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Biomedical subjects

P Pop

Publications and source records attributed to P Pop.

At least 19 recordsLinked to original sources
PubMed2001

Validation of a knowledge based reminder system for diagnostic test ordering in general practice.

We describe the validation of a real-time automated reminder system that assists General Practitioners (GP) in appropriate test ordering. We compared the comments of human experts with the comments of the reminder system using a retrospective random selection of 253 request forms. A panel of three expert physicians judged the requested tests independently based on their interpretations of the practice guidelines. The majority assessment of the physicians was compared with the assessment of the reminder system. In case the system's output differed from the majority assessment the written practice guidelines were consulted. On average 1.75 reminders were produced per form. In total 32 of the 442 given reminders (7%) were given incorrectly. The amount of information and the level of detail (the specificity of the terms) in which the GP describes the patients' medical status are crucial for the reminder system to react correctly.

Adult↗
PubMed2001

Reliability of the assessment of appropriateness of diagnostic test request behavior.

We describe the reliability of the assessment of the appropriateness of requested diagnostic tests. We used a retrospective random selection of 253 request forms with in total 1217 requested tests. Three experts made an independent assessment of each requested test. Interrater kappa values ranged from 0.33 to 0.44. The kappa values of intrarater agreement ranged from 0.65 to 0.68. The reliability coefficient for all three reviewers was 0.66. This reliability is not sufficient to make case-by-case decisions, for example to give individual feedback on the appropriateness of requested tests. Sixteen reviewers are necessary to obtain a reference with a reliability of 0.95.

Decision Support Systems, Clinical↗
PubMed2000

Assessing the necessity of hospital stay by means of the appropriateness evaluation protocol: how strong is the evidence to proceed?

OBJECTIVE: To review the Appropriateness Evaluation Protocol (AEP) with respect to assessing the necessity of hospital stay at the University Hospital of Maastricht. DESIGN: Literature search in Medline focusing on the validity, reliability and possibilities for intervention plus a description and the first results of pilot studies with a Dutch version of the Adult-Medical AEP (days of stay). SETTING: The University Hospital of Maastricht, a 700-bed university and regional hospital in the south of The Netherlands. MAIN OUTCOME MEASURES: Face, content, and convergent validity, and reliability in terms of overall or specific agreement and by kappa, of the Adult-Medical AEP when used by physicians and nurses. RESULTS: In comparison with other instruments, a comparatively good performance by the AEP has been reported in the literature. Literature review revealed limitations in the AEP as a general and truly valid and reliable instrument for assessing the necessity of hospital stay. In applying a Dutch version (azM-AEP) similar difficulties were encountered. CONCLUSION: Based on the literature review and our own findings, we conclude that the validity and reliability of the different versions of the AEP are not yet up to standard. Regarding the results of the interventions thus far, we do not encourage further use until additional improvements to both the instrument and the review conditions have been made. Perhaps a more disease-specific modulation and assessments based on computerized medical records could improve its applicability in clinical practice in general.

Adult↗
PubMed2000

Comparing assessment of appropriateness of diagnostic tests between a human expert and an automated reminder system.

This paper describes the validation of the GRIF automated reminder system. The reminder system has been developed to influence diagnostic test ordering of General Practitioners (GPs). It generates critical comments on the basis of accepted guidelines. A retrospective random selection of 253 request forms has been taken. We compared the comments of a human expert to the comments of the reminder system. A panel of two independent reviewers judged the requested tests based on the strict interpretation of the guidelines. The sensitivity, specificity and 'predictive values' of the comments of the reminder system and the human expert were calculated using the judgement of the two reviewers as 'gold standard'.

Artificial Intelligence↗
PubMed1999

A rational request behavior: the development of prediction instruments regarding thyroid function tests in primary care.

A prospective study was performed to encourage a rational thyroid-stimulating hormone (TSH) test request behavior of physicians, using prediction instruments. The latter give direct feedback about request adequacy on the basis of pretest probabilities of hyperthyroidism using patients' signs and symptoms. For instrument design, stepwise logistic regression was used on diagnostic data acquired through questionnaires, answered by 80 physicians and 668 patients for whom physicians requested a TSH test. Instruments were designed for clinical and subclinical hyperthyroidism and for clinical hyperthyroidism alone. Use of the instrument for clinical or subclinical hyperthyroidism on the selected group, at a 5% probability threshold, can result in a 37% reduction of unnecessary TSH test requests. With the instrument for clinical hyperthyroidism at a 5% probability threshold, the number of unnecessary test requests can be reduced by 57%. Therefore, it can be concluded that the instruments can determine TSH test request adequacy and encourage a rational TSH test request behavior of physicians at low pretest probability thresholds.

