Biomedical subjects

F M Haaijer-Ruskamp

Publications and source records attributed to F M Haaijer-Ruskamp.

At least 19 recordsLinked to original sources

PubMed2007

Prescribing for chronic heart failure in Europe: does the country make the difference? A European survey.

PURPOSE: International differences in prescribing patterns for chronic heart failure (CHF) have been demonstrated repeatedly. It is not clear whether these differences arise entirely from patient characteristics or factors related to the country itself, such as health care systems or culture. We aim to assess the role of countries in this international variation, aside from the role of patient characteristics. METHODS: In this European primary care practice survey (from 1999/2000) 11062 CHF patients from 14 countries were included. The influence of country (corrected for patient characteristics) on prescribed drug regimes was assessed by multinomial logistical regression. RESULTS: Prescribing of guideline-recommended drug regimes ranged from 28.1% in Turkey to 61.8% in Hungary. Including additional regimes justifiable by patients' co-morbidities, increased overall 'rational' prescribing by 11%, but differences among countries remained similar. Multivariate analysis for one-drug and two-drug regimes explained between 35% and 42% of the total variance, country contributed 7%-8% (p < 0.005). Countries determined the number of drugs used and the likelihood of individual drug regimes. For example, in Czech Republic digoxin alone was more likely to be given than the recommended ACE-inhibitors (OR: 3.45; 95%CI: 2.56-4.64), while the combination of digoxin with ACE-inhibitors was as likely as the recommended combination of ACE-inhibitors and beta-blockers (OR: 1.17; 95%CI: 0.88-1.55). CONCLUSION: Country of residence clearly influenced prescribed drug volume and choice of drug regimes. Therefore, optimal CHF management cannot be achieved without considering country specific factors. It remains to be established which factors within health-care systems are responsible for these effects.

Adrenergic beta-Antagonists↗

PubMed2005

[Reduction in the consumption of benzodiazepines due to a letter to chronic users from their own general practitioner].

OBJECTIVE: To investigate the effectiveness of a minimal intervention in reducing the volume of prescription of benzodiazepines at the regional level. DESIGN: Prospective. METHOD: Patients on compulsory health insurance who had received 180 or more daily doses of benzodiazepines in the course of one year received a letter from their general practitioner (GP) with information about the risks of chronic use, the advice to reduce or stop use, and an invitation to make an appointment to discuss the problem. This intervention took place in 19 GP practices in East Groningen. A reminder was sent six months later to the patients who had not responded in 9 randomly selected GP-practices. Thirty-seven practices in East Groningen and 91 practices in Northwest Groningen served as controls. Outcome measures were: (a) the percentage of patients who stopped, and (b) the change in average benzodiazepine consumption. RESULTS: During the period 6-12 months after the first letter in the intervention group (n = 1343), 11.3% of the patients (95% CI: 9.6-13.1) received no prescription whatsoever for benzodiazepines compared to 5.4% (4.6-6.3) and 4.9% (4.2-5.5) in East Groningen (n = 2932) and in Northwest Groningen (n = 4562), respectively. The average decrease in prescription volume was 13% (-9.9 to -15.1) in the intervention group compared to 3% (-0.1 to -4.1) and 3% (-1.5 to -4) in the control groups. The reminder sent half a year later had no additional effect. CONCLUSION: The informative letter from the GP to chronic users of benzodiazepines with the advice to stop or reduce this use was effective.

Anti-Anxiety Agents↗

PubMed2005

Reliability of assessment of adherence to an antimicrobial treatment guideline.

Assessment procedures for adherence to a guideline must be reliable and credible. The aim of this study was to explore the reliability of assessment of adherence, taking account of the professional backgrounds of the observers. A secondary analysis explored the impact of case characteristics on assessment. Six observers (two hospital pharmacists, two internists and two clinical microbiologists) assessed a random sample of 22 prescriptions made to infectious disease cases admitted to a department of internal medicine between February and August 2001. Agreement between observers with regard to adherence of these prescriptions to guideline recommendations concerning drug choice, duration of treatment, dosage and route of administration was measured using Cohen's kappa. Case characteristics were compared between cases where observers agreed and disagreed with two-sided Fisher's exact test. Agreement between all professionals was moderate for drug choice (0.59), fair for duration of therapy (0.36), moderate for dosage (0.48), and fair for route of administration (0.37). Agreement on drug choice was good within (0.75 and 0.83) and between (0.74) the internists and the hospital pharmacists, but was less within (0.31) the clinical microbiologists and between the clinical microbiologists and the internists (0.44) and the hospital pharmacists (0.42). Within the clinical microbiologists, agreement was good for dosage (0.79) and route of administration (0.66). There was frequent disagreement between observers regarding cases with combination therapy and non-immunocompromised patients. Despite the small number of cases, our results suggest that internists and hospital pharmacists can reliably be used to assess adherence for drug choice. The level of agreement seems to be affected by combination therapy and the immune status of the patient.

