Experiences of general practices with a participatory pay-for-performance program: a qualitative study in primary care.

The involvement of target users in the design choices of a pay-for-performance program may enhance its impact, but little is known about the views of participants in these programs. To explore general practices' experiences with pay-for-performance in primary care we conducted a qualitative study in general practices in the Netherlands. Thirty out of 65 general practices participating in a pay-for-performance program, stratified for bonus, were invited for a semistructured interview on feasibility, feedback and the bonus, spending of the bonus, unintended consequences, and future developments. Content analysis was used to process the resulting transcripts. We included 29 practices. The feasibility of the pay-for-performance program was questioned due to the substantial time investment. The feedback on clinical care, practice management and patient experience was mostly discussed in the team, and used for improvement plans, but was also qualified as annoying for one GP and for another GP it brought feelings of insecurity. Most practices considered the bonus a stimulus to improve quality of care, in addition to compensation for their effort and time invested. Distinctive performance features were not displayed, for instance, on a website. The bonus was mainly spent on new equipment or team building. Practices referred to gaming and focusing on those aspects that were incentivised ('tunnel vision') as unintended consequences. Future developments should be directed to absolute thresholds, new indicators to keep the process going, and an independent audit. Linking a part of the bonus to innovation was also suggested. The participants thought the pay-for-performance program was a labour-intensive positive breakthrough to stimulate quality improvement, but warned of unintended consequences of the program and the sustainability of the indicator set.

Assessment of a pay-for-performance program in primary care designed by target users.

BACKGROUND: Evidence for pay-for-performance (P4P) has been searched for in the last decade as financial incentives increased to influence behaviour of health care professionals to improve quality of care. The effectiveness of P4P is inconclusive, though some reviews reported significant effects. OBJECTIVE: To assess changes in performance after introducing a participatory P4P program. DESIGN: An observational study with a pre- and post-measurement. Setting and subjects. Sixty-five general practices in the south of the Netherlands. Intervention. A P4P program designed by target users containing indicators for chronic care, prevention, practice management and patient experience (general practitioner's [GP] functioning and organization of care). Quality indicators were calculated for each practice. A bonus with a maximum of 6890 Euros per 1000 patients was determined by comparing practice performance with a benchmark. MAIN OUTCOME MEASURES: Quality indicators for clinical care (process and outcome) and patient experience. RESULTS: We included 60 practices. After 1 year, significant improvement was shown for the process indicators for all chronic conditions ranging from +7.9% improvement for cardiovascular risk management to +11.5% for asthma. Five outcome indicators significantly improved as well as patients' experiences with GP's functioning and organization of care. No significant improvements were seen for influenza vaccination rate and the cervical cancer screening uptake. The clinical process and outcome indicators, as well as patient experience indicators were affected by baseline measures. Smaller practices showed more improvement. CONCLUSIONS: A participatory P4P program might stimulate quality improvement in clinical care and improve patient experiences with GP's functioning and the organization of care.

A review of strategies to stimulate dental professionals to integrate smoking cessation interventions into primary care.

OBJECTIVE: To summarise evidence regarding the effectiveness of various implementation strategies to stimulate the delivery of smoking cessation advice and support during daily dental care. BASIC RESEARCH DESIGN: Search of online medical and psychological databases, correspondence with authors and checking of reference lists. Only studies were selected which examined a support strategy to promote tobacco use cessation having a component to be delivered by a dentist, dental hygienist or dental assistant in the daily practice setting. Furthermore only controlled studies and systematic reviews were included. Methodological quality and outcomes were independently summarised and checked by two reviewers. RESULTS: Eight studies met the inclusion criteria: 4 addressed strategies aimed at the dental professional and 4 addressed strategies aimed at both professional and patient. Only 4 of the studies were of a good quality. The 8 studies used combinations of implementation strategies, which made it difficult to evaluate the effectiveness of distinct components. Professional education appeared to enhance motivation for smoking cessation activities and advice giving. Organisational interventions (e.g., protocols, involvement of the whole team, referral possibilities) and incorporation of patient-oriented tools also contributed to the delivery of smoking cessation interventions. CONCLUSIONS: Multifaceted support strategies positively influence dental professionals' knowledge of smoking and smoking cessation, their motivation to give advice and their performance. As only 4 studies were of good methodological quality, it was not possible to draw firm conclusions about specific components. Additional research is needed to unravel which strategies best stimulate the provision of smoking cessation advice and support during daily dental practice.

