Biomedical subjects

P J van der Maas

Publications and source records attributed to P J van der Maas.

At least 19 recordsLinked to original sources

PubMed2006

[Trends in the agents used for euthanasia and the relationship with the number of notifications].

OBJECTIVE: To provide insight into the relationship between the drugs used for euthanasia and its notification. DESIGN: Retrospective and descriptive. METHODS: By comparing the drugs used for euthanasia according to different components of studies carried out in 1990, 1995 and 2000, insight was obtained into the drugs used in all cases of euthanasia satisfying the definition thereof (death-certificate studies), those cases of euthanasia that, in addition, were defined as such by the physician (physician interviews), and the cases of euthanasia that, in addition, had been reported (reported case studies). RESULTS: In 2001, standard drugs for euthanasia were used in 76% of cases and opioids in 23%. Euthanasia with standard drugs was reported in 73% of cases in 1995, and in 71% of cases in 2000, while euthanasia with opioids was reported in 2% and 1% of cases, respectively. The total percentage of euthanasia reported was higher in 2001 than in 1995 (54% versus 44%), since in 2001 euthanasia was apparently performed more often with standard drugs and less with opioids. CONCLUSION: An increasing proportion of cases of euthanasia is being carried out with the drugs recommended for this purpose. Euthanasia with opioids was rarely reported. Possibly, physicians did not always consider these cases to be euthanasia.

Barbiturates↗

PubMed2005

[Fourth evaluation of the law on the review of termination of life on request and assisted suicide (Euthanasia Act)].

This fall, an extensive study will start to evaluate the Dutch Euthanasia Act. This law was enacted in 2002. According to this law, physicians must report cases of euthanasia and physician-assisted suicide. The cases are then judged by regional euthanasia review committees consisting of a lawyer, a physician and an ethicist. Only if they conclude that the case does not meet the requirements for prudent practice, it will be sent to the public prosecutor. The study will be focused on the practice of medical end-of-life decision-making, the functioning and effects of the Euthanasia Act, and opinions of physicians about the scope of the law and the demarcation between different end-of-life decisions. The study will comprise 4 sub-studies: a judicial evaluation, a death certificate study, a survey among physicians and a panel study among physicians, nurses, members of euthanasia review committees, lawyers and ethicists. This study is the fourth in a row of nationwide studies into end-of-life practices that have been performed since 1990. The previous studies contributed to the public debate about medical care at the end of life and to the development of policy in this field. It is expected that this study, by providing up-to-date information on and insight into end-of-life care in the Netherlands, will do the same.

Attitude to Health↗

PubMed2005

[No conspicuous changes in the practice of medical end-of-life decision-making for neonates and infants in the Netherlands in 2001 as compared to 1995].

OBJECTIVE: To establish whether the practice of end-of-life decision-making for neonates and infants under the age of 1 in the Netherlands in 2000 was different from that in 1995. DESIGN: Retrospective descriptive and comparative study. METHODS: In both years, all deaths of children under the age of one year that took place in August-November (1995: n = 338; 2001: n = 347) were studied. The response rate was 96% in 1995 and 84% in 2001. The questionnaires which were sent to the physicians who reported the deaths, included structured questions about whether or not death had been preceded by end-of-life decisions, i.e. decisions to withhold or withdraw potentially life-prolonging treatment or to administer (potentially) life-shortening drugs, and questions about the decision-making process. RESULTS: The proportion of end-of-life decisions increased slightly from 62% to 68% of all deaths in the first year of life, but the difference was not statistically significant. The large majority of these decisions involved withholding or withdrawing life-sustaining treatment. The frequency of decisions to actively terminate the life of an infant who was not dependent on life-sustaining treatment remained stable at 1%. The proportion of decisions that had been discussed with the parents increased slightly, from 91% in 1995 to 97% in 2001; similar percentages of the decisions had been discussed with other physicians. The percentage of decisions that had been discussed with the nursing staff decreased from 40 in 1995 to 28 in 2001. CONCLUSION: The findings suggest that the practice of end-of-life decision-making in neonatology was rather stable between 1995 and 2001. The frequency of the active termination of life had not increased, despite the new euthanasia regulation in the Netherlands.