Aged↗

PubMed2004

Indicators of prescribing quality in drug utilisation research: report of a European meeting (DURQUIM, 13-15 May 2004).

An invitational expert meeting on indicators of prescribing quality was held on 13-15 May 2004, bringing together--from 19 European countries, the US, Canada, and Australia--40 researchers specialized in the development and application of indicators. The meeting was organized by the European Drug Utilization Research Group (EuroDURG), the Belgian National Health Insurance Institute (RIZIV-INAMI), and the World Health Organisation Regional Office for Europe (WHO-Euro). The field of prescribing quality was defined and delineated from the medical error field. A conceptual grid for classifying quality indicators was discussed, combining two axes (a drug/disease/patient axis and a structure/process/outcome axis). In addition, available databases were listed for continuous monitoring of drug utilization in Europe, with a description of the content and the richness of the collected data, as well as the impact on the potential and limitations to develop quality indicators. The importance of the origin of data for validity assessment was stressed, as data on drug utilization may originate from physician sources (prescribing data), from pharmacist or health insurer sources (distribution data), or directly from patient sources (compliance data). The different aspects of validity and their methods of assessment were listed. An overview of the (in)appropriate uses of indicators was given. The state of the art of the development and application of prescribing quality indicators in all represented countries was made, together with a first draft of a database of prescribing quality indicators, already subjected to validation procedures.

Drug Prescriptions↗

PubMed2004

Physicians' views on joint treatment guidelines for primary and secondary care.

OBJECTIVE: Joint drug formularies and treatment guidelines have been developed to reduce problems arising at the interface between primary and secondary care. The aim is to compare the willingness of hospital specialists and general practitioners to use joint treatment guidelines, and to determine the most relevant barriers and facilitators. STUDY DESIGN: A structured survey, consisting of questions about the use of guidelines and formularies in general, and possible barriers and facilitators for using a specific joint guideline. These specific guidelines concerned the treatment of hypertension, heart failure, or diabetes mellitus. SETTING AND STUDY PARTICIPANTS: One hundred and ninety-seven general practitioners and 34 general internists and cardiologists from the north of the Netherlands. RESULTS: Most hospital specialists relied for their prescribing on international guidelines and agreements within their own department, while general practitioners relied more on national and regional guidelines. General practitioners were more supportive than specialists of the initiative to develop joint treatment guidelines, although both groups had concerns regarding the development process. An important barrier for specialists was that they did not perceive a need for these guidelines. As enabling factors, physicians stated that these joint guidelines can lead to harmonization between specialists and general practitioners, and that they can be useful as an educational tool. CONCLUSION: Specialists are less ready to adopt joint treatment guidelines than general practitioners, indicating the need for a different approach to implement such guidelines in the two sectors.

Attitude of Health Personnel↗

PubMed2004

Relationship between guideline treatment and health-related quality of life in asthma.

The aim of this study was to compare the health-related quality of life (HRQL) of asthma patients treated according to the 1997 National Institute of Health (NIH) international asthma guideline and that of asthmatics receiving non-guideline treatment. The suitability of 146 asthmatics' medication regimes was determined according to the 1997 NIH asthma guideline. Quality of life was assessed on a seven-point scale using the Asthma Quality of Life questionnaire. Just over half of the patients were not currently using the treatment considered necessary for controlling their asthma. Patients treated according to the guideline (n=72) had a significantly higher overall HRQL than patients with non-guideline treatment (5.7 versus 5.3). The differences were also significant for the subscales measuring symptoms and environmental exposure, but not for activities or emotional function. An association between non-guideline treatment and a poorer health-related quality of life in asthma patients treated in general practice was observed. This study supports the role of evidence-based guidelines in daily practice. Further studies are needed to determine if guideline treatment is responsible for the increase in health-related quality of life observed in this work.