Adolescent↗
PubMed1998

High incidence of inflammatory bowel disease in The Netherlands: results of a prospective study. The South Limburg IBD Study Group.

PURPOSE: To gain recent epidemiologic information about inflammatory bowel disease in The Netherlands, a prospective study over four years (1991-1995) was performed. METHODS: The incidence of inflammatory bowel disease and its subgroups was examined using standardized reports of newly diagnosed patients. A separate study compared the Inflammatory Bowel Disease Registration and computerized diagnostic files of a subgroup of general practitioners with the aim of estimating completeness of case ascertainment. RESULTS: The following mean incidence rates (per 100,000 inhabitants and year) were found: 6.9 (95 percent confidence interval, 5.9-7.9) for Crohn's disease, 10 (95 percent confidence interval, 8.7-11.2) for ulcerative colitis (23 percent of these with ulcerative proctitis), and 1.1 (95 percent confidence interval, 0.7-1.5) for indeterminate colitis. In the age category 20 to 29 years, the incidence rate of Crohn's disease with small-bowel involvement was higher in females than in males. In extended ulcerative colitis, a male preponderance was observed in the older age groups. Estimated case ascertainment was 78 percent. CONCLUSIONS: Compared with recent studies in neighboring countries, the observed age and gender standardized incidence rates are high in the south of The Netherlands. Completeness of case ascertainment might have contributed to this observation; however, case ascertainment was low in ulcerative proctitis. In the study area, differences in age and gender standardized incidence rates and in disease localizations could be compatible with an influence of environmental risk factors.

Adolescent↗
PubMed1998

Computer-based assistance in family medicine.

In this paper, the fully integrated General Practitioner (GP) Information and Research System HIOS and Decision Support System HIOS+ are described. Both systems were developed with the Phased Development Methodology (PDM), which is also presented. HIOS consists of an administrative module, medical modules, and a research module to support GPs in daily practice activities and research. It was implemented at a general practice and a health centre, and was evaluated positively. HIOS+ was developed by extending HIOS with modules which offer several types of decision support to assist GPs in (diagnostic) decision making. The modules offer passive and active decision support. HIOS+ can present textbook information, generate advice and warnings, support the creation of models, generate reports, and can be used in education. Some HIOS+ modules were evaluated by GPs in evaluation studies, all with positive results.

Computer Systems↗
PubMed1997

Fitting a routine health-care activity into a randomized trial: an experiment possible without informed consent?

Due to possible methodological and practical problems, many researchers refrain from using a randomized controlled trial design to evaluate procedures already embedded in routine health care. We performed a randomized controlled trial on the effects of routine individual feedback on test ordering behavior of family physicians. The trial started after 4 years of feedback and lasted for 2.5 years. With some adaptations a randomized trial proved to be possible. In evaluating health-care procedures that cannot be blinded in a traditional way, asking full and study-specific informed consent may conflict with the validity of the design. In such studies, an alternative procedure is to be considered. Our trial, with doctors as study subjects, was held on an already accepted routine procedure (feedback). This made it possible to refrain from obtaining study-specific informed consent. Consequently, a Hawthorne effect and contamination of the trial arms through information leakage could be avoided. Justification and general criteria for not obtaining full and study-specific informed consent are worked out. In health-care research on the performance of doctors or on interventions into the quality of care, obtaining a general informed consent in advance is an acceptable alternative approach.

Diagnostic Tests, Routine↗
PubMed1996

OpenLabs services for ordering laboratory investigations.

An automated system is described that screens requests for laboratory investigations from GPs and delivers feedback with respect to the adequacy of the requests. The system has to replace and extend the current system in which feedback is provided on a manual basis each half year, based on the tests requested during a period of one month, randomly selected from the previous half year. It has been reported elsewhere that the manual system reduced the number of tests requested considerably. The criteria used by the automated system and the manual system are based on guidelines and work agreements that GPs have agreed to follow when requesting investigations. It is concluded that the automated system is very user-friendly and that in the order of 4-17% of the requested tests could be identified as unnecessary, with a false negative rate in between 4% (for hyperthyroidism) and 23% (for hypothyroidism). The achieved reduction in the number of tests is in addition to the reduction obtained in the manual system.