Attitude of Health Personnel↗

PubMed2005

Positive and negative affect after diagnosis of advanced cancer.

Anxiety and depression are studied thoroughly in patients with advanced cancer. However, little is known about the nature of mood disorders in this stage of the disease. We studied positive and negative affect in patients who have had a diagnosis of advanced cancer, and examined how these are related to anxiety and depression, and to other patient and care factors. One hundred and five patients filled out a written questionnaire and were interviewed personally. The PANAS positive affect scores were lower than those in the general population, but the negative affect scores were fairly similar. We found a rather low prevalence of depression (13%) and anxiety (8%) as measured by the HADS. The emotional problems patients mentioned most frequently were anxiety about metastases (26%), the unpredictability of the future (18%) and anxiety about physical suffering (15%). Both positive and negative affect were most strongly related to patient's sense of meaning and peace. We conclude that distinguishing positive and negative affect enhances the understanding of psychological distress of patients with advanced cancer, that seems to be mainly caused by low levels of positive affect. Several theories are discussed to explain this finding, that may contribute to efforts to improve care for these patients.

Adaptation, Psychological↗

PubMed2004

Medical decision making in scarcity situations.

The issue of the allocation of resources in health care is here to stay. The goal of this study was to explore the views of physicians on several topics that have arisen in the debate on the allocation of scarce resources and to compare these with the views of policy makers. We asked physicians (oncologists, cardiologists, and nursing home physicians) and policy makers to participate in an interview about their practices and opinions concerning factors playing a role in decision making for patients in different age groups. Both physicians and policy makers recognised allocation decisions as part of their reality. One of the strong general opinions of both physicians and policy makers was the rejection of age discrimination. Making allocation decisions as such seemed to be regarded as a foreign entity to the practice of medicine. In spite of the reluctance to make allocation decisions, physicians sometimes do. This would seem to be only acceptable if it is justified in terms of the best interests of the patient from whom treatment is withheld.

Adult↗

PubMed2004

A cluster-randomised trial of screening for language disorders in toddlers.

OBJECTIVE: To assess the screening performance of a specific language-screening instrument at 18 and 24 months of age and to assess its effect on the early detection and prognosis of language delay. DESIGN: Child health care physicians were randomised to the intervention group, in which specific language screening was conducted twice (at age 18 months and 24 months), or to the control group (usual care). The specific screening instrument consisted of a uniform set of questions for the parents and test elements for the child, with scaled scores to assess responses. SETTING: Child health care in the Netherlands and referral of screen-positive children. SUBJECTS: 5734 children in the intervention group and 4621 in the control group. MAIN OUTCOME MEASURES: Test characteristics and disorders at 24 months, and confirmed diagnoses of a language disorder before 36 months in both groups. Gold standard based on reports of parents, specialists and expert panel. Prognosis estimated from two diagnostic language development performance scores at 36 months (in questionnaire). RESULTS: In the intervention group, 3147 of the 5734 children (55%) were screened with the specific screening instrument and 73 of the screened children (2.3%) were screen-positive. Of the screen-positive children, 41 (55%) had confirmed language delay (diagnostic assessment and/or reported treatment). The estimated sensitivity of the test ranged between 24-52% depending on the severity of language disorders. The prevalence of language disorders in three-year olds was estimated to be 2.4-5.3%. In the intervention group, 1.25-2 times more children with language delay had been diagnosed before 36 months. The assessment of language development at 36 months showed no statistically significant differences between the intervention and the control groups. CONCLUSIONS: The inclusion of a specific language-screening instrument in child health centre activities resulted in the earlier detection of children with language delay. Short-term health benefits could not be demonstrated. Large-scale introduction cannot be recommended on the basis of this information alone.

Case-Control Studies↗

PubMed2002

[Centenary of the Health Council of the Netherlands. II 'Public health'].