Adult↗

PubMed2002

Identifying general practice patients diagnosed with asthma and their exacerbation episodes from prescribing data.

OBJECTIVE: To determine the reliability of identifying patients diagnosed with asthma in general practice and their asthma exacerbation episodes from prescribing data. DATA SOURCE: Automated database from 17 general practitioners (29,805 patients) in the northern Netherlands. STUDY DESIGN: Sensitivity, specificity and predictive values of four criteria for identifying patients diagnosed with asthma and two criteria for identifying asthma exacerbation episodes were calculated using the registered diagnosis as gold standard. RESULTS: Prescription of one or more anti-asthma medications identified 95% of patients with an asthma diagnosis (positive predictive value 0.70), while two or more anti-asthma medications identified 71% (positive predictive value 0.79). A combination of oral corticosteroids or antibiotics identified 55% of exacerbations. CONCLUSIONS: Asthma patients can be identified reliably from prescribing data, but identification of asthma exacerbations was poor. The preference for one criterion over another for identifying patients diagnosed with asthma will depend on the reason for patient selection.

Adolescent↗

PubMed2002

Dutch GPs' perceptions: the influence of out-of-pocket costs on prescribing.

The aim of this study was to explore the impact of out-of-pocket costs on Dutch general practitioners' prescribing. A qualitative study using focus groups was conducted. An open-ended topic guide was used to elucidate the influence of out-of-pocket costs on decision making for the treatment of dyspepsia, hay fever, hormone replacement therapy, and hypertension. A total of 21 Dutch GPs from University Departments of General Practice participated in four separate focus groups. These discussions were held between November 1998 and March 1999. Each discussion was tape-recorded and transcribed verbatim. From this transcription, key factors and issues were identified. GPs reported that they do not generally take out-of-pocket costs into account. Fully reimbursed drugs were usually prescribed and GPs felt that most patients were highly motivated and thus willing to pay for their medication. The patient charges were seen to be low and not likely to affect patients' willingness to pay. GPs felt that patients need not have to pay for their medication. They adjusted their drug choice in order to avoid co-payment and were willing to agree to a patient's demand for a reimbursed prescription. GPs describe their prescribing as not influenced by out-of-pocket costs. GPs seem inclined to avoid co-payment for patients when patients have financial difficulties and the disease is perceived as severe. They chose fully reimbursed drugs.

Attitude of Health Personnel↗

PubMed2002

Specialists' expectations regarding joint treatment guidelines for primary and secondary care.

OBJECTIVE: To identify factors that may hinder or facilitate specialists' use of joint treatment guidelines for primary and secondary care. DESIGN: Qualitative study using focus group discussions based on a topic guide with open-ended questions. MAIN OUTCOME MEASURES: Themes identified by two researchers that specify the specialists' views on the use and implementation of treatment guidelines in general, and transmural guidelines in particular. SETTING: Departments of Cardiology and Internal Medicine in three Dutch hospitals. STUDY PARTICIPANTS: Ten general internists, 11 cardiologists, and six gastroenterologists participating in seven group discussions. RESULTS: Specialists did not perceive the treatment guidelines as useful for their own field of expertise, but expected that joint guidelines might improve integration between primary and secondary care. Furthermore, the guidelines could be useful for areas outside their expertise, for specialists in training, and for general practitioners. Concerns were expressed regarding their content and development process. In addition, specialists feared negative consequences, such as loss of autonomy, extra administrative workload, and organizational and financial barriers such as loss of industry-sponsored research and conferences. CONCLUSION: Specialists are not very motivated to use the guidelines themselves. This is a major obstacle that should be addressed in an implementation programme. Furthermore, negative outcomes at the organizational and financial levels must be minimized or compensated for. A joint implementation programme seems worthwhile, making use of the advantage seen by specialists in making agreements with general practitioners.

Adult↗

PubMed2001

[Drug utilization by the elderly with depressive symptoms].

