A nation-wide transition in patient safety culture: a multilevel analysis on two cross-sectional surveys.

QUALITY PROBLEM OR ISSUE: Patient safety is an important topic within healthcare systems. A favourable safety culture might promote safety. We examined whether a nation-wide patient safety programme (PSP) improved patient safety culture. INITIAL ASSESSMENT: We initially measured patient safety culture among 3779 healthcare providers in 45 hospitals in the Netherlands, using the Hospital Survey on Patient Safety Culture. CHOICE OF SOLUTION: A PSP based on two pillars: the implementation of a safety management system and the focus on 10 themes in which harm to patients appeared highly preventable. Elements of the safety management system were safety management, safety culture, risk assessments and continuous safety improvements. IMPLEMENTATION: Implementation was nation-wide. EVALUATION: After implementation of the programme, we assessed patient safety culture among 6605 healthcare providers in 24 Dutch hospitals and compared the scores with the initial measurement. We hypothesized that after the programme (1) scores on safety culture dimensions improved, (2) safety culture became more homogeneous within and between hospitals and (3) relative influence of hospitals on safety culture increased. A three-level mixed model for continuous responses was fit for 11 safety culture dimensions. We calculated average individual means, between-department variances, between-hospital variances and total variances per dimension. LESSONS LEARNED: In general, a more favourable safety culture was seen after the PSP. However, hospitals and departments did not become more homogeneous, except for 'frequency of event reporting'. The variety in responses amongst departments and hospitals increased for several dimensions, implying that not all of them improved.

Postoperative pain assessment in hospitalised patients: National survey and secondary data analysis.

BACKGROUND: Measuring pain is important for the adequate pain management of postoperative patients. The actual compliance with pain assessment in postoperative patients after implementation of a national safety program is unknown. OBJECTIVES: The aim of this study is to examine the compliance with pain assessment in postoperative patients after implementation of a national safety program, according to the national quality indicators for pain assessment in postoperative patients. Furthermore, organisational factors associated with this compliance were determined. STUDY DESIGN: In this study, two data sources were used: 1) data from an evaluation study of the Dutch Hospital Patient Safety Program; and 2) data from a questionnaire survey. METHODS: The compliance with two different pain process indicators was determined: 1) 3 pain measurements a day, all three full days after surgery; and 2) ≥1 pain measurement a day, all three full days after surgery. Multilevel logistic regression analysis was used to investigate the association between organisational factors in hospitals and compliance with pain process indicators. RESULTS: Data of 3895 patient records from 16 hospitals was included in this study. In 12% of the postoperative patients, pain was measured 3 times a day, all three full days after surgery. In 53% of the postoperative patients, pain was measured ≥1 time a day, all three full days after surgery. Compliance was highest in general hospitals compared to tertiary teaching and academic hospitals, and was statistically significantly higher at the surgery and surgical oncology department compared to the other departments. CONCLUSIONS: Low compliance was shown with pain assessment in postoperative patients, according to the process indicator pain after surgery in Dutch hospitals. This suggests that the implementation of measuring pain in hospitals is still insufficient.

Lazy sunday afternoons: the negative impact of interruptions in patients' daily routine on adherence to oral antidiabetic medication. A multilevel analysis of electronic monitoring data.

PURPOSE: Considerable variability in adherence over time exists. The aim of this study was to investigate to what extent deviations from the prescribed regimen in type 2 diabetes patients can be explained by characteristics of the individual 'medication intake moments' and the patient. METHODS: Medication intake of 104 non-adherent type 2 diabetes patients from 37 community pharmacies was electronically monitored for 6 months. The primary outcome measures were: (1) whether or not the intake occurred and (2) whether or not the intake occurred within the agreed-upon time period (correct timing). Multilevel logistic regression analyses were performed to account for the nested structure of the data. RESULTS: Medication intakes in the evening and during weekends and holidays were more likely to be incorrectly timed and also more likely to be completely missed. Irrespective of timing, most intakes occurred in the mornings of Monday through Thursday (96 %), and least intakes occurred on Saturday evening (82 %). Correctly timed intakes most often occurred on Monday and Tuesday mornings (61 %) in contrast to Sunday evenings (33 %). A patient's medication regimen was significantly associated with adherence. CONCLUSION: Based on our results, among patients who already have difficulties in taking their oral antidiabetic medication, interruptions in the daily routine negatively influence the intake of their medication. Professionals need to be aware of this variation in adherence within patients. As regular medication intake is important to maintain glycaemic control, healthcare professionals and patients should work together to find strategies that prevent deviations from the prescribed regimen at these problematic dosing times.

