Patients' evaluation of quality of care in general practice: what are the cultural and linguistic barriers?

OBJECTIVE: Increased migration implies increased contacts for physicians with patients from diverse cultural backgrounds who have different expectations about healthcare. How satisfied are immigrant patients, and how do they perceive the quality of care? This study investigated which patient characteristics (such as cultural views and language proficiency) are related to patients' satisfaction and perceived quality of care. METHODS: Patients (n=663) from 38 general practices in Rotterdam (The Netherlands) were interviewed. General satisfaction with the general practitioner (GP) was measured by a report mark. Perceived quality of care was measured using the 'Quote-mi' scale (quality of care through the patient's eyes-for migrants), which contains an ethnic-specific subscale and a communication process subscale. Using multilevel regression techniques, the relation between patient characteristics (ethnicity, age, education, Dutch language proficiency, cultural views) and satisfaction and perceived quality of care was analysed. RESULTS: In general, patients seemed fairly satisfied. Non-Western patients perceived less quality of care and were less satisfied than Dutch-born patients. The older the patients and the more modern cultural views they had, the more satisfied they were about the GP in general, as well as about the communication process. However, non-Western patients holding more modern views were the most critical regarding the ethnic-specific quality items. The poorer patients' Dutch language proficiency, the more negative they were about the communication process. CONCLUSION: It is concluded that next to communication aspects, especially when the patient's proficiency in Dutch is poor, physician awareness about the patient's cultural views is very important during the consultation. This holds especially true when the immigrant patient seems to be more or less acculturated. PRACTICE IMPLICATIONS: Medical students and physicians should be trained to become aware of the relevance of patients' different cultural backgrounds. It is also recommended to offer facilities to bridge the language barrier, by making use of interpreters or cultural mediators.

Erectile dysfunction prospectively associated with cardiovascular disease in the Dutch general population: results from the Krimpen Study.

The possible relationship between erectile dysfunction and the later occurrence of cardiovascular disease while biologically plausible has been evaluated in only a few studies. Our objective is to determine the relation between ED as defined by a single question on erectile rigidity and the later occurrence of myocardial infarction, stroke and sudden death in a population-based cohort study. In Krimpen aan den IJssel, a municipality near Rotterdam, all men aged 50-75 years, without cancer of the prostate or the bladder, without a history of radical prostectomy, neurogenic bladder disease, were invited to participate for a response rate of 50%. The answer to a single question on erectile rigidity included in the International Continence Society male sex questionnaire was used to define the severity of erectile dysfunction at baseline. Data on cardiovascular risk factors at baseline (age smoking, blood pressure, total- and high-density lipoprotein cholesterol, diabetes) were used to calculate Framingham risk scores. During an average of 6.3 years of follow-up, cardiovascular end points including acute myocardial infarction, stroke and sudden death were determined. Of the 1248 men free of CVD at baseline, 258 (22.8%) had reduced erectile rigidity and 108 (8.7%) had severely reduced erectile rigidity. In 7945 person-years of follow-up, 58 cardiovascular events occurred. In multiple variable Cox proportional hazards model adjusting for age and CVD risk score, hazard ratio was 1.6 (95% confidence interval (CI): 1.2-2.3) for reduced erectile rigidity and 2.6 (95% CI: 1.3-5.2) for severely reduced erectile rigidity. The population attributable risk fraction for reduced and severely reduced erectile rigidity was 11.7%. In this population-based study, a single question on erectile rigidity proved to be a predictor for the combined outcome of acute myocardial infarction, stroke and sudden death, independent of the risk factors used in the Framingham risk profile.

Incidence of non-traumatic complaints of arm, neck and shoulder in general practice.