Design choices made by target users for a pay-for-performance program in primary care: an action research approach.

BACKGROUND: International interest in pay-for-performance (P4P) initiatives to improve quality of health care is growing. Current programs vary in the methods of performance measurement, appraisal and reimbursement. One may assume that involvement of health care professionals in the goal setting and methods of quality measurement and subsequent payment schemes may enhance their commitment to and motivation for P4P programs and therefore the impact of these programs. We developed a P4P program in which the target users were involved in decisions about the P4P methods. METHODS: For the development of the P4P program a framework was used which distinguished three main components: performance measurement, appraisal and reimbursement. Based on this framework design choices were discussed in two panels of target users using an adapted Delphi procedure. The target users were 65 general practices and two health insurance companies in the South of the Netherlands. RESULTS: Performance measurement was linked to the Dutch accreditation program based on three domains (clinical care, practice management and patient experience). The general practice was chosen as unit of assessment. Relative standards were set at the 25th percentile of group performance. The incentive for clinical care was set twice as high as the one for practice management and patient experience. Quality scores were to be calculated separately for all three domains, and for both the quality level and the improvement of performance. The incentive for quality level was set thrice as high as the one for the improvement of performance. For reimbursement, quality scores were divided into seven levels. A practice with a quality score in the lowest group was not supposed to receive a bonus. The additional payment grew proportionally for each extra group. The bonus aimed at was on average 5% to 10% of the practice income. CONCLUSIONS: Designing a P4P program for primary care with involvement of the target users gave us an insight into their motives, which can help others who need to discuss similar programs. The resulting program is in line with target users' views and assessments of relevance and applicability. This may enhance their commitment to the program as was indicated by the growing number of voluntary participants after a successfully performed field test during the procedure. The elements of our framework can be very helpful for others who are developing or evaluating a P4P program.

[Increased multimorbidity in patients in general practice in the period 2003-2009]. / Toename multimorbiditeit bij patiënten in de huisartsenpraktijk in de periode 2003-2009.

OBJECTIVE: To determine the prevalence of chronic multimorbidity and its increase in primary care. DESIGN: Descriptive longitudinal study. METHOD: We selected patients suffering from chronic pulmonary disease, chronic cardiovascular disease, or diabetes from a national representative general practice research database (LINH). For each year in the period 2003-2009, we calculated the prevalence of these separate conditions. We subsequently assessed the prevalence of multimorbidity and its increase for 4 different age groups (0-14, 15-44, 45-64, ≥ 65 years). RESULTS: The percentage of all patients suffering from at least 1 of these chronic conditions increased from 12.6% in 2003 to 15.0% in 2009, an increase of almost 20%. The multimorbidity among these patients rose from 15.9% in 2003 to 18.3% in 2009. This increase in multimorbidity was found in all 3 chronic conditions under study and in all adult age groups. To what extent this increase was caused by improvements in morbidity registration could not be identified. CONCLUSION: There appears to be a considerable increase in recent years in the prevalence of chronic diseases; multimorbidity appears also to have increased. If this trend continues, in 2015 the multimorbidity among patients over 65 years of age with diabetes, chronic pulmonary and/or cardiovascular disease will be more than 30%.

Experienced barriers and facilitators for integrating smoking cessation advice and support into daily dental practice. A short report.