Impact of remuneration on guideline adherence: empirical evidence in general practice.

BACKGROUND AND OBJECTIVE: Changes in the Dutch GP remuneration system provided the opportunity to study the effects of changes in financial incentives on the quality of care. Separate remuneration systems for publicly insured patients (capitation) and privately insured patients (fee-for-service) were replaced by a combined system of capitation and fee-for-service for all in 2006. The effects of these changes on the quality of care in terms of guideline adherence were investigated. DESIGN AND SETTING: A longitudinal study from 2002 to 2009 using data from patient electronic medical records in general practice. A multilevel (patient and practice) approach was applied to study the effect of changes in the remuneration system on guideline adherence. SUBJECTS: 21 421 to 39 828 patients from 32 to 52 general practices (dynamic panel of GPs). MAIN OUTCOME MEASURES: Sixteen guideline adherence indicators on prescriptions and referrals for acute and chronic conditions. RESULTS: Guideline adherence increased between 2002 and 2008 by 7% for (formerly) publicly insured patients and 10% for (formerly) privately insured patients. In general, no significant differences in the trends for guideline adherence were found between privately and publicly insured patients, indicating the absence of an effect of the remuneration system on guideline adherence. Adherence to guidelines involving more time investment in terms of follow-up contacts was affected by changes in the remuneration system. For publicly insured patients, GPs showed a higher trend for guideline adherence for guidelines involving more time investment in terms of follow-up contacts compared with privately insured patients. CONCLUSION: The change in the remuneration system had a limited impact on guideline adherence.

Morbidity is related to a green living environment.

BACKGROUND: As a result of increasing urbanisation, people face the prospect of living in environments with few green spaces. There is increasing evidence for a positive relation between green space in people's living environment and self-reported indicators of physical and mental health. This study investigates whether physician-assessed morbidity is also related to green space in people's living environment. METHODS: Morbidity data were derived from electronic medical records of 195 general practitioners in 96 Dutch practices, serving a population of 345,143 people. Morbidity was classified by the general practitioners according to the International Classification of Primary Care. The percentage of green space within a 1 km and 3 km radius around the postal code coordinates was derived from an existing database and was calculated for each household. Multilevel logistic regression analyses were performed, controlling for demographic and socioeconomic characteristics. RESULTS: The annual prevalence rate of 15 of the 24 disease clusters was lower in living environments with more green space in a 1 km radius. The relation was strongest for anxiety disorder and depression. The relation was stronger for children and people with a lower socioeconomic status. Furthermore, the relation was strongest in slightly urban areas and not apparent in very strongly urban areas. CONCLUSION: This study indicates that the previously established relation between green space and a number of self-reported general indicators of physical and mental health can also be found for clusters of specific physician-assessed morbidity. The study stresses the importance of green space close to home for children and lower socioeconomic groups.

Measuring patient safety culture: an assessment of the clustering of responses at unit level and hospital level.

OBJECTIVES: To test the claim that the Hospital Survey on Patient Safety Culture (HSOPS) measures patient safety culture instead of mere individual attitudes and to determine the most appropriate level (individual, unit or hospital level) for interventions aimed at improving the culture of patient safety. METHODS: National patient safety culture data were used from 1889 hospital staff working at 87 units in 19 hospitals across The Netherlands. The multilevel structure of the variation of responses to the 11 dimensions of the questionnaire was explored by fitting three-level random intercept models: individual, unit and hospital level. RESULTS: The unit level was the dominating level for the clustering of responses to the 11 dimensions. Intraclass correlations (ICC) at unit level ranged from 4.3 to 31.7, representing considerable higher-level variation. For three dimensions of patient safety culture, there was significant clustering of responses at hospital level as well: (1) Feedback about and learning from error, (2) Teamwork across hospital units and (3) Non-punitive response to error. CONCLUSIONS: At a conceptual level, the detection of clustering of responses within units and hospitals confirms the claim that the HSOPS measures group culture and not just individual attitudes. In addition, the results have implications for interventions on patient safety culture. Improvement efforts should be directed at their most relevant organisational level. In general, improvement efforts on patient safety culture should be addressed at the unit level, rather than the individual or hospital level.

The influence of specific chronic somatic conditions on the care for co-morbid depression in general practice.

