[Health and disease in the Netherlands: the Dutch National Public Health Compass as a source of information]. / Gezondheid en ziekte in Nederland; het Nationaal Kompas Volksgezondheid als informatiebron.

--The Dutch National Public Health Compass has been available on the Internet (www.nationaalkompas.nl) since 2001. This website, developed and managed by the National Institute for Public Health and the Environment, contains data and information on the population's health status, its determinants, prevention and care. The Compass brings together information from various data sources, research and expert opinions. --On the basis of this Compass, an overview has been made of the health of the Dutch population. --Both the life expectancy and the healthy life expectancy in the Netherlands increased after 1980. --Mortality from coronary heart disease, cerebrovascular accidents and lung cancer decreased, but they are still the most important causes of death. --Especially psychological disorders (alcohol dependence, anxiety disorders and depression), coronary heart disease and COPD are associated with a significant decrease in quality of life. --There are important health differences in the Netherlands between rich and poor, urban and rural areas, natives and immigrants. --The difference in life expectancy between men and women will decrease from more than 5 years in 2000 to less than 4 years in 2020. --A permanent facility for the provision of accurate public-health information is of great importance. The collaboration of registration holders and experts in maintaining the Compass is and will remain essential so that an integral overview of the health of the Dutch population can also be made in the future.

Health status and the challenges for prevention in The Netherlands.

In 2002, the third Public Health Status and Forecasts report was published, containing up-to-date information about Dutch public health and health care. A striking finding was that although life expectancy (LE) in The Netherlands increased between 1980 and 2000, the LE of men is rising less rapidly than the European Union (EU) average. The LE of Dutch women is stagnating and has now fallen below the EU average. These and many other unfavourable trends in the health status of the Dutch population were found to be largely due to unhealthy behaviour. One of the policy recommendations therefore was to strengthen the investments in prevention in order to reverse the stagnation in health status. In response to the findings, the Ministry of Health, Welfare and Sport published the National Prevention Paper. This Paper states that the Ministry, within the existing prevention policy, will pay more attention to healthy behaviour, stressing the responsibility of citizens as well as the societal responsibility of other parties, such as business communities, schools, health insurers and care suppliers. The prevention of specific diseases (diabetes, psychosocial problems, heart diseases, cancer, musculosceletal disorders, asthma and chronic obstructive pulmonary disease) has been given priority status. In this article, we present the major findings regarding the health status of the Dutch population and discuss the implications for prevention policy.

Avoidable mortality in Europe (1980-1997): a comparison of trends.

STUDY OBJECTIVE: To analyse international variations of trends in "avoidable" mortality (1980-1997). DESIGN: A multilevel model was used to study trends in avoidable and "non-avoidable" mortality and trends by cause of death. SETTING: Fifteen countries of the European Union, the Czech Republic, and Hungary. PARTICIPANTS: 19 avoidable causes of death among men and women aged 0-64 years. Mortality and population data were derived from the WHO mortality database; and perinatal mortality rates, from the Health for All statistical database. MAIN RESULTS: Avoidable mortality declined (1980-1997) in all the countries except Hungary. The difference between the trends in avoidable and non-avoidable mortality was small (-2.4% compared with -1.5%) and diminished over time. The largest trend variations between countries are attributable to causes mainly or partly amenable to prevention. For five of the 19 causes of death the international variations diminished over time. Various countries show trends that deviate significantly (p<0.003) from the mean trend. CONCLUSIONS: One explanation for the small and diminishing difference between avoidable and non-avoidable mortality is that some large avoidable causes show unfavourable trends. Another possible explanation is that the category of non-avoidable mortality is "polluted" by causes that have become avoidable with time. It is therefore suggested that Rutstein's lists of avoidable outcomes (1976) be updated to enable the appropriate monitoring of healthcare effectiveness. In countries that show unfavourable developments for specific avoidable causes, further research must unravel the causes of these trends.

Regional trend variations in infant mortality due to perinatal conditions in the Netherlands.