Incidence densities in primary care are often based on disease or region-specific code registration (e.g. 'epicondylitis', 'shoulder symptom') according to the International Classification of Primary Care (ICPC). Few estimates are available on arm, neck and shoulder complaints. Unknown, is the proportion missed due to registration with a non-region-specific code (e.g. 'muscle pain'). Therefore, we estimated the incidence in non-traumatic arm, neck and shoulder complaints in the age-group 18-64 years, and determined the contribution of non-specific codes to the total figure. In this prospective registration study, 21 general practitioners (GPs) from 13 Dutch general practices classified and registered patient's symptoms and diagnoses according to ICPC at each consultation during 12 consecutive months. Incidence densities were calculated. The incidence density was 97.4/1000 person-years (95% CI: 91.2-103.7). This results in 147 (95% CI: 138-157) incident cases/year for an average-sized GP-practice (2350 patients). Main contributors were: shoulder (L92, L08) and neck complaints (L01, L83). Of all incident consultations, 23% were registered with non-region-specific codes, mainly 'other musculoskeletal disease' (L99). Non-traumatic complaints of arm, neck and shoulder are frequently consulted for in Dutch primary care. When estimating morbidity in primary care, based on diagnostic codes, one should be aware of possible underestimation of morbidity and corresponding workload, when excluding codes not specific for that region or disease.

Association between valgus and varus alignment and the development and progression of radiographic osteoarthritis of the knee.

OBJECTIVE: Although knee malalignment is assumed to correlate with knee osteoarthritis (OA), it is still unknown whether malalignment precedes the development of OA or whether it is a result of OA. The aim of this study was to assess the relationship between malalignment and the development of knee OA as well as progression of knee OA. METHODS: A total of 1,501 participants in the Rotterdam study were randomly selected. Knee OA at baseline and at followup (mean followup 6.6 years) was scored according to the Kellgren/Lawrence (K/L) grading system. Alignment was measured by the femorotibial angle on radiographs at baseline. Multivariable logistic regression for repeated measurements was used to analyze the association of malalignment with the development and progression of OA. RESULTS: Of 2,664 knees, 1,012 (38%) were considered to have normal alignment, 693 (26%) had varus alignment, and 959 (36%) had valgus alignment. A comparison of valgus alignment and normal alignment showed that valgus alignment was associated with a borderline significant increase in development of knee OA (odds ratio [OR] 1.54, 95% confidence interval [95% CI] 0.97-2.44), and varus alignment was associated with a 2-fold increased risk (OR 2.06, 95% CI 1.28-3.32). Stratification for body mass index showed that this increased risk was especially seen in overweight and obese individuals but not in non-overweight persons. The risk of OA progression was also significantly increased in the group with varus alignment compared with the group with normal alignment (OR 2.90, 95% CI 1.07-7.88). CONCLUSION: An increasing degree of varus alignment is associated not only with progression of knee OA but also with development of knee OA. However, this association seems particularly applicable to overweight and obese persons.

Early life circumstances and atopic disorders in childhood.

The prevalence of childhood atopic disorders has risen dramatically in the last decades of the past century. Risk factors for the development of these disorders have been studied extensively. This review focuses on the role of early life risk factors such as pre-natal development, perinatal circumstances, birth order and childhood vaccinations.

Cultural dissimilarities in general practice: development and validation of a patient's cultural background scale.

Due to increased migration physicians encounter more communication difficulties due to poor language proficiency and different culturally defined views about illness. This study aimed to develop and validate a 'patient's cultural background scale' in order to classify patients based on culturally conditioned norms instead of on ethnicity. A total of 986 patients from 38 multi-ethnic general practices were included. From a list of 36 questions, non-contributing and non-consistent questions were deleted and from the remaining questions the scale was constructed by principal component analysis. Comparing the scale with two other methods of construction assessed internal validity. Comparing the found dimensions with known dimensions from literature assessed the construct validity. Criterion validity was determined by comparing the patient's score with criteria assumed or known to have relationship with cultural background. Criterion validity was reasonably good but poor for income. A valid patient's cultural background scale was developed, for use in large-scale quantitative studies.

Prevalence of visual impairment in adults with intellectual disabilities in the Netherlands: cross-sectional study.