BACKGROUND: Limited information exists on the relationship between specific chronic somatic conditions and care for co-morbid depression in primary care settings. Therefore, the present prospective, general practice-based study examined this relationship. METHOD: Longitudinal data on morbidity, prescribing and referrals concerning 991 patients newly diagnosed with depression by their general practitioner (GP) were analysed. The influence of a broad range of 13 specific chronic somatic conditions on the initiation of any depression care, as well as the prescription of continuous antidepressant therapy for 180 days, was examined. Multilevel logistic regression analysis was used to control for history of depression, psychiatric co-morbidity, sociodemographics and interpractice variation. RESULTS: Multilevel analysis showed that patients with pre-existing ischaemic heart disease (72.1%) or cardiac arrhythmia (59.3%) were significantly less likely to have any depression care being initiated by their GP than patients without chronic somatic morbidity (88.0%). No other specific condition had a significant influence on GP initiation of any care for depression. Among the patients being prescribed antidepressant treatment by their GP, none of the conditions was significantly associated with being prescribed continuous treatment for 180 days. CONCLUSIONS: Our study indicates that patients with ischaemic heart disease or cardiac arrhythmia have a lower likelihood of GP initiation of any care for depression after being newly diagnosed with depression by their GP. This finding points to the importance of developing interventions aimed at supporting GPs in the adequate management of co-morbid depression in heart disease patients to reduce the negative effects of this co-morbidity.

Shared help seeking behaviour within families: a retrospective cohort study.

OBJECTIVE: To examine the extent to which the family influences individual use of general practitioner care. DESIGN: Retrospective cohort study of all consultations in one calendar year. Multilevel modelling was used to analyse contact frequencies of individuals within families within practices. SETTING: General practice in the Netherlands. PARTICIPANTS: 42 262 families with children aged 2-21 years registered in 96 practices. MAIN OUTCOME MEASURES: Family influence on individual frequency of contact with general practice and correlation in frequency of contacts between parents and children. RESULTS: After correction for patients' age and sex, analysis of siblings indicates that 22% of the variance in frequencies of contact can be ascribed to influence of the family. This means that contact frequencies of family members within families resemble each other, whereas differences in contact frequencies exist between families. Almost 6% of the variance refers to differences between practices and 73% of the variance refers to individual differences. The strongest correlations were found between mothers and children and between children. CONCLUSIONS: The extent of shared help seeking behaviour within families has considerable implications in the context of the practice.

Medical practice variations in hospital care; time trends of a spatial phenomenon.

A persistent finding in health services research is that health care delivery and hospital utilisation in the Western world varies widely between areas, both within and between countries. Most studies have concentrated on cross-sectional variations in medical practice. The aim of this article is to investigate whether or not small area variation changed through time. We used hospital discharge rates in the Netherlands for 12 diagnostic or surgical categories to indicate medical practice patterns. The data cover a time span of almost two decades: 1980-1997. First, it was found that in most cases regions are consistently above or below the national trend in the study period. Second, the analysis revealed a statistically significant decline of regional variation in hospital discharges in general during the 1980s and the 1990s. In all but one medical category the results of the separate analyses point towards a downward trend. In one-third of the medical categories this downward trend was statistically significant. Potential parallel changes in regional disparities in need for care, e.g. morbidity or age composition of regional populations or changes in regional differences in care supply are discussed.

Cancer patients seeking a second surgical opinion: results of a study on motives, needs, and expectations.

PURPOSE: To explore the sociodemographic and clinical characteristics of cancer patients seeking a second-opinion consultation and to analyze their second opinion-related motives, needs, and expectations. PATIENTS AND METHODS: In 212 consecutive patients seeking a second opinion at the Surgical Oncology Outpatient Clinic, satisfaction with the first specialist, motivation for the second opinion, need for information, preference for decision participation, and hope for and expectation of a different second opinion were assessed with a questionnaire. RESULTS: The mean age was 53 years. Most patients were women (82%), of whom 76% were diagnosed with breast cancer. Half of the patients (51%) had a low educational level. The majority of patients (62%) only had internal motives for second-opinion seeking associated with the need for reassurance and more certainty, whereas a substantial minority of patients (38%) also had external motives related to negative experiences or unfulfilled needs. The externally motivated patients had a higher anxiety disposition, were less satisfied with their first specialist, preferred a more active role in medical decision making, and more often hoped for and expected a different second opinion. CONCLUSION: Motives for second-opinion consultations differ greatly. Understanding the difference between internal and external motivation is necessary to develop strategies to prevent unnecessary second-opinion seeking. Additional studies are warranted to evaluate the objective and subjective outcomes of second-opinion consultations.