CONDENSATION: In the Netherlands, regional variations in trends in infant mortality due to perinatal conditions (1984-1994) exist, which could not be explained by health care characteristics (i.e., place or supervision of delivery and the presence of specialised neonatal care). The only sociodemographic factor that showed a consistent correlation with mortality was the percentage of Roman Catholic inhabitants of a region. OBJECTIVE: To describe and explain regional variations in trends in infant mortality due to perinatal conditions. STUDY DESIGN: A mixed (geographical and temporal) ecological design has been used. Infant mortality due to perinatal conditions was defined as mortality in the first year of life caused by diseases of the newborn period (chapter XV of the ICD-9). Trends in sex-adjusted mortality for the period 1984-1994 as well as mortality levels at the start of this period were calculated using log linear regression. Linear regression was used to examine the association between mortality trends and starting levels on the one hand and both health care and sociodemographic factors on the other. RESULTS: Statistically significant variations in mortality trends were found between regions. The trends in the two Southern regions were found to deviate significantly from the national trend. No strong association was found between mortality and each of the health care factors (i.e. place and/or supervision of delivery and the presence of specialised neonatal care). The only sociodemographic factor that showed consistent results was the percentage of Roman Catholic inhabitants of a region: A higher percentage in 1985 was associated with a higher mortality in 1985 and a stronger mortality decline during the period 1984-1994. This association could not be explained by parity or the age of the mother. CONCLUSIONS: Regional differences in trends in infant mortality due to perinatal conditions in the Netherlands could not be explained by variations in health care factors. This is an important finding as the Dutch system of obstetric care, that includes a considerable number of home deliveries, has been subject to much debate. Further research that includes other causes of death and determinants is needed to unravel the causes of the trend variations.

Variations in 'avoidable' mortality: a reflection of variations in incidence?

BACKGROUND: Variations in 'avoidable' mortality may reflect variations in the quality of care, but they may also be due to variations in incidence or severity of diseases. We studied the association between regional variations in 'avoidable' mortality and variations in disease incidence. For a selection of conditions we also analysed whether the proportion of in-hospital deaths can explain the regional variations in incidence-adjusted mortality. METHODS: Relative risks for mortality, incidence, incidence-adjusted mortality and in-hospital mortality (1984-1994) were calculated by log-linear regression. Linear regression was used to examine the relationship between mortality and incidence on the one hand, and between incidence-adjusted mortality and in-hospital mortality on the other. RESULTS: Significant regional mortality variations were found for cervical cancer, cancer of the testis, hypertensive and cerebrovascular disease, influenza/pneumonia, cholecystitis/lithiasis, perinatal causes and congenital cardiovascular anomalies. Regional mortality differences in general were only partly accounted for by incidence variations. The only exception was cervical cancer, which no longer showed significant variations after adjustment for incidence. The contribution of inhospital mortality variations to total cause-specific mortality variations varied between conditions: the highest percentage of explained variance was found for mortality from CVA (60.1%) and appendicitis (29.2%). CONCLUSIONS: Incidence data are a worthy addition to studies on 'avoidable' mortality. It is to be expected that the incidence-adjusted mortality rates are more sensitive for quality-of-care variations than the 'crude' mortality variations. Nevertheless, further research at the individual level is needed to identify possible deficiencies in health care delivery.

[Variations in health: a starting point for quality assurance in health care]. / Variaties in gezondheid: een aanknopingspunt voor kwaliteitsbewaking in de zorg.

Variations in health outcomes may reflect variations in the quality of care. The monitoring of health outcome variations (for example between hospitals or groups of caregivers) may therefore be considered as an instrument for quality assessment in health care. As health care is not the only determinant of health, further research is needed to find out whether health outcome variations are related to variations in the quality of care. Until now, health outcomes have been based mainly on mortality and morbidity measures. In the Netherlands various registries are useful for the monitoring of health outcome variations, such as the cause of death statistics, the national medical registry, the national obstetrics registry and the complications registry of the Netherlands Association of Surgeons.

Health-related quality of life: an indicator of quality of care?

There is an increasing interest in the use of outcome indicators to monitor the quality of care. Traditionally, outcome indicators have been based mainly on biological indicators reflecting death or disease. Now that various instruments for health status measurement have become available, questions have been raised as to the potential application of health status scores in monitoring the quality of care. This paper identifies conditions which should be fulfilled before such applications can be recommended. Firstly, the relationship between care delivery processes and health status outcomes must be established. In order to achieve this, health status measures which are clearly able to detect health status variations between groups of patients (i.e. discriminative ability) and variations over time (i.e. sensitivity to change) are needed. Secondly, health status data should be available, preferably from established data collection registries (e.g. computerized hospital records or national registries) where data relating to the description of variations in health status (between physicians, hospitals, regions, etc.) are routinely collected. Thirdly, methods should be found to collect additional data, including 'case-mix' information and health status reference data, in order to enable the interpretation of variations in health status. Because most of these conditions are currently not being fulfilled, we conclude that the state-of-the-art of health status measurement has not yet matured sufficiently to allow for the use of health status as an indicator of quality of care. The present paper provides a framework for both future research and data collection that is needed to improve the applicability of health status measures as quality-of-care indicators.

[Zoonoses as a public health problem]. / Zoonosen als volksgezondheidsprobleem.

