[Sub-standard factors in primary obstetric care]. / Substandaardfactoren in de verloskundige eerstelijnszorg.

OBJECTIVE: Investigating the frequency and nature of sub-standard care factors in non-complicated pregnancies in primary obstetric care. DESIGN: Retrospective investigation of medical files. METHOD: Data concerning obstetric care in 3 midwifery practices in the Delft area (Pijnacker, Nootdorp, Den Hoorn and Schipluiden), the Netherlands, from 1989-1999 were gathered from the primary National Obstetrics Register. Of the 8362 pregnancy records, 72 were selected at random. Using a checklist containing criteria based on the Obstetrics Indication List, the Cochrane Pregnancy and Childbirth Database, and from an expert panel, the records were analysed for the frequency of occurrence of sub-standard factors in perinatal care. RESULTS: Of the 72 pregnancy records, only 1 was found to contain no sub-standard factors. On average 1.7 sub-standard factors were seen with a maximum of 7. Most frequently found were: too few check-ups during the first trimester (39%), no testing for proteinuria at the first visit (26%) and no administration of prophylactic vitamin K1 (43%). Less frequently found sub-standard care factors were: no ultrasound despite indication (11%), no referral to secondary care in the event of foetal distress (6%), no consultation with secondary care in the event of hypertension (3%), or in the case of membranes ruptured for more than 24 hours (1%). Frequently the circumstances surrounding the departure from the main checklist criteria were found to justify the action. CONCLUSION: Sub-standard care factors were demonstrated in many of the pregnancies investigated. A limited number of these factors gave reason to question whether guidelines for good quality perinatal care are being properly applied.

[Evaluation and validation of a perinatal death audit by means of feedback to the caregivers]. / Evaluatie en validatie van perinatale-sterfte-audit door terugkoppeling naar zorgverleners.

OBJECTIVE: To evaluate a perinatal audit procedure by communicating the results to the caregivers (midwives and obstetricians) involved, in order to determine whether the audit led to specific suggestions for improving practice and whether evaluation of the panel assessments by caregivers leads to a different evaluation of the audit process. DESIGN: Descriptive evaluation study. METHOD: Because of privacy regulations, the results of a recently published audit concerning perinatal mortality were reported at an aggregated level. At their own request, two participating hospitals received panel assessment reports of their own cases. The audit procedure, the 77 panel assessments and the care provided were then evaluated during closed meetings with the caregivers affiliated to the respective hospitals. RESULTS: In two audited cases of mortality the caregivers judged the panel's assessments as being too light and as too severe in one other case (Cohen's kappa: 0.98). Detailed case description was considered essential to the audit procedure. While aggregated reporting of audit results provides a general understanding of substandard factors in the care provided, feedback of results on an individual practice level led to specific suggestions for improvement (in relation to medical aspects, patient-caregiver relationship and collaboration between caregivers). Lack of anonymity appeared not to be an issue for the caregivers. CONCLUSION: The feedback of perinatal audit results to the caregivers involved as well as discussion of these results led to specific starting points in the areas of collaboration, documentation and policymaking at both individual and institutional level.

The impact of immigration on the elimination of tuberculosis in The Netherlands: a model based approach.

OBJECTIVE: To determine whether elimination of tuberculosis in the Dutch population can be achieved by the year 2030, taking into account the impact of immigration. METHODS: The incidence of tuberculosis (all forms) in the period 1970 to 2030 was estimated using a life-table model for the Dutch population without the impact of immigration. The influence of immigration on tuberculosis incidence among the Dutch was modelled using four immigrant scenarios, distinguished by the assumed contact rate between immigrants and the Dutch population, and by different projections (middle, upper) of the future size of the immigrant population in The Netherlands. RESULTS: The incidence of smear-positive tuberculosis among the Dutch is projected to be 1.4 per million in the scenario without the influence of immigrant cases, and ranging from 3.8 to 11.8 per million in the four immigrant scenarios. In all immigrant scenarios, the prevalence of tuberculosis infection will continue to decline and be less than 1% by the year 2030. At least 60% of Dutch tuberculosis cases in the year 2030 are expected to be the result of transmission from a foreign source case. CONCLUSION: Using a prevalence of tuberculosis infection of less than 1% as the elimination criterion, tuberculosis will probably be eliminated from the indigenous Dutch population by 2030. However, the incidence of smear-positive tuberculosis is expected to remain higher than 1 per million, and the majority of new tuberculosis cases among the Dutch may be attributable to recent infection from a foreign source case.

The role of cultural and economic determinants in mortality decline in the Netherlands, 1875/1879-1920/1924: a regional analysis.