Clinical Laboratory Information Systems↗
PubMed1996

Factors predicting differences among general practitioners in test ordering behaviour and in the response to feedback on test requests.

BACKGROUND: In a population of 85 general practitioners diagnostic test ordering behaviour has been changed by means of repeated individual feedback provided since 1985. OBJECTIVES: We studied practitioner and practice characteristics which may explain differences in test ordering behaviour and in the extent to which general practitioners tend to change their behaviour according to the feedback. METHOD: In order to trace such variables, 75 general practitioners were interviewed. In our study request data from individual general practitioners were related to data from several questionnaires. RESULTS: We found no practice characteristics which were of influence on the number of test requests by the general practitioner. Explanatory practitioner characteristics for this were found to be years of experience and working hours per week in practice. CONCLUSIONS: More years of experience as a general practitioner and a shorter duration of consultations correlated with a better response to advice given in the feedback.

Adult↗
PubMed1995

Effectiveness of joint consultation sessions of general practitioners and orthopaedic surgeons for locomotor-system disorders.

Joint consultation sessions between general practitioners (GPs) and specialists to examine patients for whom decisions about referral are difficult are thought to be helpful, but their effects have not been evaluated. In a randomised, controlled trial we studied the effects of joint sessions of GPs and orthopaedic surgeons on referral and intervention rates. During 1.5 years, 12 GPs (in groups of three) held monthly joint consultation sessions with four participating orthopaedic surgeons: patients were seen by one orthopaedic surgeon in the presence of three GPs. Patients were included in the trial if the GP was uncertain about the diagnostic or therapeutic management and if referral was considered; and excluded if referral was urgently necessary or if there was some other clear indication for referral. By a randomised consent design, patients were assigned to joint consultation sessions (n = 144) or a usual-care control group (n = 128). A year later the patients were examined by an independent orthopaedic surgeon. There were significantly fewer referrals (51/144 [35%] vs 87/128 [68%], p < 0.01) and diagnostic actions in the intervention group than in the control group, without negative effects on health or functional status. More patients in the intervention group were symptom-free at 1 year (35% vs 24%, p < 0.05). Joint consultation sessions of GPs and orthopaedic surgeons within the framework of general practice resulted in more efficient care, with better targeted examination, treatment, and referrals.

Family Practice↗
PubMed1995

Randomised controlled trial of routine individual feedback to improve rationality and reduce numbers of test requests.

Feedback can be described as a way to provide information on doctors' performance to enable changes in future behaviour. Feedback is used with the aim of changing test-ordering behaviour. It can lead to reductions in test usage and cost savings. It is not sufficiently clear, however, whether feedback leads to more appropriate test use. Since 1985, the Diagnostic Coordinating Center Maastricht has been giving feedback on diagnostic tests as a routine health care activity to all family doctors in its region. Both quantity and quality of requests are discussed. In a randomised, controlled trial over 2.5 years, discussion of tests not included previously was added to the existing routine feedback. One group of family doctors (n = 39) received feedback on test-group A (electrocardiography, endoscopy, cervical smears, and allergy tests), the other (n = 40) on test-group B (radiographic and ultrasonographic tests). Thus, each group of doctors acted as a control group for the other. Changes in volume and rationality of requests were analysed. The number of requests decreased during the trial (p = 0.036). Request numbers decreased particularly for test-group A (p = 0.04). The proportion of requests that were non-rational decreased more in the intervention than in the control groups (p = 0.009). Rationality improved predominantly for test-group B (p = 0.043). Thus, routine feedback can change the quantity and quality of requests.

Diagnostic Services↗
PubMed1995

Does a reduction in general practitioners' use of diagnostic tests lead to more hospital referrals?

BACKGROUND: Individual feedback on general practitioners' requests for tests can improve the quality of their test ordering behaviour. Little is known of the side effects on hospital referral behaviour when the use of tests is reduced through feedback. AIM: A study was undertaken to explore changes in general practitioners' hospital referral rates in a region where their use of diagnostic tests is reduced through feedback. METHOD: Trends in test requests and of first referrals to specialists were compared among 64 general practitioners in the Maastricht region of the Netherlands where routine feedback on test ordering behaviour is provided by the diagnostic coordinating centre. RESULTS: Reduction in diagnostic test use was not accompanied by a higher hospital referral rate, not even for specialties related to tests discussed in feedback. Good responders to feedback had decreased hospital referral rates in contrast to increased rates for poor responders (P < 0.01). CONCLUSION: Reducing the volume of general practitioners' diagnostic tests through feedback does not lead to more specialist referrals. Together with lower test use, fewer hospital referrals were seen.