In a controlled study, primary care dental professionals in the intervention group were encouraged to provide smoking cessation advice and support for all smoking patients with the help of a stage-based motivational protocol. The barriers and facilitators reported by the dental professionals on two occasions for their efforts to incorporate smoking cessation advice and counselling into daily patient care are summarised here. Lack of practice time and anticipated resistance on the part of the patient were cited as barriers by over 50% of the dental professionals in the first interviews. Periodontal treatment and the presence of smoking-related diseases were mentioned as the most important stimuli. The experience-based interviews revealed key points for the implementation of smoking cessation advice and support in daily dental care. Education on the associations between smoking and oral health, vocational training on motivational interviewing and the offering of structured advice protocols were identified as promising components for an implementation strategy to promote the involvement of dental professionals in the primary and secondary prevention of tobacco addiction.

High spatial resolution and high contrast visualization of brain arteries and veins: impact of blood pool contrast agent and water-selective excitation imaging at 3T.

PURPOSE: To investigate a blood pool contrast agent and water-selective excitation imaging at 3 T for high spatial and high contrast imaging of brain vessels including the veins. METHODS AND RESULTS: 48 clinical patients (47 ± 18 years old) were included. Based on clinical findings, twenty-four patients received a single dose of standard extracellular Gadoterate-meglumine (Dotarem®) and 24 received the blood pool contrast agent Gadofosveset (Vasovist®). After finishing routine MR protocols, all patients were investigated with two high spatial resolution (0.15 mm (3) voxel size) gradient echo sequences in random order in the equilibrium phase (steady-state) as approved by the review board: A standard RF-spoiled gradient-echo sequence (HR-SS, TR/TE 5.1/2.3 msec, FA 30°) and a fat-suppressed gradient-echo sequence with water-selective excitation (HR-FS, 1331 binominal-pulse, TR/TE 8.8/3.8 msec, FA 30°). The images were subjectively assessed (image quality with vessel contrast, artifacts, depiction of lesions) by two investigators and contrast-to-noise ratios (CNR) were compared using the Student's t-test. The image quality and CNR in the HR-FS were significantly superior compared to the HR-SS for both contrast agents (p < 0.05). The CNR was also improved when using the blood pool agent but only to a minor extent while the subjective image quality was similar for both contrast agents. CONCLUSION: The utilized sequence with water-selective excitation improved image quality and CNR properties in high spatial resolution imaging of brain arteries and veins. The used blood pool contrast agent improved the CNR only to a minor extent over the extracellular contrast agent.

Are oral health complaints related to smoking cessation intentions?

OBJECTIVE: Smoking influences oral health in several ways (such as the occurrence of periodontitis, teeth discolouration and oral cancer); therefore, smoking behaviour should be addressed in dental care. Dentists can play a role in primary and secondary prevention of tobacco dependence. They see their patients repeatedly over time. This study investigates whether oral health complaints can be seized as an opportunity to start smoking cessation counselling. METHODS: A structured patient questionnaire in a sample of 1101 smokers (52.1% women, mean age 40.4 years) in a convenience sample of 87 primary care dental practices. The I-change model was used to describe factors influencing behavioural change. Dependent factors such as intention to quit smoking and related factors (attitude, social support and self-efficacy) were analysed in relation to independent factors such as oral health complaints (gingiva problems, gingiva inflammation, oral cancer and discoloured teeth) using a general linear model (univariate analysis), multinomial logistic regression analysis and multiple linear regression analysis. RESULTS: A total of 56.3% had discoloured teeth, 27% of the smokers had a problem with their gums and 15.7% had gingiva inflammation. We found no direct relation between oral health complaints and the intention to quit smoking. However, teeth discolouration was positively related to attitudes towards smoking cessation [ß, Confidential interval (95%); 1.92 (1.45-2.40 for advantages and -0.86(-1.18 to -0.53) for disadvantages] and negatively to self-efficacy regarding quitting [-2.69 (-3.49 to 1.88)]. CONCLUSIONS: We found no direct relation between oral health complaints and the intention to quit smoking, but oral health complaints and especially teeth discolouration were related to factors influencing the quit intention. Patients with discoloured teeth are more likely to have a positive attitude towards smoking cessation but are uncertain to persist smoking cessation. It is suggested that teeth discolouration can be a good entrance for addressing smoking cessation in daily dental practice.