The objective of this study was to determine the relative importance of cultural and economic factors in mortality decline in the Netherlands in the periods 1875/1879-1895/1899 and 1895/1899-1920/1924. Mortality data by region, age, sex and cause of death as well as population data were derived from Statistics Netherlands for the years 1875/1879, 1885/1889, 1895/1899, 1910/1914, 1920/1924. Regional mortality declines were estimated on the basis of Poisson regression models. In a multivariate analysis the estimated declines were associated with economic (wealth tax) and cultural variables (% Roman Catholics and secularisation) corrected for confounders (soiltype, urbanisation). In the period from 1875/1879-1895/1899, %Roman Catholics was significantly associated with all-cause mortality decline and with mortality decline from diseases other than infectious diseases. Mortality declined less rapidly in areas with a high percentage of Roman Catholics. Secularisation was significantly associated with infectious-disease mortality decline. In areas with a high percentage population without a religious affiliation, mortality declined more rapidly. In the period from 1895/1899 to 1920/1924, wealth tax was significantly associated with all-cause and infectious-disease mortality decline. Mortality declined more rapidly in wealthy areas. Intermediary factors in the relationship between cultural factors and mortality decline were fertility decline, but more importantly, the number of medical doctors per 100,000 inhabitants. No intermediary factors were found for the association between the economic variable and mortality decline. Cultural and economic factors both played an important role in mortality decline in The Netherlands, albeit in different periods of time. The analysis of intermediary factors suggests that the acceptance of new ideas on hygiene and disease processes was an important factor in the association between culture and mortality decline in the late 19th century.

[Perinatal mortality assessed: results of a regional audit]. / Perinatale sterfte getoetst: resultaten van een regionale audit.

OBJECTIVE: To assess the level of suboptimal care prior to cases of perinatal death and the extent to which perinatal mortality can be reduced by further improvements in care. DESIGN: Retrospective panel audit investigation. METHOD: Cases of perinatal death occurring in 1996 and 1997 among women living in the region Zuid-Holland-Noord, the Netherlands, were identified by approaching midwives, obstetricians/gynaecologists and paediatricians/neonatologists. The medical records of the cases were studied by an expert panel using a checklist of evidence-based criteria for standard care in order to determine circumstances and actions that did not comply with professional protocols, or that indicated either low compliance of the mother or an inadequate healthcare infrastructure (so-called sub-standard factors). The panel also assessed whether the perinatal death could have been prevented. RESULTS: A total of 342 perinatal deaths were found. For 332 cases sufficient information was available for a panel assessment and for 318 cases the panel reached a consensus on the assessment. One or more sub-standard care factors were identified in more than half of the cases. In 19% of the cases the panel agreed that the sub-standard factor had 'possibly' contributed to the death, and in 6% they agreed that the sub-standard factor had 'probably' contributed to the death. In the last group the main problems involved were antenatal care (particularly a failure to detect or inadequate management of intrauterine growth retardation) and intrapartum care (too much of a 'wait and see' approach). CONCLUSIONS: This regional audit revealed that further quality improvement of obstetric care is possible if clinical practice guidelines for effective and safe care are better implemented. It is expected that these improvements could reduce the perinatal mortality rate by between 6% and 25%.

Determinants of infant and early childhood mortality levels and their decline in the Netherlands in the late nineteenth century.

OBJECTIVE: To study the relative importance of various determinants of total and cause-specific infant and early childhood mortality rates and their decline in The Netherlands in the period 1875-1879 to 1895-1899. DATA AND METHODS: Mortality and population data were derived from Statistics Netherlands for 16 towns and 11 rural areas. Mortality levels and their decline were estimated with a Poisson regression model. The associations of the estimated levels and declines, and determinants of infant and early childhood mortality were analysed using multivariate linear regression analysis. The causes of death studied were major contributors to infant mortality (convulsions, acute digestive disease, acute respiratory disease) and early childhood mortality (encephalitis/meningitis, acute respiratory disease, measles). RESULTS: Infant mortality rates were high in the south-western part of The Netherlands in 1875-1879. Due to a rapid decline in the western regions, this pattern changed to a north-south gradient in 1895-1899. Early childhood mortality showed an urban-rural gradient in 1875-1879 with mortality high in towns. This gradient had largely disappeared by 1895-1899, due to a rapid decline in mortality in towns. Roman Catholicism was significantly associated with infant mortality (particularly from diarrhoeal disease) in 1875-1879 and 1895-1899. The association with Roman Catholicism was stronger in 1895-1899 because mortality declines were less rapid in Roman Catholic areas in 1875-1879 to 1895-1899. Urbanization was significantly associated with early childhood mortality (particularly from respiratory disease) in 1875-1879 and 1895-1899. This association weakened over time, due to the rapid decline in mortality in towns. CONCLUSIONS: Different determinants of mortality (decline) were important in infant and early childhood mortality and they acted on different causes of death. Therefore, infant and childhood mortality should be studied separately. International comparison of the results showed that findings with respect to determinants of mortality (decline) for one country do not necessarily apply to other countries. The results for The Netherlands with respect to infant mortality differed from England and Wales.