OBJECTIVE: Obtain a picture of non-psychiatric medication use and depressogenic medication use by elderly people suffering from depression. DESIGN: Cross-sectional, self-reported by respondents. METHOD: Information about medication usage and the presence of chronic diseases was obtained from 183 depressive respondents and 96 control respondents. The respondents were aged 55 years or over. They were recruited between April 1996 and May 1998 in the provinces Groningen, Drenthe and Friesland, the Netherlands. Recruitment was via Regional Institutes for Outpatient Mental Health Care (RIAGGs), a psychiatric outpatient clinic, general practitioners participating in the 'Groningen longitudinal ageing study' (GLAS), a survey under the elderly within the general population, and screening with the 'Geriatric depression scale' (score > or = 6) in the GLAS main file. RESULTS: Respondents with subsyndromal depression recruited via screening were prescribed more depressogenic medication (mean: 3.26 drugs per patient, of which 45.6% depressogenic) than the control group (respective figures: 1.78; 26.1%) and the depressive groups recruited via general practitioners (2.77; 31.8%) or those recruited via RIAGGs/psychiatric outpatient clinic (2.60; 38.3%).

Aged↗

PubMed2001

Comparison of indicators assessing the quality of drug prescribing for asthma.

OBJECTIVE: To compare different indicators for assessing the quality of drug prescribing and establish their agreement in identifying doctors who may not adhere to treatment guidelines. DATA SOURCES/STUDY SETTING: Data from 181 general practitioners (GPs) from The Netherlands. The case of asthma is used as an example because, in this area, different quality indicators exist whose validity is questioned. The study is part of the European Drug Education Project. STUDY DESIGN: Spearman rank correlations were assessed among the GPs' scores on self-report instruments, aggregated prescribing indicators, and individualized prescribing indicators. Kappa values were calculated as agreement measures for identifying low adherence to the guidelines. DATA COLLECTION: Prescribing data from GPs were collected through pharmacies, public health insurance companies, or computerized GP databases. Two self-report instruments were mailed to the GPs. The GPs first received a questionnaire assessing their competence regarding the treatment of asthma patients. Three months later they received a series of 16 written asthma cases asking for their intended treatment for each case. PRINCIPAL FINDINGS: Correlations between scores based on self-report instruments and indicators based on actual prescribing data were mostly nonsignificant and varied between 0 and 0.21. GPs identified as not adhering to the guidelines by the prescribing indicators often had high scores on the self-report instruments. Correlations between 0.20 and 0.55 were observed among indicators based on aggregated prescribing data and those based on individualized data. The agreement for identifying low adherence was small, with kappa values ranging from 0.19 to 0.30. CONCLUSIONS: Indicators based on self-report instruments seem to overestimate guideline adherence. Indicators assessing prescribing quality at an aggregated level give clearly different results, as compared to indicators evaluating prescribing data on an individual patient level. Caution is needed when using such prescribing indicators to identify low adherence to guidelines. Further validation studies using a gold standard comparison are needed to define the best possible indicator.

Administration, Inhalation↗

PubMed2000

The cost of prescription medicines to patients.

The study compares the cost-sharing (co-payment) arrangements for prescribed medicines in a sample of EU countries. Through a set of typical prescription scenarios, the cost burden to individual patients of prescriptions are examined, in the context of drug price, and from the perspective of therapeutic need. The cost to patients of medicines is consistently lower in some, and higher in other, countries, regardless of the type of prescription charge system. Fixed charge systems, as opposed to graduated co-payment systems, are obviously more likely to lead to similar charges for the treatment of comparable clinical conditions, but depending on the level of the charge, can result in the patient paying a higher charge than the price of the drug to the health organisation. Exemption from charges for prescription medicines, commonly relate to clinical condition and level of income. Some systems also have age-related criteria and apply ceilings to the total prescription cost burden borne by the patient. The impact on patient costs of specific policy formulations is discussed and a proposal is made for cost convergence for comparable therapies. The method used in this study may also provide a route for investigating model systems prior to implementation.

Cost Sharing↗

PubMed2000

Improving drug treatment in general practice.

