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Biomedical subjects

J van der Lei

Publications and source records attributed to J van der Lei.

At least 19 recordsLinked to original sources
PubMed1996

Cough due to ACE inhibitors: a case-control study using automated general practice data.

OBJECTIVES: To determine the risk of coughing as an adverse reaction to ACE inhibitors under everyday circumstances in a large population, and to study whether this adverse effect was duration or dose dependent. DESIGN: A population-based case-control study. SETTING: Ten general practices of 14 Dutch general practitioners (GP), in which all consultations, morbidity and medical interventions, including drugs prescribed, were registered over the 18 month period from 1st September, 1992 to 1st March, 1994. SUBJECTS: 1458 patients with incident coughing and up to four controls per case were obtained (total 4182 controls), matched for GP. All cases and controls were 20 years or older and had no record of respiratory infection, influenza, tuberculosis, asthma, chronic bronchitis, emphysema, congestive heart failure, sinusitis, laryngitis, haemoptysis or respiratory neoplasms during the study period. RESULTS: Cases were 2.1-times more likely than controls to have been exposed to ACE inhibitors (95% CI 1.5-3.1), but after adjustment the odds ratio was 1.4 (95% CI 0.9-2.1). The crude odds ratio for captopril was 1.3 (95% CI 0.7-2.5), for enalapril 2.6 (95% CI 1.6-4.2) and for lisinopril 2.0 (95% CI 0.5-9.3). The adjusted odds ratio for captopril was 0.9 (95% CI 0.4-1.7), for enalapril 1.7 (95% CI 1.03-2.8) and for lisinopril 1.7 (95% CI 0.4-7.9). For patients who had been on ACE inhibitor treatment for no longer than 2 months the odds ratio was 4.8 (95% CI 1.7-13.3). The odds ratio declined to 2.0 (95% CI 1.1-3.8) for those who had taken an ACE inhibitor for 2-6 months, and to 1.6 (95% CI 0.9-2.7) for those on ACE-inhibitors for more than 6 months. CONCLUSION: The risk of coughing was increased twofold among ACE inhibitor users, but the odds ratios were no longer significant after controlling for several confounding factors. The risk of developing cough due to ACE-inhibitors declines with the duration of treatment, possibly due to depletion of susceptible persons.

Adult↗
PubMed1995

Laboratory services utilization: a survey of repeat investigations in ambulatory care.

BACKGROUND: Earlier studies have shown that repeat investigations are a common cause of unnecessary duplication of laboratory test procedures. Most of the interventions aimed at reducing the number of repeat investigations have not resulted in long-term improvements. None of these studies, however, assessed utilization of laboratory services by physicians, simultaneously treating the same patient. METHODS: For a random sample of 1500 patients, we examined laboratory services utilization by physicians during an 8-month period. We counted the number of patients for whom more than one physician ordered laboratory test procedures simultaneously, and to what extent these procedures overlapped. RESULTS: For 28% of the patients more than one physician had ordered tests. Of all 41,655 tests, 5536 (13%) were repeated by a physician other than the physician who ordered the initial test: 1527 (4%) of the tests were repeated within 5 days. Patients between 70 and 90 years had the highest average number of tests, the highest number of involved physicians, and the smallest mean time between similar tests. CONCLUSIONS: There is a need for better coordination of care. Improved communication among physicians simultaneously treating a patient may lead to a reduction of repeat investigations.

Adolescent↗
PubMed1995

Postmarketing surveillance with computer-based patient records.

Postmarketing Surveillance (PMS) concerns the investigation of side-effects of drugs after they are introduced into the market. Traditionally, data collection for PMS-studies has been paper-based. The increasing number of general practitioners (GP) that use Computer-Based Patient Records (CBPR) and the central role these general practitioners in the Netherlands play in the delivery of care makes the use of CBPRs as a resource of data for PMS studies possible. Analysis of the current available CBPRs, however, proved them insufficient for PMS studies, because too much data is available only in free text, and other necessary data for PMS is lacking. To make the CBPR suitable for PMS, we had to build a software-module that could be plugged into the computer system of the GP. The module checks the data immediately after they it has been entered into the system, and missing data is requested. Initial filed studies have shown that, with this module, the collection of PMS data is feasible.

Medical Records Systems, Computerized↗
PubMed1995

The separation of reviewing knowledge from medical knowledge.