In its 100-year existence (1902/2002), the Health Council has played an important role in the introduction of effective measures in the area of public health and in doing so has made a significant contribution to improving health in the Netherlands. Successes have been achieved in vaccinations (from before 1900 to about 1985), infectious-diseases control (since about 1900), safety at work (since about 1900), healthier mothers and babies (since about 1900) and safer and healthier food (since 1920). Success factors in implementing an advisory report are the extent to which political support is forthcoming, the evidence on which the advisory report is based, the economic consequences of implementing the advisory report, the ethical implications and the extent to which social and/or scientific developments provide a basis for the advisory report.

Financing, Government↗

PubMed2002

[Idiopathic scoliosis in adolescents; an inventory into the possibilities of studying the efficacy of screening and treatment].

OBJECTIVE: To collect information for the purpose of establishing starting points and possibilities for a cost-effectiveness analysis of screening for adolescent idiopathic scoliosis (AIS). DESIGN: Interviews, literature review, questionnaires, an estimation of costs and discussions with experts and involved parties. METHOD: Following an initial interview with 16 orthopaedic surgeons and school doctors a literature study into the efficacy of treatment was carried out regarding the years 1989-1999. The variation in current practice was delineated by means of a questionnaire sent to all 51 municipal health services in the Netherlands. The costs of screening and treatment were estimated on the basis of health insurance premiums and a municipal health service cost model. All of the results were presented to five methodological experts and finally the study results and the recommendations of the five methodological experts were evaluated during a meeting of persons especially invited for this purpose. RESULTS: Screening for AIS was established to realise early diagnosis and treatment with a brace, so as to reduce unsatisfactory cosmetic outcomes and the need for surgery. Screening was performed using the bending test and was performed in 40/48 (83%) of the participating municipal health services. The overall costs of screening and treatment amount to 6 million euros per year. There was no convincing evidence that the screening programme was sufficiently sensitive and bracing sufficiently effective. Neither was there proof of the opposite. The following was recommended: obtain reliable data by carrying out a randomised controlled trial on the effectiveness of treating AIS with bracing in an early stage; carry out a case-control study combined with a retrospective patient follow-up study to evaluate the current screening practice; draw up a national standard for the screening of postural disorders in youth healthcare to ensure effective practice.

Adolescent↗

PubMed2002

[The scientific basis for population screening for breast cancer in the Netherlands].

A recent Cochrane review stated that there was a lack of evidence for a decrease in mortality as a result of population breast-cancer screening. The principal data were drawn from five Swedish randomized controlled trials and one Canadian trial. However, the studies cannot be so easily combined because there were important differences in the attendance rate, detection rate, technical quality, referral rate, clinical baseline situation and screening interval. For example, in one of the studies the women from the control arm underwent an annual clinical palpation carried out by a trained nurse or physician, which could have led to an underestimation of the screening effect. Further breast-cancer mortality might not be a good outcome measure because this was not reliably determined; only total mortality was to be observed. This is clinically and methodologically incorrect because breast-cancer mortality was meticulously studied, documented and validated. In the Cochrane review it is suggested that the randomisation was inadequate, but evidence for this was not supplied. The discussion about age differences as a marker for incorrect randomisation is out of date and has been revealed to be unjust. It seems likely that an important part of the decreasing trend in breast-cancer mortality in several countries (including the Netherlands) is due to screening programmes. However, the evaluation of breast-cancer mortality over the next five years is crucial, if greater certainty is to be gained about this.

Breast Neoplasms↗

PubMed2002

[Arguments for offering triple test serum screening for Down's syndrome to all pregnant women].

In an advisory report to the Dutch Government, the Health Council of the Netherlands has recently recommended offering triple test serum screening for Down's syndrome to all pregnant women. According to a critical review in this journal, the Council should have proposed excluding those less than 30 years of age. However, there is no age at which a logical limit can be set. Moreover, to suggest that the negative aspects of the screening will prevail for those under a specific age, denies the women involved the right to make a judgment based on their own values and preferences. Secondly, although limited resources may be a reason for limiting access to screening, doing so would be a politico-ethical decision, which raises the issue of justice. Finally, there are reasons for thinking that a new age limit would complicate the necessary counselling as opposed to making it easier.