PURPOSE: To obtain the first representative and valid population-based prevalence figures on visual impairment and blindness in adults with intellectual disabilities (ID) and to identify risk groups. STUDY DESIGN: Cross-sectional survey. An age-Down's syndrome-stratified random sample of 1,598 persons from a base population of 9,012 adult users of ID services with mild to profound intellectual disabilities was screened. Participants underwent protocollised on-site screening of visual functions. Results were related to degree of ID, occurrence of Down's syndrome (DS) and age. MAIN OUTCOME MEASURE: Prevalences of visual impairment and blindness in the study population and in subgroups and weighted prevalences in the total Dutch population using ID services. RESULTS: Prevalences of visual impairment ranged from 2.2% (95% confidence interval (CI), 0.5-6.4) in young adults with mild ID and no Down's syndrome to 66.7% (95% CI, 41.0-86.7) in older adults with profound ID and Down's syndrome; prevalences of blindness ranged from 0.7% (95% CI, 0.1-4.1) to 38.9% (95% CI, 28.1-50.3). Weighted prevalences of visual impairment and blindness in the total Dutch population of adult users of intellectual disability services are 13.8% (95% CI, 9.3-18.4) and 5.0% (95% CI, 3.8-6.2), respectively. Prior to this study, visual impairment or blindness had remained undiagnosed in 106/261 (40.6%) persons. CONCLUSIONS: As compared to published figures for the general Dutch population aged 55 years and over (visual impairment 1.4%, blindness 0.5%), prevalences of visual impairment and blindness are higher in all subgroups with intellectual disabilities, including the young and mildly handicapped group. The diagnosis is too often missed. All persons with severe or profound intellectual disabilities, and all older adults with Down's syndrome, should be considered visually impaired until proved otherwise.

Assessment of mutual understanding of physician patient encounters: development and validation of a Mutual Understanding Scale (MUS) in a multicultural general practice setting.

Mutual understanding between physician and patient is essential for good quality of care; however, both parties have different views on health complaints and treatment. This study aimed to develop and validate a measure of mutual understanding (MU) in a multicultural setting. The study included 986 patients from 38 general practices. GPs completed a questionnaire and patients were interviewed after the consultation. To assess mutual understanding the answers from GP and patient to questions about different consultation aspects were compared. An expert panel, using nominal group technique, developed criteria for mutual understanding on consultation aspects and secondly, established a ranking to combine all aspects into an overall consultation judgement. Regarding construct validity, patients' ethnicity, age and language proficiency were the most important predictors for MU. Regarding criterion validity, all GP-related criteria (the GPs perception of his ability to explain to the patient, the patient's ability to explain to the GP, and the patient's understanding of consultation aspects), were well-related to MU. The same can be said of patient's consultation satisfaction and feeling that the GP was considerate. We conclude that the Mutual Understanding Scale is regarded a reliable and valid measure to be used in large-scale quantitative studies.

Perinatal characteristics and obstetric complications as risk factors for asthma, allergy and eczema at the age of 6 years.

BACKGROUND: Considerable effort has been put into identifying early determinants for atopic disorders. Many studies have evaluated the role of fetal development and obstetric complications. However, the results are not unequivocal. STUDY OBJECTIVE: To assess the relationship between perinatal characteristics and obstetric complications, and the presence of reported current asthma, allergy and eczema at the age of 6 years in the framework of a previously conducted study. METHOD: Seven hundred families in the Netherlands with index children born in 1988-1990 were retrospectively selected. Data were extracted from the Municipal Health Service's records of health examinations of these children and their siblings. These examinations were carried out at the age of 6 years. The records contained data on reported atopic disorders and perinatal characteristics. RESULTS: Gestational age was inversely related to the risk of asthma (P for trend: 0.03). Children with low birth weight tended to have a lower risk of any allergy, albeit not significant (P=0.07). However, no link was found between neonatal head circumference and atopic disorders. The ratio of neonatal head circumference to birth weight was positively associated with the risk of atopic disorders, especially with the risk of asthma (odds ratio (OR)=1.87; 95% confidence interval (CI(95%))=[1.11, 3.15]). Vacuum extraction was a risk factor for allergy (OR=1.84, CI(95%)=[1.03, 3.28]), but not for asthma. Induced labour was positively associated with the risk of inhalant allergy (OR=2.22, CI(95%)=[1.09, 4.51]) and, to a lesser extent, asthma (OR=1.72, CI(95%)=[0.95, 3.10]). For caesarean section and forcipal extraction there were no such relationships. CONCLUSIONS: Prematurity is a risk factor for asthma reported at 6 years. A high ratio of head circumference to birth weight is a risk factor for any atopic disorder. Vacuum extraction was associated with a higher risk of allergy, and induced labour is a risk factor for inhalant allergy. All results should be viewed with the possibility of residual confounding.