The developers of reviewing systems that rely on computer-based patient-record systems as a source of data need to model reviewing knowledge and medical knowledge. We simulate how the same medical knowledge could be entered in four different systems: CARE, the Arden syntax, Essential-attending and HyperCritic. We subsequently analyze how the original knowledge is represented in the symbols or syntax used by these systems. We conclude that these systems provide different alternatives in dealing with the vocabulary provided by the computer-based patient records. In addition, the use of computer-based patient records for review poses new challenges for the content of that record: to facilitate review, the reasoning of the physician needs to be captured in addition to the actions of the physician.

Artificial Intelligence↗
PubMed1994

The contents of free-text endoscopy reports: an inventory and evaluation by peers.

Insight into the current status of endoscopy reports is needed for a discussion on the desirability and feasibility of (more) standardized endoscopy reporting. We collected, from ten endoscopists, 181 reports in two diagnostic and two indication categories. An inventory was made of the subjects dealt with in the reports, such as: indication, premedication, therapy plan, and descriptive aspects of ventricular ulcers and lower tract polyps. To assess endoscopists' opinions on their reports, 16 randomly selected reports were reviewed by the ten endoscopists, using the Delphi method. The reports varied enormously in content and detail; 19 of the 28 subjects were not explicitly described in more than 50% of the studied reports. Such variation in the contents of reports may decrease the quality of care. The large number of topics that endoscopists indicate to be missing in their reports (on average 14 topics per report) suggests that more detail should be given in endoscopy reports. The current method of reporting causes endoscopists to omit information that they consider important. Due to the low overall consensus among endoscopists on which specific topics to include (eight or more endoscopists agreed on 15% of topics) we conclude that general criteria for the contents of reports cannot yet be formulated. However, the fact that the endoscopists agreed with more than one-third of the remarks made by colleagues opens a perspective towards identifying criteria for the formalization of certain report categories.

Delphi Technique↗
PubMed1994

A model for structured data entry based on explicit descriptional knowledge.

Clinical narratives in patient records are usually recorded in free text, limiting the use of this information for research, quality assessment, and decision support. This study focuses on the capture of clinical narratives in a structured format by supporting physicans with structured data entry (SDE). We analyzed and made explicit which requirements SDE should meet to be acceptable for the physician on the one hand, and generate unambiguous patient data on the other. Starting from these requirements, we found that in order to support SDE, the knowledge on which it is based needs to be made explicit: we refer to this knowledge as descriptional knowledge. We articulate the nature of this knowledge, and propose a model in which it can be formally represented. The model allows the construction of specific knowledge bases, each representing the knowledge needed to support SDE within a circumscribed domain. Data entry is made possible through a general entry program, of which the behavior is determined by a combination of user input and the content of the applicable domain knowledge base. We clarify how descriptional knowledge is represented, modeled, and used for data entry to achieve SDE, which meets the proposed requirements.

Artificial Intelligence↗
PubMed1994

A standardized message for supporting shared care.

As health care becomes more complex, interest in the benefits of coordination of care has increased. Especially patients that are being treated jointly by more than one physician (shared care), are vulnerable to adverse effects resulting from inadequate coordination and communication. We describe a study in which care providers support shared care by using computer-based patient records for data storage, and structured electronic data interchange as a means of communication. In this study, we are aiming at the development and implementation of protocols for shared care.

Computer Communication Networks↗
PubMed1993

The introduction of computer-based patient records in The Netherlands.

Computer-based patient records, although an area of active research, are not in widespread use. In June 1992, 38% of Dutch general practitioners had introduced computer-based patient records. Of these, 70% had replaced the paper patient record with a computer-based record to retrieve and record clinical data during consultations. Possible reasons for the use of computer-based patient records include the nature of Dutch general practice and the early and active role of professional organizations in recognizing the potential of computer-stored patient records. Professional organizations issued guidelines for information systems in general practice, evaluated available systems, and provided postgraduate training that prepares physicians to use the systems. In addition, professional organizations successfully urged the government to reimburse general practitioners part of the expenses related to the introduction of computer-based patient records. Our experience indicates that physicians are willing and able to integrate information technology in their practices and that professional organizations can play an active role in the introduction of information technology.

Database Management Systems↗
PubMed1993

Response of general practitioners to computer-generated critiques of hypertension therapy.