What determines the provision of smoking cessation advice and counselling by dental care teams?

OBJECTIVE: To investigate determinants of the provision of smoking cessation advice and counselling by various dental professionals in the dental team (dentists, dental hygienists and prevention auxiliaries). DESIGN: Cross-sectional design. SETTING: Sixty-two general dental practices in the Netherlands. METHODS: Multivariate logistic analyses of self-reported counselling behaviour collected from questionnaires for dentists (n = 72), dental hygienists (n = 31) and prevention auxiliaries (n = 50) in general dental practices. MAIN OUTCOME MEASURES: Stimuli and barriers for smoking cessation counselling and advice behaviour to patients with or without oral health problems. RESULTS: Dental hygienists provided more general cessation advice and counselling than dentists. However, when patients had oral complaints, dentists counselled more often compared to prevention auxiliaries. The support from experienced colleagues positively influenced the provision of advice and counselling as well as the perceived self-efficacy for all kinds of dental professionals. CONCLUSIONS: The provision of general smoking cessation advice to patients with no acute oral complaints can be improved by more involvement of the dentist and/or task delegation to prevention auxiliaries and dental hygienists. Social support is important in encouraging more smoking cessation advice and counselling. Implementation strategies for support of smoking cessation in dental care should focus on creating a positive advice culture among colleagues.

[Stop smoking advice for patients who smoke: feasible in the dental practice?]. / Stopadvies aan rokende patiënten: haalbaar in de tandartspraktijk?

Smoking may cause periodontal diseases and raises the chance of getting oral cancer. The Dutch Guideline for the Treatment of Tobacco Addiction recommends that dental professionals explicitly advise all patients who smoke to stop smoking. In 12 dental practices a study was made of how the guidelines could be implemented. The strategy consisted of a patient protocol for minimal, one-time cessation advice or for more intensive supervision, a patient leaflet, centralized training for the dental team, and repeated monitoring with feedback on the patients' experience of the behaviour that they have been advised to follow. Before the training and again 3 months after, professionals (n = 38) and an a-select sample of smoking patients (n = 197) completed questionnaires. A majority of patients was receptive to cessation advice of a dentist (95%) or counseling (68%). After 3 months it appeared that patient behaviour as reported by patients with respect to all points of the patient protocol had significantly improved.

Impact of spirometry on GPs' diagnostic differentiation and decision-making.

BACKGROUND: Spirometry is increasingly implemented in general practice, while the ability of general practitioners (GPs) to interpret flow volume curves (F-V curves) has been questioned. Furthermore, the role of spirometry in the GPs decision-making process has barely been studied. AIM: To compare the achievements of trained GPs in spirometric diagnosis with an expert consensus panel (1) and to assess the influence of spirometry on the GPs decision-making (2). METHOD: Twelve cases including a wide range of F-V curves were interpreted by 39 GPs as well as the expert panel. Diagnostic test characteristics were calculated using multi-level analysis and summarised by diagnostic odds ratios (DOR). Differences in decision-making indicators were expressed as odds ratios and 95% confidence intervals. RESULTS: Normal F-V curves (DOR 65.0) and obstructive F-V curves (DOR 48.9) were reasonably well diagnosed, while rare and mixed pathological patterns achieved considerably lower scores (DOR 3.8). Intermediate scores were obtained in the recognition of incorrect test manoeuvres (DOR 24.4). Spirometry influenced the GPs decision-making in reducing the number of alternative diagnoses (OR 0.266 [0.200, 0.353]), but also increased referral rates (7.26 [4.71, 11.2]) and the use of diagnostic prednisolone courses (4.55 [3.12, 6.64]) substantially. CONCLUSION: Trained GPs were able to differentiate between normal and obstructive disease patterns, while F-V curves suggestive of rare and mixed pathology were often missed. Spirometry seems to influence the decision-making process of the GP; whether this represents an initial or a more sustained effect remains to be evaluated in studies of daily primary care practice.