Role of radiography in predicting progression of osteoarthritis of the hip: prospective cohort study.

OBJECTIVES: To investigate which variables identify people at high risk of progression of osteoarthritis of the hip. DESIGN: Population based cohort study. SETTING: Ommoord district in Rotterdam, Netherlands. PARTICIPANTS: 1904 men and women aged 55 years and older from the Rotterdam study were selected on the basis of the presence of osteoarthritic signs on radiography at baseline, as defined by a Kellgren and Lawrence score > or = grade 1. MAIN OUTCOME MEASURES: Radiological progression of osteoarthritis of the hip, defined as a decrease of joint space width (> or = 1.0 mm) at follow-up or the presence of a total hip replacement. METHODS: Potential determinants of progression of hip osteoarthritis were collected at baseline. x Ray films of the hip at baseline and follow-up (mean follow-up time 6.6 years) were evaluated. Multivariate logistic regression models were used to assess the association between potential risk factors and progression of hip osteoarthritis. RESULTS: In 13.1% (1904 subjects) of the study population (mean age 66.2 years), progression of hip osteoarthritis was evident on the radiograph. Starting with a simple model of only directly obtainable variables, the Kellgren and Lawrence score at baseline, when added to the model, was a strong predictor (odds ratio 5.8, 95% confidence interval 4.0 to 8.4), increasing to 24.3 (11.3 to 52.1) in subjects with hip pain at baseline. CONCLUSIONS: The Kellgren and Lawrence score at baseline was by far the strongest predictor for progression of hip osteoarthritis, especially in patients with existing hip pain at baseline. In patients with hip pain, a radiograph has strong additional value in identifying those at high risk of progression of hip osteoarthritis.

No clear effect of diabetes education on glycaemic control for Turkish type 2 diabetes patients: a controlled experiment in general practice.

BACKGROUND: In Turkish immigrant diabetics, problems with communication and cultural differences may hinder delivery of diabetes care. METHODS: In a prospective controlled study, the effect of an ethnic-specific diabetes education programme on glycaemic control and cardiovascular risk factors in Turkish type 2 diabetes patients was assessed, by comparing Turkish diabetics who were offered the education programme with Turkish diabetics offered routine care only (control group). From 16 general practices (31 GPs) in Rotterdam, 104 Turkish type 2 diabetes patients were recruited, 85 of whom could be assessed at one-year follow-up. Glycaemic control, lipid concentrations, blood pressure and body mass index were measured. RESULTS: Compared with the control group, mean HbA(1C) in the intervention group decreased by 0.3% (95% CI -0.8 to 0.2). A significant decrease in HbA(1C) was observed in women with HbA(1C) >7% at baseline (-0.9%; 95% CI -1.73 to -0.09) but not in the other subgroups studied. serum lipid concentrations, blood pressure and body mass index remained unchanged in the intervention group. CONCLUSION: Ethnic-specific diabetes education by Turkish female educators has no obvious beneficial effect on glycaemic control or cardiovascular risk profile. More focus on specific patient selection and gender equality between educators/patients may prove worthwhile.

Incidence rates of erectile dysfunction in the Dutch general population. Effects of definition, clinical relevance and duration of follow-up in the Krimpen Study.