We recently have shown that a computer system, known as HyperCritic, can successfully audit general practitioners' treatment of hypertension by analyzing computer-based patient records. HyperCritic reviews the electronic medical records and offers unsolicited advice. To determine which unsolicited advice might be perceived as inappropriate, builders of programs such as HyperCritic need insight into providers' responses to computer-generated critique of their patient care. Twenty medical charts, describing in total 243 visits of patients with hypertension, were audited by 8 human reviewers and by the critiquing-system HyperCritic. A panel of 14 general practitioners subsequently judged the relevance of those critiques on a five-point scale ranging from relevant critique to erroneous or harmful critique. The panel judged reviewers' comments to be either relevant or somewhat relevant in 61 to 68% of cases, and either erroneous or possibly erroneous in 15 to 18%; the panel judged HyperCritic's comments to be either relevant or somewhat relevant in 65% of cases, and either erroneous or possibly erroneous in 16%. Comparison of individual members of the panel showed large differences; for example, the portion of HyperCritic's comments judged relevant ranged from 0 to 82%. We conclude that, from the perspective of general practitioners, critiques generated by the critiquing system HyperCritic are perceived equally beneficial as critiques generated by human reviewers. Different general practitioners, however, judge the critiques differently. Before auditing systems based on computer-based patient records that are acceptable to practitioners can be introduced, additional studies are needed to evaluate the reasons a physician may have for judging critiques to be irrelevant, and to evaluate the effect of critiques on physician behavior.

Artificial Intelligence↗
PubMed1992

Electronic communication between providers of primary and secondary care.

OBJECTIVE: To study the effects of the introduction of electronic data interchange between primary and secondary care providers on speed of communication, efficiency of data handling, and satisfaction of general practitioners with communication. DESIGN: Comparison of traditional paper based communication for laboratory reports and admission-discharge reports between hospital and general practitioners and electronic data interchange. SETTING: Twenty-seven general practitioners whose offices were equipped with a practice information system and two general hospitals. OUTCOME MEASURES: Paper based communication was evaluated by questionnaire responses from and interviews with care providers; electronic communication was evaluated by measuring time intervals between generation and delivery of messages and by assessing doctors' satisfaction with electronic data interchange by questionnaire. RESULTS: Via paper mail admission-discharge reports took a median of 2-4 days, and laboratory reports 2 days, to reach general practitioners. With electronic data interchange almost all admission-discharge reports were available to general practitioners within one hour of generation. When samples were analysed on the day of collection (as was the case for 174/542 samples in one hospital and 443/854 in the other) the laboratory reports were also available to the general practitioner the same day via electronic data interchange. Fifteen general practitioners (of the 24 who returned the questionnaire) reported that the use of electronic admission-discharge reports provided more accurate and complete information about the care delivered to their patients. Ten general practitioners reported that electronic laboratory reports lessened the work of processing the data. CONCLUSION: Electronic communication between primary and secondary care providers is a feasible option for improving communication.

Communication↗
PubMed1992

Towards unambiguous representation of patient data.

In the early eighties, the goal set for the development of computer-based patient records was the creation of patient records that were analogous to the paper record. In the Netherlands, where the number of physicians using computer-based patient records is steadily increasing, this strategy has been proven successful. Although these "paper-like" computer-based patient records were suitable for patient care, they were much less suited for other purposes. Experiments showed that the use of data for other purposes than those for which they were recorded, can only be performed reliably when these data permit unambiguous interpretation. Due to a physician's limited time there is a constant tension between benefit and effort. Therefore, we should not expect the physician to provide the large amount of additional information, required for unambiguous interpretation of his record. Many of the inferences made by physicians are based on general knowledge and do not require specific, patient related information. We have focused our research on the potential of using knowledge about concepts in the patient record, to infer information, that is implicit in the patient data. The paper discusses considerations with respect to possible strategies to elicit a maximum of information with a minimum of effort from the physician.

Forms and Records Control↗
PubMed1991

Comparison of computer-aided and human review of general practitioners' management of hypertension.

Computer programs that automatically review decisions can help physicians provide better patient care. In the Netherlands, the ELIAS computer information system has replaced paper medical records in some general practices. We have written a computer program called 'HyperCritic' that audits general practitioners' management of patients with essential hypertension by taking patient-specific data from the ELIAS system. We investigated whether the computer-based medical records contain sufficient information to generate critiques, and compared the limitations of audit by hypercritic with those of review by a panel of eight physicians. Hypercritic and the physicians independently reviewed the medical records of 20 randomly selected patients with hypertension and commented on the decisions made at each of 243 patient visits. Of 468 comments on patient management, 260 were judged correct by six or more of the physicians; hypercritic also made 118 of these 260 comments. The main reasons why the program did not produce the other 142 comments were: insufficient data in the computer-based medical record; absence of sufficient medical consensus; and omissions in the database of hypercritic. Calculation of an "index of merit" ([sensitivity + specificity] - 1) for individual reviewers showed that hypercritic performed better (index of merit 0.62) in its limited domain than did physician reviewers (0.3-0.56). At least in hypertension management, automated review of computer-based medical records compares favourably with review by physicians. Further development of computer-aided clinical audit requires the introduction of computer-based medical records that capture the reasoning of physicians, and of widely accepted practice guidelines.