Symptom attribution after a plane crash: comparison between self-reported symptoms and GP records.

BACKGROUND: On 4 October 1992, an El Al Boeing 747-F cargo aeroplane crashed on two apartment buildings in Amsterdam. Thirty-nine residents on the ground and the four crew members of the plane died. In the years after, a gradually increasing number of people attributed physical signs and symptoms to their presence at the disaster scene. AIM: To investigate the consistency between patients' symptoms attributed to the crash and GPs' diagnoses and perception of the association with the crash. DESIGN OF STUDY: Comparison between self-reported symptoms to a call centre and GPs' medical records on onset and type of symptoms, diagnoses, and GPs' perception of association with the disaster, assessed by questionnaire. SETTING: Consenting patients (n = 621) contacting the call centre and their GPs. METHOD: Patients were interviewed by the call centre staff and interview data were recorded on a database. Questionnaires were sent to the consenting patients' GPs, requesting their opinions on whether or not their patients' symptoms were attributable to the effects of disaster. Baseline differences and differences in reported symptoms between interviewed patients and their GP records were tested using the chi2 test. RESULTS: The 553 responders reported on average 4.3 symptoms to the call centre. The majority of these symptoms (74%) were reported to the GP. Of the ten most commonly reported symptoms, fatigue, skin complaints, feeling anxious or nervous, dyspnoea, and backache featured in 80% of symptoms reported to the GP. One out of four symptoms was either reported to the GP before the disaster took place, or six or more years after (1998/1999, during a period of much media attention). Depression (7%), post-traumatic stress disorder (PTSD) (5%) and eczema (5%) were most frequently diagnosed by GPs. They related 6% of all reported symptoms to the disaster. CONCLUSIONS: Most of the symptoms attributed to a disaster by patients have been reported to their GP, who related only a small proportion of these to the disaster.

Motives for seeking a second opinion in orthopaedic surgery.

OBJECTIVES: The number of second opinions in orthopaedic surgery is increasing rapidly, yet the grounds on which patients and their doctors decide to seek a second opinion have been little studied. The goal of the study was to identify patient and consultant factors that appeared to contribute to a second opinion being sought. METHODS: Two thousand and seventy-nine consecutive new patients visiting an orthopaedic surgical outpatient clinic in 1996-1997 participated in the study. Patients were self-defined as seeking a second opinion if they had visited at least one other consultant for the same condition within the previous two years. Each of these patients completed a questionnaire before seeing the orthopaedic surgeon; this included details about the physician-patient relationship, reasons for seeking a second opinion and perceived health status. The first-opinion consultants were contacted by mail; their practice characteristics and the motives for seeking a second opinion were also obtained. RESULTS: Thirty per cent of the study population (n = 625) had sought a second opinion. Patients sought a second opinion because of disappointment concerning their original treatment, or because they wanted more information about their condition and/or its treatment. First-opinion consultants were usually unaware of these communication issues. Patients' inclination to initiate a second opinion was best predicted by their evaluation of their relationship with their first-opinion consultant. The propensity to initiate referrals for a second opinion varied widely among the first-opinion consultants (10-70%) and was inversely proportional to the size of the group they worked in and their distance from the referral centre. CONCLUSIONS: Patients did not seek a second opinion because they had doubts about the competence of their treating consultant, but because they were dissatisfied about the level of communication or about the results of their treatment. Medical educators should continue to increase their efforts to improve specialists' communication and relationship skills since these seem to generate referrals for second opinions, which occupy clinic space that could be used by other patients.

Content and outcomes of Dutch nurse clinics for children with asthma.

Dutch specialist asthma nurses run extramural and transmural nurse clinics for children with asthma. Extramural clinics are run under the responsibility and in the premises of a home care organization. Transmural clinics are run in an outpatient clinic in close collaboration and joint responsibility between home care organizations and hospitals. Effects of and differences between these clinics were determined by using a quasiexperimental design. Visiting a nurse clinic appears to result in a reduced information need and reduced use of health care services. Parents of asthmatic children visiting transmural nurse clinics appeared to have a lower information need than those attending extramural nurse clinics.

Hormone replacement therapy: changes in frequency and type of prescription by Dutch GPs during the last decade of the millennium.