The efficacy of smoking cessation strategies in people with chronic obstructive pulmonary disease: results from a systematic review.

Smoking cessation is the most effective way to reduce the risk of developing chronic obstructive pulmonary disease (COPD). It prevents or delays the development of airflow limitation and also reduces its progression. The objective of this study was to systematically review the effects of interventions for smoking cessation in people with COPD. Comprehensive searches of electronic and internet databases were carried out from 1966 to March 2002, using the Cochrane Airways Group search strategy. The reference lists of all selected randomized trials and relevant reviews were inspected for additional published reports and citations of unpublished research. We evaluated the efficacy of behavioural interventions (e.g. counselling), pharmacotherapy (nicotine replacement therapy and non-nicotine therapy such as bupropion), and combinations of both. The main clinical outcome measure was prolonged abstinence after at least 6 months, confirmed by a biochemical test. Five trials comprising 6491 patients with COPD were included. Results of the Lung Health Study show that, by using an intensive behavioural (relapse prevention) programme combined with nicotine replacement therapy, prolonged abstinence rates are not only significantly higher compared with no intervention, but the difference in efficacy was sustained for over 5 years. A 12-week treatment course with bupropion sustained release combined with individual counselling, however, did not result in significantly higher prolonged abstinence rates after 12 months. Present evidence suggests that the most effective intervention for prolonged smoking cessation in patients with COPD is the combination of nicotine replacement therapy, coupled with an intensive, prolonged relapse prevention programme.

Assessing the quality of life of adults with chronic respiratory diseases in routine primary care: construction and first validation of the 10-Item Respiratory Illness Questionnaire-monitoring 10 (RIQ-MON10).

BACKGROUND: As doctors' judgements about the burden of a disease often differ from patients' own assessments a manageable method to incorporate the latter into routine care might support patient-centered decision-making. For this purpose we shortened the 55-Item Quality of Life for Respiratory Illness Questionnaire (QoL-RIQ). METHODS: Secondary analyses of the data of 3 controlled studies (n = 328, 502 and 555). PROCEDURES: inter-item correlations, scale distributions, Cronbach's alpha and factor analysis. Dyspnoea, forced expiratory volume in 1 s (FEV1), COOP/WONCA charts, the Medical Research Council-ECCS symptoms questionnaire and the MOS-SF 36 served as criteria to test validity and responsiveness. RESULTS: Item-reduction resulted in a 10-item short form (alpha's 0.87-0.90), consisting of 2 5-item factors: (1) physical and emotional complaints and (2) physical and social limitations. The correlations of the short form with dyspnoea (r from 0.57 to 0.60), the generic health status instruments (r from 0.39 to 0.59) and lung function (r from 0.10 to 0.15) fulfilled the criteria. FURTHER RESULTS: a clinical relevant score difference (> 0.5) between upper and lower quartiles of the convergent instruments, an intraclass correlation between repeated scores in a stable group of 0.82 and a standardised response mean of 0.86 in an improved group of patients. CONCLUSIONS: The short form (RIQ-MON10) maintained the psychometric properties of the original instrument and is promising for assessing quality of life (QoL) during routine primary care visits.

Validity of spirometric testing in a general practice population of patients with chronic obstructive pulmonary disease (COPD).