In the international Drug Education Project, an educational program involving auditing and feedback in peer groups to improve the treatment of asthma and urinary tract infections (UTI) was developed and tested in primary care. Individualized feedback was provided and discussed in 24 Dutch peer groups showing doctors their prescribing practices and underlying reasons for treatment. A parallel, randomized controlled design was used to test the effect on competence and actual prescribing; in one study arm doctors received feedback on asthma treatment and in the other on UTI treatment. Especially the messages to treat asthma exacerbations with oral corticosteroids (17% increase) and to prescribe short courses for UTI (decrease duration of 1.8 days) brought about large improvements. Both messages concerned acute situations, and were clear and relatively easy for GPs to implement. GPs will experience more barriers when changing maintenance treatment of an asthma patient, which could explain the more limited success of this part of the educational program: the proportion of patients treated with inhaled corticosteroids increased 5%. A ceiling effect was experienced regarding drug choice for UTI.

Adult↗

PubMed2000

Treatment of uncomplicated urinary tract infections: exploring differences in adherence to guidelines between three European countries. Drug Education Project Group.

OBJECTIVE: To evaluate adherence of general practitioners to treatment guidelines regarding urinary tract infections in three European countries and to investigate whether differences in adherence at the prescribing level within and between countries could be explained by general practitioners' knowledge and attitudes, characteristics, or national setting. DESIGN: Prescribing data collected in 1994-1995 were analyzed regarding use of first-choice drugs and duration of treatment, knowledge and attitudes were assessed with a questionnaire, and multiple regression analysis was used to explain differences in prescribing behavior within and between countries. RESULTS: Our study is based on data from 85.6% of the 584 general practitioners who were scheduled to participate in a continuing education program. The mean proportion of responses in agreement with the guidelines regarding first-choice drugs was 0.69 in Sweden, 0.78 in the Netherlands, and 0.79 in Norway; regarding duration of treatment, the mean proportion was 0.56 in Sweden, 0.67 in the Netherlands, and 0.59 in Norway. The proportion of first-choice drugs prescribed for women (18-75 y) was 0.55 in Sweden, 0.83 in the Netherlands, and 1.00 in Norway (patients >16 y). The duration of treatment was 7.6 defined daily doses per prescription in Sweden, 5.9 in the Netherlands, and 6.6 in Norway. Knowledge and attitudes explained 0-17% of the variation in prescribing. Years in practice explained 0-11%, and the general practitioners' gender had no explanatory value. The national setting explained most of the variation between countries. CONCLUSIONS: Differences in prescribing behavior can be explained only to a small extent by deviations from the guidelines in terms of knowledge and attitudes. Between countries, differences in regulation, marketing, and distribution of drugs seem to be of much greater importance.

Adolescent↗

PubMed2000

Asthma management in five European countries: doctors' knowledge, attitudes and prescribing behaviour. Drug Education Project (DEP) group.

The aim of the study was to examine the relationship between guideline recommendations on asthma management, and the performance of doctors in five different European health care contexts. Knowledge, attitudes and prescribing behaviour of doctors recruited to an educational project was investigated. A total of 698 general practitioners from Germany, The Netherlands, Norway and Sweden, and 94 specialists from the Slovak Republic participated. A questionnaire was used to assess their knowledge and attitudes. Antiasthmatic drugs dispensed to their patients reflected their prescribing behaviour. In response to questions on how to treat chronic asthma, most doctors were in agreement with guideline recommendations. In practice, however, the proportion of asthma patients receiving inhaled steroids varied almost twofold, ranging 31% in Germany to 58% in The Netherlands. On questions related to exacerbation of asthma, German and Slovakian doctors often preferred treatment with antibiotics to steroids. They also more often associated yellow-green sputum with bacterial infection. In conclusion, although many doctors in different health care contexts have accepted the recommendations given in guidelines, the proportion of their patients treated accordingly differed. German and Slovakian doctors seem to attach less importance to the inflammatory features of asthma than the doctors from the other three European countries.

Adolescent↗

PubMed1999

[Chronic polypharmacy in one-third of the elderly in family practice].