OBJECTIVE: The present study was conducted in order to determine the change of frequency and type of hormone replacement therapy (HRT) regimen newly prescribed by Dutch GPs. METHODS: A comparison was made of two data sets (multi-stage random samples) collected in 1987/88 and from 1995 to 1998 concerning women 40 years and older who were newly prescribed HRT. RESULTS: Compared with 1987/88, 50% more patients were newly prescribed HRT in 1998 (2.0 in 1987/88 and 3.0 in 1998 per 1000 registered women, P < 0.01). The age distribution remained about the same, with a peak between 50 and 54 years in each year of registration. Unopposed oestrogens (including plasters) were prescribed less frequently (1.3 per thousand in 1987/88 versus 0.7 per thousand in 1998, P < 0.001), and combinations of oestrogen and progestogen more frequently in 1998 (0. 2 per thousand in 1987/88 versus 1.8 per thousand in 1998, P < 0. 01). Sequential therapy was prescribed slightly more frequently than continuous therapy (65% sequential therapy in 1995; 55% in 1998). The most frequent reason for starting HRT in 1995-1998 was climacteric symptoms (89-98%), followed by osteoporosis prevention (16-28%) and early menopause (13-25%). Rarely were preventive goals the only reason (6%) for prescribing HRT. CONCLUSIONS: The number of HRT prescriptions increased by 50% over the last decade of the millennium. The age distribution remained the same. There was a tendency to shift from prescribing unopposed oestrogens to combinations of oestrogens and progestogens. Alleviation of climacteric symptoms was the main reason for prescribing HRT throughout the registration period. Prescription of HRT for prevention of osteoporosis and/or cardiovascular disease has so far not been adopted on a large scale by Dutch GPs.

Neighbourhood characteristics and use of benzodiazepines in The Netherlands.

This paper analyses the relationship between individual and neighbourhood characteristics and the use of benzodiazepines within a Dutch city. It is hypothesized that the proportion of users is lower in more socially integrated and less deprived neighbourhoods. Hypotheses have been tested by using multi-level analysis to distinguish between composition and context effects. Age and gender have a clear relation to the use of benzodiazepines and neighbourhood differences in the proportion of users are partly the effect of population composition by age and gender. The proportion of users is higher in neighbourhoods with a higher percentage of one-parent families, with a lower percentage of social rented housing and with a larger number of rooms per person. The strength of the relation between age and use is influenced by neighbourhood characteristics. Neighbourhood variation in the amount used only depends on population composition.

Patients with irritable bowel syndrome: health status and use of health care services.

BACKGROUND: The reason for consulting a physician is more related to illness behaviour than to the severity of complaints. Yet, little is known about the course of complaints, the health care seeking behaviour, and psychosocial factors influencing these items in patients with irritable bowel syndrome (IBS) attending the general practitioner (GP). AIM: To study health status, lifestyle, and use of health care services of patients with IBS in order to indicate problem areas accessible for intervention strategies. METHOD: Structured interviews of 53 patients with IBS aged 15 years and older compared with a general population of 12,975 in the same age range, all drawn from the Dutch National survey of Morbidity and Intervention in General Practice. RESULTS: Patients with IBS revealed a lower grade of education (P < 0.001), poorer health (P < 0.001), a higher mean complaint score (8.3 versus 4.0, P < 0.001), a higher score on the General Health Questionnaire (P < 0.001), a higher score on the biographic problem list (BIOPRO, 2.3 versus 1.4, P < 0.001), and more absence from work (32% versus 18% in two months, P < 0.01). Patients with IBS consulted the family physician (1.6 versus 0.8 in three months, P < 0.001), the physical therapist (30% versus 15% in one year, P < 0.001), and the alternative therapist (32% versus 15% in five years, P < 0.001) more often than those without. CONCLUSIONS: The study shows an excess of comorbidity, psychosocial problems, use of health care services, and absence owing to disease in patients with IBS. Special guidelines and training of GPs to apply a more integral approach may reduce the cost of health care and may lead to a more favourable course in patients with IBS.

[Management of psoriasis in family practice is now in closer agreement with the guidelines of the Netherlands Society of Family Physicians]. / Beleid bij psoriasis in de huisartspraktijk nu meer in overeenstemming met de standaard van het Nederlands Huisartsen Genootschap.