Zoonoses can be defined as infectious diseases that are transmitted from vertebrate animals to man under natural conditions. Applying this definition, a review is presented of zoonoses, occurring in the Netherlands. Data about this group of infectious diseases were collected from public health and veterinary data sources. From the results of the inventory it can be concluded that the major part of the zoonoses is caused by foodborne infections. It has been estimated that yearly a total number of 420,000 persons suffer from Salmonella and Campylobacter infections. The remaining zoonoses under study were found to be of limited importance for the general population; because of their concentration in some professional groups and because of the availability of preventive measures, these infections are important in certain subgroups of the population.

Sexually transmitted diseases reported by STD services in The Netherlands, 1984-1990.

OBJECTIVE: To present general trends in sexually transmitted disease (STD) in the Netherlands during the period 1984-1990 and to describe characteristics of the patients in order to get insight into possible factors underlying these trends. METHODS: Since 1984 patients diagnosed with STD visiting STD clinics and local public health services in the Netherlands are reported by the nursing staffs. In addition to diagnosis and gender of the patient epidemiological background information is registered. The reported annual cases of gonorrhoea, syphilis and Chlamydia trachomatis infections are presented. Further, the epidemiological features of over 25,000 patients with infections due to Chlamydia trachomatis, gonorrhoea or syphilis infections were compared. RESULTS: During the period 1984-1990 an overall decrease in the total number of gonorrhoea infections was reported; among homosexual males; however, an increase in gonorrhoea rates and an increasing number of sexual partners after 1989 was reported. Furthermore, the percentage of gonorrhoea infections caused by penicillinase-producing Neisseria gonorrhoeae was found to be on the increase in various subgroups but not in homosexual males. Syphilis rates among females declined from 1984 to 1987 after which an increase was reported reaching a peak in 1989; syphilis rates among males peaked during 1989. After 1988 Chlamydia trachomatis infections increased which, however, is largely due to the introduction of screening among all visitors of the Amsterdam STD service resulting in improved case-detection. Finally, it appeared that STDs are not randomly distributed over the population but are associated with certain patient characteristics. CONCLUSION: The data provided by STD services reveal an epidemiological pattern for STDs in the Netherlands. The increase in the reported number of gonorrhoea infections among homosexuals together with the increasing number of sexual partners among homosexual males suggest that a group of highly sexually active individuals switch or return to higher risk behaviours. Further research is needed to determine the causes of the described trends and behavioural changes in order to undertake preventive activities.

[Trends in incidence of sexually transmissible disorders in The Netherlands]. / Trends in de frequentie van seksueel overdraagbare aandoeningen in Nederland.

In 1983 the Chief Medical Inspectorate set up a national registration of sexually transmitted diseases (STD), beside the system of statutorily notifiable diseases in the Netherlands. Data for this registration are collected by the nursing staff in STD clinics. Besides diagnosis and sex of the patient epidemiological background information is registered. The data show a decrease in the total number for gonorrhoea and syphilis in the period 1984-1990. Among homosexual men gonorrhoea increased after 1989. A decrease in STD was demonstrated among prostitute women. Further, the share of penicillinase producing Neisseria gonorrhoeae was found to be increasing in various subgroups, but not in homosexual men. Comparison of age, sex, prostitution, and sexual inclination of over 25,000 patients with Chlamydia trachomatis, gonorrhoea or syphilis infections indicate that syphilis was significantly more frequent among older patients and women than gonorrhoea, but less frequent among prostitutes. Syphilis patients were significantly more often visitors of prostitutes than patients with gonorrhoea, and were more often homosexual or bisexual. Chlamydiosis patients were mostly women and younger than gonorrhoea patients, they were less often working as a prostitute and less often homosexual or bisexual.

Differences in breast cancer risk factors to neu (c-erbB-2) protein overexpression of the breast tumor.

To investigate whether overexpression of the neu protein in breast tumors differentiates risk factor patterns for breast cancer, neu protein overexpression was determined in 296 breast carcinomas of patients participating in an ongoing population-based case-control study. Risk factor information on these patients and 737 controls was obtained during home interviews. Most breast cancer risk factors showed similar associations with neu-positive and neu-negative tumors, but remarkable differences were found for breast-feeding and age at first full-term pregnancy. In contrast to the slightly protective effect of breast-feeding in the neu-negative group, the risk of neu-positive breast cancer was 4.2-fold increased in women who ever breast-fed. Increasing age at first full-term pregnancy was positively associated with both neu-positive and neu-negative breast cancer, but the association was about 2 times stronger for neu-positive tumors. We conclude that neu oncogene overexpression of the breast tumor seems to be associated with a distinct risk factor pattern.