This study aims to describe the incidence rate of erectile dysfunction (ED) in older men in the Netherlands according to three definitions. The influence of the duration of follow-up on the incidence rate is also explored. In a large community-based follow-up study, 1661 men aged 50-75 y completed the International Continence Society sex questionnaire and a question on sexual activity, at baseline and at a mean of 2.1 and 4.2 y of follow-up. We defined 'ED' as a report of erections with 'reduced rigidity' or worse; 'Significant_ED' as 'severely reduced rigidity' or 'no erections'; and 'Clinically_Relevant_ED' as either 'ED' reported as 'quite a problem' or 'a serious problem', or 'Significant_ED' reported as at least 'a bit of a problem'. Incidence rates of ED status were calculated in those men who completed at least one period of follow-up and were not diagnosed with prostate cancer (n = 1604). For 'ED' the incidence rate (cases per 1000 person-years) is 99 and ranges over the 10-y age groups from 77 (50-59 y) to 205 (70-78 y); for 'Significant_ED' these rates were 33, 21, and 97, respectively and for 'Clinically_Relevant_ED' 28, 25, and 39, respectively. In general, incidence rates should not vary with the duration of follow-up. However, for 'ED' the 4.2 y incidence rate is about 69% of the 2.1 y incidence rate. This study presents incidence rates, for the general population, as well as based on a definition of ED that takes concern/bother into account. 'Clinically_Relevant_ED' has a lower increase in incidence with increasing age than other definitions that do not take concern/bother into account. The phenomenon of lower incidence rates with longer duration of follow-up may account for the differences in reported incidence rates between different studies. The effects of differences related to the duration of follow-up should be taken into consideration in future incidence reports.

Influenza vaccination in asthmatic children: effects on quality of life and symptoms.

This study aimed to detect the effect of influenza vaccination on quality of life, symptomatology and spirometry in asthmatic children. A randomised double-blind placebo-controlled trial in 696 (296 in 1999-2000 and 400 in 2000-2001) asthmatic children aged 6-18 yrs, which were vaccinated with either vaccine or placebo, was performed. Children participated for only one influenza season. They recorded symptoms in a diary and reported when symptom scores reached a predefined severity level. If this occurred research nurses visited them twice, first to take a pharyngeal swab and spirometry, and a week later to assess quality of life over the past illness week. Compared with placebo, vaccination improved health-related quality of life in the weeks of illness related to influenza-positive swabs. However, no effect was found for respiratory symptoms recorded in the diaries during those weeks. Similarly, no differences were found for quality of life in all weeks of illness or for respiratory symptoms throughout the seasons. Influenza vaccination was found to have a moderately beneficial effect on quality of life in influenza-positive weeks of illness in children with asthma.

Validity and reliability of three definitions of hip osteoarthritis: cross sectional and longitudinal approach.

OBJECTIVES: To compare the reliability and validity in a large open population of three frequently used radiological definitions of hip osteoarthritis (OA): Kellgren and Lawrence grade, minimal joint space (MJS), and Croft grade; and to investigate whether the validity of the three definitions of hip OA is sex dependent. SUBJECTS: from the Rotterdam study (aged > or= 55 years, n = 3585) were evaluated. The inter-rater reliability was tested in a random set of 148 x rays. The validity was expressed as the ability to identify patients who show clinical symptoms of hip OA (construct validity) and as the ability to predict total hip replacement (THR) at follow up (predictive validity). RESULTS: Inter-rater reliability was similar for the Kellgren and Lawrence grade and MJS (kappa statistics 0.68 and 0.62, respectively) but lower for Croft's grade (kappa statistic, 0.51). The Kellgren and Lawrence grade and MJS showed the strongest associations with clinical symptoms of hip OA. Sex appeared to be an effect modifier for Kellgren and Lawrence and MJS definitions, women showing a stronger association between grading and symptoms than men. However, the sex dependency was attributed to differences in height between women and men. The Kellgren and Lawrence grade showed the highest predictive value for THR at follow up. CONCLUSIONS: Based on these findings, Kellgren and Lawrence still appears to be a useful OA definition for epidemiological studies focusing on the presence of hip OA.

Pharmacotherapy for patellofemoral pain syndrome.