OBJECTIVE: To investigate the validity of spirometric tests performed in general practice. METHOD: A repeated within subject comparison of spirometric tests with a "gold standard" (spirometric tests performed in a pulmonary function laboratory) was performed in 388 subjects with chronic obstructive pulmonary disease (COPD) from 61 general practices and four laboratories. General practitioners and practice assistants undertook a spirometry training programme. Within subject differences in forced expiratory volume in 1 second and forced vital capacity (DeltaFEV1 and DeltaFVC) between laboratory and general practice tests were measured (practice minus laboratory value). The proportion of tests with FEV1 reproducibility <5% or <200 ml served as a quality marker. RESULTS: Mean DeltaFEV1 was 0.069 l (95% CI 0.054 to 0.084) and DeltaFVC 0.081 l (95% CI 0.053 to 0.109) in the first year evaluation, indicating consistently higher values for general practice measurements. Second year results were similar. Laboratory and general practice FEV1 values differed by up to 0.5 l, FVC values by up to 1.0 l. The proportion of non-reproducible tests was 16% for laboratory tests and 18% for general practice tests (p=0.302) in the first year, and 18% for both in the second year evaluation (p=1.000). CONCLUSIONS: Relevant spirometric indices measured by trained general practice staff were marginally but statistically significantly higher than those measured in pulmonary function laboratories. Because of the limited agreement between laboratory and general practice values, use of these measurements interchangeably should probably be avoided. With sufficient training of practice staff the current practice of performing spirometric tests in the primary care setting seems justifiable.

Smoking cessation for chronic obstructive pulmonary disease.

BACKGROUND: Smoking cessation is the most important treatment for smokers with chronic obstructive pulmonary disease (COPD), but little is known about the effectiveness of different smoking cessation interventions for this particular group of patients. OBJECTIVES: To determine the effectiveness of smoking cessation interventions in people with COPD. SEARCH STRATEGY: Electronic searches were undertaken on MEDLINE (from 1966 to March 2002), EMBASE (from 1989 to March 2002) and Psyclit (from 1971 to March 2002), and CENTRAL (Issue 1, 2002). SELECTION CRITERIA: Randomised controlled trials in which smoking cessation was assessed in participants with confirmed COPD. DATA COLLECTION AND ANALYSIS: Two authors extracted the data and performed the methodological quality assessment independently for each study, with disagreements resolved by consensus. High-quality was defined, based on pre-set criteria according to the DelphiList. MAIN RESULTS: Five studies were included in this systematic review, two of which were of high-quality. The high-quality studies show the effectiveness of psychosocial interventions combined with pharmacological intervention compared to no treatment: psychosocial interventions combined with nicotine replacement therapy (NRT) and a bronchodilator versus no treatment at a 5 year follow-up (RD = 0.16, 95% CI 0.14 to 0.18), (RR = 4.0, 95% CI 3.25 to 4.93), psychosocial interventions combined with NRT and placebo versus no treatment at a 5 year follow-up (RD = 0.17, 95% CI 0.14 to 0.19), (RR = 4.19, 95% CI 3.41 to 5.15). Furthermore the results show the effectiveness of various combinations of psychosocial and pharmacological interventions at a 6 months follow-up (RD = 0.07, 95% CI 0.0 to 0.13), (RR = 1.74, 95% CI 1.01 to 3.0). Unfortunately, none of the included studies compared psychosocial interventions with no treatment. Therefore we found no evidence with regard to the effectiveness of these interventions. REVIEWER'S CONCLUSIONS: Based on this systematic review, the authors found evidence that a combination of psychosocial interventions and pharmacological interventions is superior to no treatment or to psychosocial interventions alone. Furthermore we conclude that there is no clear or convincing evidence for the effectiveness of any psychosocial intervention for patients with COPD due to lack of a sufficient number of high-quality studies.

Focal fatty sparing of the pancreatic head in cystic fibrosis: CT findings.

The most common imaging appearance of the pancreas in cystic fibrosis is diffuse, complete fatty replacement. We present a case of complete fatty replacement of the pancreatic body and tail with total sparing of the pancreatic head. To our knowledge, this pattern of fatty sparing and its associated computed tomographic appearance have not been previously reported in cystic fibrosis.

A Delphi technique as a method for selecting the content of an electronic patient record for asthma.

