common use in the study location (13 x 23 cm and 16 x 23 cm) were compared with the current size (13 x 36 cm). A fully randomised, experimental study was carried out on a study population comprising 130 subjects (61 men, 69 women, aged between 22 and 70, mean 49) who were not undergoing special treatment for cardiovascular disease or hypertension at that time. The mean arm circumference was 32.9 cm (range 25-40 cm). BP measurements were carried out by one person, using a Hawksley random zero sphygmomanometer under standardised conditions. With the smallest bladder (13 x 23 cm) the highest systolic and diastolic BP was measured (mean SBP 127.2 mean DBP 77.0 mm Hg), followed by the bladder of 13 x 36 cm (125.1 resp. 75.4 mm Hg). The lowest BP was measured with the bladder of 16 x 23 cm (123.7 resp. 74.4 mm Hg). Differences between bladders were significant for all arm circumferences. Over the entire range of arm circumferences in the present study there is a small systematic difference in the BP measurements taken by the various bladder sizes. For individual readings the difference is less marked, in comparison to other factors that can affect BP measurements. However, in longitudinal studies a systematic error in BP can occur when measurements are made with different bladders during the study.

Adult↗
PubMed1997

Morbidity in family medicine: the potential for individual nutritional counseling, an analysis from the Nijmegen Continuous Morbidity Registration.

Nutritional counseling is a common primary care intervention but few empirical data are available. This study analyzed morbidity in family medicine practices and the relevance of nutritional counseling. Morbidity data from the Nijmegen University family medicine Continuous Morbidity Registration were studied. Since 1967 four practices (seven family physicians) have recorded all new episodes of illness. Physicians were trained and supervised monthly in their coding and classification of morbidity with diagnostic criteria. Two experienced family physicians assessed the nutrition sensitivity of all 400 diagnostic rubrics of the classification list. Incidence and prevalence of all morbidity and of nutrition-sensitive morbidity were calculated. The most common (chronic) diseases in family practice were a mixture of diseases of organ and body systems: hypertension, obesity, cardiovascular disease, chronic arthritis, asthma, chronic obstructive pulmonary disease, eczema, and diabetes mellitus. The prevalence of these diseases gradually increased in the past decade. Forty-eight diagnostic rubrics were considered to be nutrition sensitive, accounting for 16.5% of diagnoses recorded. Their prevalence also increased in the past decade. The survey supports the importance of nutrition-related interventions in family medicine but underlines that these interventions are directed at a variety of illnesses and patient groups. Common nutritional intervention techniques that can be applied in the personal care of patients in the context of their family life should be developed.

Adolescent↗
PubMed1997

Long-term effect of nutritional counseling: a study in family medicine.

This paper reports research using data in the Nijmegen Family Practice Monitoring Project. One part of the research is follow-up, after 17 y, of a 1977 trial of dietary advice for patients with hypertension or a family history of premature cardiovascular disease. In the intervention group, 840 patients were given health education every 2 mo by trained practice nurses for 1 y. There were 497 patients with similar coronary risk factors in the control group, who received usual care. One year after the intervention a significant decrease was found (and published) in serum cholesterol concentrations and blood pressure in the intervention group. By the time of the 1995 reexaminations, however, there were no differences in coronary risk factors between the two groups. Blood pressures had come down, more so in the control group, and the percentage of smokers had decreased equally in both groups. There were no significant differences in intake of dietary fat or in type of fat. The lack of difference was still found when the groups were divided into those with serum cholesterol concentrations > and < 6.5 mmol/L. A second part of the research was to investigate in 1995 the relation between patients' stage of change of fat intake and their dietary intake. It was found that those in stage 5 (sustaining desired changes in behavior) had the lowest saturated fat intake. Since 1977 both groups have been treated equally if hypertension was diagnosed. The two groups were not managed differently with regard to dietary advice after 1977.

Adult↗