BACKGROUND: Patellofemoral pain syndrome (PFPS) is common among adolescents and young adults. It is characterised by pain behind or around the patella and crepitations, provoked by ascending or descending stairs, squatting, prolonged sitting with flexed knees, running and cycling. The symptoms impede function in daily activities or sports. Pharmacological treatments focus on reducing pain symptoms (non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticosteroids), or restoring the assumed underlying pathology (compounds containing glucosamine to stimulate cartilage metabolism, anabolic steroids to increase bone density of the patella and build up supporting muscles). In studies, drugs are usually applied in addition to exercises aimed at building up supporting musculature. OBJECTIVES: This review aims to summarise the evidence of effectiveness of pharmacotherapy in reducing anterior knee pain and improving knee function in people with PFPS. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group and Cochrane Rehabilitation and Related Therapies Field trials registers, the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2003), PEDro (up to January 2004), MEDLINE (1966 to January 2004), EMBASE (1988 to January 2004), and CINAHL (1982 to January 2004). SELECTION CRITERIA: Controlled trials (randomised or not) comparing pharmacotherapy with placebo, different types of pharmacotherapy, or pharmacotherapy to other therapies for people with PFPS. DATA COLLECTION AND ANALYSIS: The literature search yielded 780 publications. Eight trials were included, of which three were of high quality. Data were analysed qualitatively using best evidence synthesis, because meta-analysis was impeded by differences in route of administration of drugs, care programs and outcome measures. MAIN RESULTS: Four trials (163 participants) studied the effect of NSAIDs. Aspirin compared to placebo in a high quality trial produced no significant differences in clinical symptoms and signs. Naproxen produced significant short term pain reduction when compared to placebo, but not when compared to diflunisal. Laser therapy to stimulate blood flow in tender areas led to more satisfied participants than tenoxicam, though not significantly. Two high quality RCTs (84 participants) studied the effect of glycosaminoglycan polysulphate (GAGPS). Twelve intramuscular injections in six weeks led to significantly more participants with a good overall therapeutic effect after one year, and to significantly better pain reduction during one of two activities. Five weekly intra-articular injections of GAGPS and lidocaine were compared with intra-articular injections of saline and lidocaine or no injections, all with concurrent quadriceps training. Injected participants showed better function after six weeks, though only the difference between GAGPS injected participants and non-injected participants was significant. The differences had disappeared after one year. One trial (43 participants) found that intramuscular injections of the anabolic steroid nandrolone phenylpropionate significantly improved both pain and function compared to placebo injections. REVIEWERS' CONCLUSIONS: There is only limited evidence for the effectiveness of NSAIDs for short term pain reduction in PFPS. The evidence for the effect of glycosaminoglycan polysulphate is conflicting and merits further investigation. The anabolic steroid nandrolone may be effective, but is too controversial for treatment of PFPS.

Diabetes care in Dutch general practice: differences between Turkish immigrants and Dutch patients.

AIM: To compare the adherence to clinical guidelines by GPs as registered and glycaemic control in Turkish and Dutch type 2 diabetes patients. DESIGN: A retrospective cohort study. Search of general practice medical records for diabetes-related variables of Turkish and Dutch diabetes patients, stratified for age and gender. SETTING: Seventeen general practices (37 GPs) in the inner city of Rotterdam. SUBJECTS: 196 type 2 diabetes patients (106 Turkish and 90 Dutch), known with diabetes for at least 18 months, were followed for two years during the 1992-1997 period. MAIN OUTCOME MEASURES: 1) Level of care as registered in the medical records based on eight quantifiable criteria derived from the national guidelines for GPs; and 2) glycaemic control (fasting and non-fasting blood glucose levels). RESULTS: Turkish patients visited the GP for periodic control more often than Dutch patients. The other seven criteria were followed in an equal number of Turkish and Dutch patients. Turkish patients had a higher mean non-fasting plasma glucose level (12.9 mmol/l) than Dutch patients (10.8) (p=0.001) during the two-year follow-up. CONCLUSIONS: Although adherence to clinical guidelines as registered in Turkish and Dutch type 2 diabetes patients is comparable, Turkish patients have higher mean non-fasting plasma glucose level than their Dutch counterparts.