Adult↗

PubMed2002

Healthcare costs of intellectual disability in the Netherlands: a cost-of-illness perspective.

Healthcare costs are continuously increasing, and impose a strong responsibility on governments for an adequate allocation of resources among healthcare provisions and patients. The aims of the present study were to describe the healthcare costs of intellectual disability (ID) and other mental disorders in the context of the total costs of all other diseases, and to determinate the future need of healthcare resources, especially for ID and mental disorders. The present authors performed a top-down cost-of-illness study comprising all healthcare costs of the Netherlands in 1994. Data on healthcare use were obtained for all 22 healthcare sectors, and used to ascribe costs to disease groups, age and sex. Costs of mental disorders are by far the largest in the Dutch healthcare system. Some 25.8% of total disease-specific costs could be ascribed to mental disorders: psychiatric conditions, 10.6%; ID, 9.0%; and dementia, 6.2%. There are large differences between age and sex groups. The costs of ID and schizophrenia are higher among men, and the costs of dementia and depression are higher among women. The age pattern shows two peaks: the first occurs at 25-35 years of age (ID and psychiatric conditions); and the second at 75-85 years of age (dementia). Time trends between 1988 and 1994 show an average annual growth rate of 5.2% for total healthcare costs: psychiatric conditions, 4.8%; ID, 5.4%; and dementia, 9.4%. Demographic projections suggest a less-than-average cost increase for ID and psychiatric disorders (with annual growth rates of 0.2% and 0.4%, respectively) compared to the costs of dementia and total healthcare (with annual growth rates of 1.6% and 0.9%, respectively). Intellectual disability and mental disorders represent a large part of healthcare use in the Netherlands. The costs will inevitably increase because of the ageing of the population and increasing life expectancy among people with disabilities. Non-specific cost containment measures may endanger the quality of care for vulnerable people at younger and older ages.

Adult↗

PubMed2001

The emotional impact on physicians of hastening the death of a patient.

OBJECTIVE: To investigate the emotional feelings reported by physicians in The Netherlands after having performed euthanasia or other medical end-of-life decisions. DESIGN: Nationwide interview study in The Netherlands, November 1995 through February 1996. PARTICIPANTS AND SETTING: A random sample of 405 physicians (general practitioners, nursing home physicians, and clinical specialists). MAIN OUTCOME MEASURES: Subsequent feelings of physicians about their most recent cases (if any) of euthanasia, assisted suicide, life-ending without an explicit request from the patient, and alleviation of pain and other symptoms with high doses of opioids. RESULTS: The response rate was 89%. In 52% of all cases of hastening death, physicians had feelings of comfort afterwards, which included feelings of satisfaction in 44% and of relief in 13%. Feelings of discomfort were reported in 42%, most frequently referred to as emotional (28%) or burdensome (25%). Feelings of discomfort were highest for euthanasia (75%; P<0.000). 95% of physicians were willing to perform euthanasia or assisted suicide again in similar situations. Afterwards, 5% had doubts, but none had regrets, about performing euthanasia. CONCLUSIONS: Hastening the death of a patient evokes different feelings among physicians. Although performing euthanasia is often experienced as burdensome and emotional, granting the ultimate wish of a competent patient may also give physicians a feeling of having contributed to the quality of the dying process.

Adaptation, Psychological↗

PubMed2001

[New research on the practice, reporting and reviewing of euthanasia and other medical end-of-life decisions, 2001/2002].