OBJECTIVE: Description of the extent and nature of polypharmacy in the elderly in general practice. DESIGN: Retrospective cross-sectional study. METHOD: Medication and morbidity data were collected over July-December 1994 on all 2197 patients > or = 65 years registered in 3 family practices connected with the Medication and Morbidity Registration Network Groningen, the Netherlands. Special attention was paid to the simultaneous use of > or = 2 drugs during > or = 120 days in the study period ('chronic use'). Three categories of polypharmacy were distinguished: mild (2-3 drugs), moderate (4-5) and extensive (> 5). RESULTS: Forty per cent of the study group were males; 54% were 65-74 years, 34% were 75-84 years and 12% were > or = 85 years. The mean number of drugs used was 3.9 per person (SD: 3.6), of which 1.4 (SD: 1.8) chronically. Polypharmacy occurred in 35%: mild in 23%, moderate in 8% and extensive in 4%. All occurred mostly in the group between 75 and 84 years old. Cardiovascular drugs, in particular diuretics, and psycholeptics were mostly prescribed concomitantly with each other and with other drugs. The prevalence of concomitant use of drugs with potential interactions was low (< 3%). The indications for psycholeptic drugs were quite often not clear. Congestive heart failure, chronic obstructive pulmonary disease (COPD)/asthma and diabetes mellitus were mainly responsible for extensive polypharmacy.

Aged↗

PubMed1999

Adverse drug reactions and polypharmacy in the elderly in general practice.

OBJECTIVES: The risk of adverse drug reactions (ADRs) increases with the number of drugs used. Most studies refer to potential interactions; the results regarding the severity of occurring and registered ADRs are inconsistent. Therefore, we examined the relevance of drug-induced problems in the elderly in general practice and their association with polypharmacy. DESIGN: Retrospective cross-sectional analysis of prospectively collected data. SETTING: Three family practices participating in the medication and morbidity Registration Network Groningen (RNG). METHODS: From 2185 elderly patients (>64 years) medication and morbidity data were collected over the period of 2 years (1994 and 1995). Polypharmacy was defined as the long-term simultaneous use of two or more drugs. Adverse reactions recognised as such were coded as a separate 'diagnosis' A85. The most risky drug groups and the most prevalent diseases in relation to ADRs were studied. RESULTS: The incidence of ADRs in general practice was 5.7 per 100 elderly patients and the prevalence 6.1 per 100. Moderate polypharmacy was more frequent in the elderly who experienced adverse effects; no other differences in degree of polypharmacy could be found. The elderly who experienced adverse reactions used overall more different drugs (14.4 +/- 7.6, of which 1.5 +/- 1.5 were used long term) than the other elderly patients (8.1 +/- 5.7, of which 1.0 +/- 1.5 were long term). The incidence of ADRs increased non-significantly with the number of drugs used long term. Antibiotics, antihypertensives and non-steroidal anti-inflammatory drugs were mainly responsible for gastrointestinal complaints (nausea, diarrhoea and stomach pain) and rash. In the cases of treating urinary tract infections and sleeping disorders, there was a significantly high risk of ADRs. Slightly more at risk for adverse drug reactions were older patients with coronary heart disease or asthma/chronic obstructive pulmonary disease. CONCLUSION: Most of the ADRs observed in general practice turn out to be rather harmless. This is in agreement with outpatient studies, though not with hospital studies. An increased risk of adverse effects with the number of drugs used simultaneously, as reported in other studies, was not confirmed in our study. This study however is limited to actually registered effects.

Abdominal Pain↗

PubMed1999

Changing doctor prescribing behaviour.

The aim of this overview was to identify interventions that change doctor prescribing behaviour and to derive conclusions for practice and further research. Relevant studies (indicating prescribing as a behaviour change) were located from a database of studies maintained by the Cochrane Collaboration on Effective Professional Practice. This register is kept up to date by searching the following databases for reports of relevant research: DHSS-DATA; EMBASE; MEDLINE; SIGLE; Resource Database in Continuing Medical Education (1975-1994), along with bibliographies of related topics, hand searching of key journals and personal contact with content area experts. Randomised controlled trials and non-equivalent group designs with pre- and post-intervention measures were included. Outcome measures were those used by the study authors. For each study we determined whether these were positive, negative or inconclusive. Positive studies (+) were those that demonstrated a statistically significant change in the majority of outcomes measured at level of p < or = 0.05 between the intervention and control groups. Negative studies (-) showed a significant change in the opposite direction and inconclusive studies (approximately) showed no significant change compared to control or no overall positive findings. We identified 79 eligible studies which described 96 separate interventions to change prescribing behaviour. Of these interventions, 49 (51%, 41%-61%) showed a positive significant change compared to the control group but interpretation of specific interventions is limited due to wide and overlapping confidence intervals.

Data Collection↗