Adult↗
PubMed1991

A model for critiquing based on automated medical records.

We describe the design of a critiquing system, HyperCritic, that relies on automated medical records for its data input. The purpose of the system is to advise general practitioners who are treating patients who have hypertension. HyperCritic has access to the data stored in a primary-care information system that supports a fully automated medical record. Hyper-Critic relies on data in the automated medical record to critique the management of hypertensive patients, avoiding a consultation-style interaction with the user. The first step in the critiquing process involves the interpretation of the medical record in an attempt to discover the physician's actions and decisions. After detecting the relevant events in the medical record, HyperCritic views the task of critiquing as the assignment of critiquing statements to these patient-specific events. Critiquing statements are defined as recommendations involving one or more suggestions for possible modifications in the actions of the physician. The core of the model underlying HyperCritic is that the process of generating the critiquing statements is viewed as the application of a limited set of abstract critiquing tasks. We distinguish four categories of critiquing tasks: preparation tasks, selection tasks, monitoring tasks, and responding tasks. The execution of these critiquing tasks requires specific medical factual knowledge. This factual knowledge is separated from the critiquing tasks and is stored in a medical fact base. The principal advantage demonstrated by HyperCritic is the adaption of a domain-independent critiquing structure. We show how this domain-independent critiquing structure can be used to facilitate knowledge acquisition and maintenance of the system.

Artificial Intelligence↗
PubMed1991

Understanding differential diagnostic disagreement in pathology.

The Diagnostic Encyclopedia Workstation (DEW) was developed to support pathologists in diagnosing ovarian tumors. In this evaluation study, we had pathologists at several levels of experience diagnose a number of cases using either books or the DEW. In the context of this study, we needed a standard by which to measure performance of these pathologists. We, therefore, had experts enumerate for each test case the diagnoses they considered morphologically similar. To our surprise, the resulting lists of the experts varied considerably. The differential diagnosis of a disease based on its morphological characteristics, however, constitutes important reference knowledge in solving diagnostic problems. The question rose why the experts differed so much in their differential diagnostic knowledge. The ontogeny of a pathologist's personal knowledge is discussed and used to derive a model that can explain the limited consensus in differential diagnosis. The model helps to identify factors that may cause pathologists to diverge and others that may cause them to converge with respect to their knowledge. Strategies are proposed that are useful in achieving a better (differential) diagnostic consensus.

Diagnosis, Computer-Assisted↗
PubMed1990

Incidence and duration of total occlusion of the radial artery in newborn infants after catheter removal.

The incidence and duration of total occlusion of the radial artery after catheter removal was determined using repeated Doppler flow measurements. Thirty-two newborn infants with birthweights ranging from 945 g to 3890 g (median 1935 g) and gestational age ranging from 26 to 40 weeks (median 32 weeks) were studied. In 20 out of 32 infants (63%), complete occlusion of the radial artery occurred. The number of occlusions were not related to birthweight, gestational age or duration of cannulation. In all infants, blood flow in the radial artery resumed within 1-29 days after catheter removal. The duration of occlusion was directly related to the duration of cannulation and inversely related to birthweight. This study demonstrates a high frequency of total occlusion of the radial artery in newborn infants after percutaneous radial artery cannulation. In the majority of infants with a radial artery catheter, blood flow to the tissue distal to the cannulation site is dependent solely on the existence of an adequate arterial palmar collateral circulation.

Arm↗
PubMed1990

Ocular examination in nine-month-old infants with very low birthweights.

In the period 1980-1987 ocular examinations were performed on 185 infants with a very low birthweight (less than 1500 g) at the age of nine months corrected for the duration of pregnancy. The mean gestational age of the infants was 30 weeks, while the mean birthweight was 1160 g. The mean spherical refraction was 0.9 D (S.D. 1.3 D), the mean astigmatism was C-0.6 D (S.D. 1.0 D), while convergent strabismus was found in 10% of the patients. The purpose of the investigation was to see if there was a relation between spherical equivalent of refraction, astigmatism and strabismus on the one hand and 11 perinatal parameters and cerebral palsy diagnosed at the age of nine months on the other hand. Statistical analysis was performed with the Student t-test. No significant correlation between the findings of ocular examination and the perinatal parameters could be detected.

Aging↗