Diagnostic Tests, Routine↗
PubMed1994

Feasibility of transcolonic and transgastric abdominal vascular ultrasound.

Abdominal vascular ultrasound is hampered by tissue attenuation. To improve imaging, the feasibility of real-time color Doppler transcolonic and transgastric abdominal vascular ultrasound was evaluated. A monoplane 5 MHz transesophageal probe was inserted via a proctoscope in five patients with normal colons. At 25 cm (end of proctoscope), the aortic bifurcation and iliac arteries were dynamically imaged with high resolution. In three patients undergoing abdominal surgery, the surgeon grasped the probe and advanced it further through the descending to the transverse colon to examine further vascular structures. High resolution two-dimensional imaging and color Doppler flow were obtained from the abdominal aorta, the origins and proximal portions of the superior mesenteric artery, and the renal and the inferior mesenteric arteries. Additionally, the inferior vena cava, left renal vein, and portal system were imaged. All vascular structures imaged were within 3 cm of the probe. In two additional patients undergoing abdominal surgery and transesophageal echocardiography, the surgeon grasped the probe in the stomach and placed it on various vascular structures. The results were similar and the celiac trunk was also imaged. This technique, when integrated with fiberoptics for guidance, could provide a method for abdominal vascular ultrasound with less tissue-imposed attenuation, providing high resolution imaging and allowing additional structure recognition. This has potential applications for studying patients with disease of the abdominal aorta or its branches.

Abdomen↗
PubMed1994

Discriminant value of symptoms in patients with dyspepsia.

BACKGROUND: Family physicians encounter many pitfalls in managing and treating dyspeptic patients, most of whom are treated in family practice based solely on their signs and symptoms. METHODS: A computer literature search followed by a systematic methodological appraisal was performed to identify studies that evaluated clinical symptomatology in dyspeptic patients. RESULTS: Ten studies, none of which took place in a family practice, fulfilled our inclusion criteria. The main conclusion drawn from outpatient populations and patients referred for open-access endoscopy was that certain clusters of symptoms have a negative predictive value for organic causes of dyspepsia. Higher age, male sex, pain at night, relief by antacids or food, and previous history of peptic ulcer disease were identified as predictors of organic causes for abdominal symptoms. CONCLUSIONS: These findings can be helpful to family physicians in determining the need for endoscopy referral. However, since the diagnostic values of tests in family practice may differ from those in referred populations, there is a need for prospective studies in primary care.

Dyspepsia↗
PubMed1993

To test or not to test, that is the question.

This paper describes a system that is used in Maastricht, the Netherlands, to provide general practitioners with feedback about the adequateness of their test requesting behaviour. The system has proven to be effective. Since the screening of test requests and additional patient data is work-intensive a project was started in the framework of the AIM programme OPENLABS to design a computer-based feedback system. In this system the general practitioner sends test requests to the laboratory decision support system by means of electronic data interchange (EDI). The authors were involved in the development of the EDI messages, which are now accepted standards in the Netherlands. The requests are stored in a database that is part of the laboratory decision support system. The other part of the decision support system, an expert system, obtains the request data (including patient data) from the database, screens the requests for adequateness and provides feedback when necessary.

Clinical Laboratory Information Systems↗
PubMed1993

The diagnostic value of rectal examination.

The rectal examination is a much advocated procedure for assessing abdominal and urinary symptoms. A Medline literature search yielded only a few studies, not one of them in a general practice setting. The sensitivity of the rectal examination to rectal carcinoma and appendicitis is low, while it is high for prostate carcinoma. When reviewing the likelihood ratios of normal and abnormal findings of rectal examinations it was concluded that it may be a useful procedure in the case of abnormal findings in patients presenting rectal problems and in assessing men with prostate problems, although it does not seem useful in diagnosing appendicitis. However, since the diagnostic values in general practice and in referred populations may be different, there is a need for further prospective studies in settings of general medical practice.

Appendicitis↗