In the second half of 2001, an extensive study will start which will evaluate the review procedure for euthanasia in the Netherlands. Since the end of 1998, euthanasia has to be reviewed by regional review committees, which include a physician and an ethicist, in addition to a legal expert. The aim of this study is to examine whether the reporting procedure meets the aim and whether there are any points which require improvement. This study follows on from those carried out in 1990/1991 and 1995/1996, which investigated euthanasia and other medical end-of-life decisions (assisted suicide, termination of life without the patient's explicit request, treatment of pain and symptoms with a possible life-shortening effect, and forgoing potentially life-prolonging treatment). The study consists of an analysis of cases of death (in which the numbers and nature of various medical end-of-life decisions will be established), physician interviews (to gain insight into the context in which medical end-of-life decisions are made), a study of reported cases (to give an overview of doctors' experiences with the review committees), and a study carried out amongst the general public (around 1,500 Dutch adults will be given a written questionnaire about their opinions concerning medical end-of-life decisions and the reporting procedure). In addition to this Dutch study, a European study subsidized by the European Commission is being carried out which will examine attitudes and experiences regarding medical end-of-life decisions in six European countries (Belgium, Denmark, Italy, the Netherlands, Sweden and Switzerland). This will, for the first time, enable a true comparison to be made between the Netherlands and other countries in terms of euthanasia and other medical end-of-life decisions.

Adult↗

PubMed2001

Health-related quality-of-life effects of radical prostatectomy and primary radiotherapy for screen-detected or clinically diagnosed localized prostate cancer.

PURPOSE: The current study was undertaken within the framework of a screening trial to compare the health-related quality-of-life (HRQOL) outcomes of two primary treatment modalities for localized prostate cancer: radical prostatectomy and external-beam radiotherapy. PATIENTS AND METHODS: We conducted a prospective longitudinal cohort study among 278 patients with early screen-detected (59%) or clinically diagnosed (41%) prostate cancer using both generic and disease-specific HRQOL measures (SF-36, UCLA Prostate Cancer Index [urinary and bowel modules] and items relating to sexual functioning) at three points in time: t1 (baseline), t2 (6 months later), and t3 (12 months after t1). RESULTS: Questionnaires were completed by 88% to 93% of all initially enrolled patients. Patients referred for primary radiotherapy were significantly older than prostatectomy patients (63 v 68 years, P <.01). Analyses (adjusted for age and pretreatment level of functioning) revealed poorer levels of generic HRQOL after radiotherapy. Prostatectomy patients reported significantly higher (P <.01) posttreatment incidences of urinary incontinence (39% to 49%) and erectile dysfunction (80% to 91%) than radiotherapy patients (respectively, 6% to 7% and 41% to 55%). Bowel problems (urgency) affected 30% to 35% of the radiotherapy group versus 6% to 7% of the prostatectomy group (P <.01). Patients with screen-detected and clinically diagnosed cancer reported similar posttreatment HRQOL. CONCLUSION: Prostatectomy and radiotherapy differed in the type of HRQOL impairment. Because the HRQOL effects may be valued differently at the individual level, patients should be made fully aware of the potential benefits and adverse consequences of therapies for early prostate cancer. Differences in posttreatment HRQOL were not related to the method of cancer detection.

Aged↗

PubMed2001

Health-related quality of life in patients with screen-detected versus clinically diagnosed prostate cancer preceding primary treatment.

BACKGROUND: The purpose of this study was to evaluate baseline health-related quality of life (HRQOL) in patients with localized prostate cancer before primary treatment (radical prostatectomy or radiotherapy). METHODS: Two hundred patients with newly diagnosed localized (screen-detected or clinically diagnosed) prostate cancer completed HRQOL questionnaires (generic and disease-specific measures). Clinical data were collected from patients' medical records in four Rotterdam hospitals. RESULTS: Screen-detected tumors were of more favorable stages and grades than clinically diagnosed ones. The diagnostic groups did not differ significantly in bowel and sexual functioning. Differences were found in urinary functioning, favoring patients with screen-detected tumors of T2-T3 stages. Patients with screen-detected T2 cancer reported better generic HRQOL (physical aspects) than the clinical group, but HRQOL of the latter group was similar to the population norm. Radiotherapy patients were significantly older and had more comorbidity than subjects referred to prostatectomy. Urinary, bowel, and sexual problems were uncommon. Older (> 65 years) radiotherapy patients appeared to be less sexually active. Radiotherapy patients also reported poorer levels of generic HRQOL. CONCLUSIONS: Screen-detected prostate cancer patients presented with more favorable cancer stage and grade. HRQOL was related to both the tumor stage and the detection method. Pre-treatment HRQOL differences between prostatectomy and radiotherapy patients were associated neither with tumor characteristics nor with the detection method. Baseline differences in HRQOL should be taken into account when evaluating post-treatment HRQOL.