OBJECTIVE: To assess changes in incidence of psoriasis and to study changes in the management of psoriasis in general practice after the sending of guidelines on management of psoriasis to general practitioners (GPs) by the NHG. DESIGN: Secondary data analysis. SETTING: Netherlands Institute for Health Care Research (NIVEL), Utrecht, the Netherlands. METHOD: Data on the incidence of psoriasis and its management by general practitioners were collected from a file predating the publication of the NHG guideline 'Psoriasis' in 1994, namely the 'Dutch National Survey of General Practice' (NS; 1987/'88), and from a subsequent file, the 'Registration Network Groningen' (RNG; 1995). RESULTS: In the NS there were 106 new patients with psoriasis (incidence: 1.3/1000/year; 95% confidence interval (95% CI): 1.2-1.4) while in the RNG there were 24 (incidence: 1.2/1000/year; 95% CI: 0.7-1.9). In all, there were 466 psoriasis patients in the NS and 125 in the RNG. The number of referrals to dermatologists was halved in 1995 (7.2%) compared with 1987/'88 (14.4%; p < 0.05). The most frequently prescribed dermatologica in psoriasis was in 1995 corticosteroid group 3 (32.8%; in 1987/'88: 28.5%), but the rise was stronger in corticosteroid group 2 (29.6%; in 1987/'88: 16.0%; p < 0.001) and group 4 (16.0%; in 1987/'88: 8.8%; p < 0.05). CONCLUSION: The incidence of psoriasis in general practice had not changed between 1987/'88 en 1995. Referral pattern and prescription shifted towards the guidelines issued by the NHG.

Patient satisfaction with the general practitioner: a two-level analysis.

OBJECTIVES: The authors examine how patient satisfaction with health care providers relates to either the individual characteristics of respondents or the characteristics of health care providers and the structural setting in which they work. METHODS: Measures of three dimensions of patient satisfaction with the general practitioner (GP)--accessibility, interpersonal relationship, information given--were derived from an existing data set. Patients were nested with GPs. Multilevel analysis was used as the analyzing technique. RESULTS: Between 90% and 95% of the variance in patient satisfaction scores is at the patient level, whereas the remaining 5% to 10% is at the GP or practice level. At the patient level, in addition to the usual predictor variables such as age and morbidity, which explain approximately 5% of the variance at this level, previous experiences with the general practitioner in the form of misunderstandings or incidents may play an important role in the emergence of dissatisfaction among patients. CONCLUSIONS: This study demonstrated the usefulness of multilevel analysis in studying patient satisfaction scores. Findings indicate that the effectiveness of strategies directed at health care providers or services and aiming to improve the quality of care through the patient's eyes can be questioned when these strategies are based on general satisfaction scores only. More attention should be paid to the interaction process between patient and GP.

Epilepsy patients: health status and medical consumption.

OBJECTIVE: To study the health status and medical consumption of outpatients with active epilepsy in comparison with the general population. DESIGN: Descriptive population study (multi-stage random sample). SETTING: Structured questionnaire. PATIENTS: Thirty-nine epilepsy patients compared with a general population of 12,975. RESULTS: Epilepsy patients revealed poorer health, a higher mean complaint score (5.3 versus 3.7, P < 0.05), a higher score on the General Health Questionnaire (P < 0.05), a somewhat higher score on the bio-logical problem list (BIOPRO) (1.8 versus 1.4, P > 0.05), less active sports engagement (16% versus 39%, P < 0.01), more fatigue (46 vs 29%, P < 0.05), dizziness (33 vs 10%, P < 0.01), nervousness (28 vs 18%, P > 0.05), sleep disturbance (23 vs 15%, P > 0.05) and excitability (33 vs 15%, P < 0.01) when compared with the general population. The BIOPRO showed problems in epilepsy patients on specific items related to self-confidence (P < 0.001) Epileptic patients do not show more absence due to illness, from work, school or at home (15 vs 18%, P > 0.05) and/or more problems at work or in the family when compared with the general population. Almost half of epilepsy patients had consulted a specialist in the past 2 months (46 vs 23% of the general population, P < 0.001). Epilepsy patients consulted the family physician slightly more often than other responders (3.0 versus 2.3, P > 0.05) and contacted the family physician's assistant considerably more often (2.3 versus 0.7, P < 0.001). One-third of epilepsy patients consulted an alternative healer in the past 5 years versus 14% in the general population (P < 0.001). CONCLUSIONS: The study shows an excess of psychosocial problems and medical consumption in epilepsy patients, but not more absence from work or problems at work or in the family. Further development of a quality of life instrument specific to epilepsy is advised.