INTRODUCTION: An electronic patient record (EPR) with disease-specific data may support improvement of the quality of care for patients with chronic diseases. The structure and content of such a record can only be assessed by clinicians in co-operation with IT-specialists, because, the result has to be clinically relevant, easily accessible and adjusted to the information needs of different workers in primary care. METHODS: We applied a modified Delphi-procedure--a method characterized by anonymous written comments by an expert panel. The panel had to agree about the question whether or not an item should be included in the EPR. The questions for the written comments were prepared by a steering committee (general practitioners (GP) and health scientists, either expert in asthma and disease management or IT-specialist) based on the guidelines for diagnosing and treating asthma of the Dutch College of General Practitioners (DCGP). When agreement within the panel was < or = 70%, we sent a modified format to the expert panel for reassessment. RESULTS: Three written commentary rounds were necessary, in which 95 potential items were discussed with the expert panel. In the first round they selected 50 items relating to diagnosing asthma and 22 concerning the treatment of asthma. During the second round 17 items were still under discussion and six were rejected. In subsequent rounds, the expert-panel assessed the best registration format (operationalisation). The written rounds failed to create a full consensus. Therefore the study ended with a consensus meeting of the expert panel. Due to the presence and contribution of nearly all experts, consensus could be reached about the structure and contents of the EPR on asthma. DISCUSSION: The modified Delphi procedure, proved to be a feasible method for selecting the optimal content of an electronic registration protocol. Both, written and verbal commentary rounds were necessary. The existence of a set of guidelines was essential.

Management of patients with asthma and COPD: monitoring quality of life and the relationship to subsequent GP interventions.

OBJECTIVES: The aim of this study was to investigate the feasibility of systematic monitoring of patients' quality of life and its relationship to GPs' interventions concerning management of asthma and chronic obstructive pulmonary disease (COPD). METHODS: A cross-sectional study on patients' self-reported quality of life in relation to GPs' subsequent interventions during consultation was performed. Fourteen GPs at six general practices in The Netherlands monitored 175 patients aged 18 years and older with asthma and COPD. Directly before each planned follow-up consultation, patients completed a self-report questionnaire (27 items, five dimensions) about their quality of life; GPs reviewed the monitoring scores during consultation and recorded their diagnostic and therapeutic interventions. The relationship between patients' perceived quality of life and GPs' medication prescription, smoking cessation advice, patient education and counselling was analysed. RESULTS: During 15 months, 175 patients underwent 537 consultations. In 57% of the consultations, patients reported impairments in their quality of life. This information was significantly associated with subsequent GP interventions (chi-square = 0.05), especially with providing patient education and counselling. Multivariate logistic regression analyses showed that reported physical complaints were positively associated with changes in medication prescription [odds ratio (OR) 1.7; 95% confidence interval (CI) 1.0-2.8] and with education about the control regimen (OR 1.9; 95% CI 1.1-3.3). Reported emotional complaints were related to extra follow-up appointments (OR 4.3; 95% CI 1.5-12.8) and to counselling (OR 7.3; 95% CI 2.9-18.3). In general, more advanced age was related to less patient education. Patients' and GPs' opinions about the quality of life monitoring were positive. CONCLUSIONS: Information about quality of life of patients, gathered systematically and routinely directly before consultation, could be integrated into a complex medical decision-making process; scores were related to various therapeutic interventions.

Omental infarction as a delayed complication of abdominal surgery.

Omental infarction, an uncommon cause of acute abdominal pain, is the result of compromised perfusion to the greater omentum. Although its etiology remains uncertain, predisposing factors include obesity [Surg. Today 30 (2000) 451], strenuous activity [N. Z. Med. J. 111 (1998) 211], trauma, and idiopathic omental torsion. Often confused with acute appendicitis or cholecystitis on clinical grounds [Surg. Today 30 (2000) 451], its diagnosis has traditionally been one of exclusion, based on intraoperative and pathologic findings. This diagnosis can be made radiologically based on the characteristic findings of an inflammatory mass containing fat and fluid. We describe a case of right lower quadrant omental infarction temporally related to bowel surgery.