Age Factors↗

PubMed2001

Nationwide breast cancer screening programme fully implemented in The Netherlands.

The period 1990-1997 saw the implementation of a nationwide breast cancer screening programme in the Netherlands, which provided biennial mammography for all women aged 50-69 years (50-75 years at present). The National Evaluation Team monitors the programme annually collecting regional data on screening outcomes; regional cancer registries provide data on interval cancers and on breast cancers in unscreened women by linkage of cancer registry data to data on screened women. Of 4 million women invited, 78.5% attended for screening. Screening resulted in 13.1 referrals, 9.2 biopsies and 6.1 breast cancers detected per 1000 women screened initially (6.9, 4.5 and 3.5 per 1000 in subsequently screened women, respectively). Within the first 2 years following screening 0.95 interval cancers per 1000 women-years were diagnosed. The stage distribution of screen-detected cancers was more favourable than that of interval cancers and of those diagnosed in unscreened women. The results are largely consistent with expectations. Results may nonetheless be further improved, particularly the detection rate in subsequent screens.

Journal Article↗

PubMed2001

Breast cancer screening programme in The Netherlands: an interim review.

The year 1988 saw the introduction of a nationwide breast cancer screening programme in the Netherlands. Some 10 years on, a network that extended throughout the country was in place and all women in the target group had been invited to undergo screening at least once. Of the original target group, which was made up of women aged 50-70, around 80% responded to this invitation, an indication of their trust. Is that trust justified? and do the results justify the enormous effort of all those who make the screening programme possible, the cooperation of the nearly 4 million women who by now have taken part and the 17 million pound sterling that are currently needed per year to fund the programme? The time has come to assess and review. The ultimate test is obviously whether women participating in the screening programme have a lower chance of dying of breast cancer than women not participating in the programme. Yet, as the breast cancer screening programme is one of the best documented facilities in the Dutch health care system, a reliable mid-term review can be made. The article by Fracheboud that appears in this issue provides a number of important results. Important elements of this programme are considered in this review.

Comment↗

PubMed2001

Patient follow up screening evaluations. Examples with regard to congenital hip dislocation and congenital heart disease.

OBJECTIVE: To discuss the merits of the patient follow up study design for the evaluation of some specific mass screening programmes. DESIGN: Theoretical evaluation illustrated by two examples. SETTING: Department of Public Health Erasmus University Rotterdam. MAIN RESULTS: The gold standard for evaluation of favourable effects of screening is the randomised controlled trial (RCT). Application of an RCT, however, is often not feasible, in which cases observational studies will have to be relied on. The case-control study design is generally considered to be second best. In some situations, however, a patient follow up study design may be applicable and may have some major advantages. The use of the patient follow up design for screening evaluation will often be very problematic or even unacceptable, particularly as far as screening for cancer is concerned. The most important objections are resulting from lead time bias, length bias, selection bias and over-treatment bias. For the evaluation of screening for congenital heart disease and congenital hip dislocation in Dutch child health care, however, these objections may relatively simply be overcome. Lead time bias will be of little importance, as the ages of onset of these disorders are fixed, namely at birth, and their ultimate outcomes may be expected within relatively short time. Length bias may largely be avoided by correction for severity of the disorder, which can be adequately assessed by modern diagnostic procedures. Selection bias is generally hard to rule out, but in these cases it probably plays a minor part. Over-treatment can be avoided by the policy of "watchful waiting", which in these disorders can be applied with little risk for fatal outcomes. In principle bias might be avoided more successfully in a case-control screening evaluation than in a patient follow up study. However, the patient follow up study is for both screening programmes discussed here the more feasible design and can provide more supplementary information. The results of two example studies suggest that both screenings probably yield considerable benefits CONCLUSION: Under a number of specific conditions a patient follow up study is an efficient alternative to more customary designs for screening evaluation.

Child↗