Mortality decline in The Netherlands in the period 1850-1992: a turning point analysis.

The aim of this paper is to give a detailed and fairly objective description of rapid mortality decline in The Netherlands between 1850 and 1992 with respect to the start, end, and phases of the decline. Turning points were estimated for the standardized mortality trend, and for age and sex-specific trends between 1850-1992. The technique used was derived from spline functions. The turning points divided the trends into phases with different paces of decline. Standardized mortality started to decline rapidly in The Netherlands around 1880. Four phases in the period of decline could be distinguished: 1880-1917 (1.2% annually), 1917-1955 (1.6%), 1955-1970 (0.4%), 1970-1992 (1.1%). For nearly all age groups, the most rapid decline occurred in a period comparable to 1917-1955. Causes of death which might have shaped the standardized mortality trend are, among others, respiratory tuberculosis (1917), heart disease (except ischemic) (1955), and ischemic heart disease (1970). Causes of death that shaped the mortality trend are related to trends of determinants of mortality decline. The technique used in this paper can also be applied to other trends e.g. fertility decline.

Cause-specific mortality trends in The Netherlands, 1875-1992: a formal analysis of the epidemiologic transition.

BACKGROUND: The objective of this study is to produce a detailed yet robust description of the epidemiologic transition in The Netherlands. METHODS: National mortality data on sex, age, cause of death and calendar year (1875-1992) were extracted from official publications. For the entire period, 27 causes of death could be distinguished, while 65 causes (nested within the 27) could be studied from 1901 onwards. Cluster analysis was used to determine groups of causes of death with similar trend curves over a period of time with respect to age- and sex-standardized mortality rates. RESULTS: With respect to the 27 causes, three important clusters were found: (1) infectious diseases which declined rapidly in the late 19th century (e.g. typhoid fever), (2) infectious diseases which showed a less precipitous decline (e.g. respiratory tuberculosis), and (3) non-infectious diseases which showed an increasing trend during most of the period 1875-1992 (e.g. cancer). The 65 causes provided more detail. Seven important clusters were found: four consisted mainly of infectious diseases, including a new cluster that declined rapidly after the Second World War (WW2) (e.g. acute bronchitis/influenza) and a new cluster showing an increasing trend in the 1920s and 1930s before declining in the years thereafter (e.g. appendicitis). Three clusters mainly contained non-infectious diseases, including a new one that declined from 1900 onwards (e.g. cancer of the stomach) and a new one that increased until WW2 but declined thereafter (e.g. chronic rheumatic heart disease). CONCLUSIONS: The results suggest that the conventional interpretation of the epidemiologic transition, which assumes a uniform decline of infectious diseases and a uniform increase of non-infectious diseases, needs to be modified.

The East-West life expectancy gap: differences in mortality from conditions amenable to medical intervention.

BACKGROUND: Although mortality from conditions amenable to medical intervention has frequently been shown to be higher in the countries of Central and Eastern Europe (CCEE) than in the countries of Western Europe (CWE), the contribution of these mortality differences to the East-West gap in life expectancy is unknown. We have determined the contribution of mortality from nine amenable causes to differences in temporary life expectancy from birth to age 75 (TLE0-75) between 12 CCEE and the average TLE0-75 for CWE in ca. 1988. DATA AND METHODS: Population and mortality data were extracted from publications of the World Health Organization. Chiang's method was used for constructing abridged life tables, and Arriaga's method was used for decomposition by cause of death of the differences in TLE0-75 between each of the CCEE and the average for CWE. RESULTS: Differences in TLE0-75 between CCEE and the average for CWE ranged between 1.25 and 6.29 years in men, and between 1.09 and 3.44 years in women. After exclusion of early neonatal deaths, for which data were not available in all CCEE, amenable causes accounted for between 11% and 50% of the difference in TLE0-75 in men, and between 24% and 59% in women. The results for countries where data on early neonatal deaths were available show that inclusion of this category generally raises these estimates substantially. The contribution of conditions amenable to medical intervention to the East-West life expectancy gap is of the same order of magnitude as that of cardiovascular diseases, and much larger than that of neoplasms, respiratory diseases or external causes. CONCLUSION: Although the contribution of conditions amenable to medical intervention should not be taken as a direct estimate of the contribution of medical care to the East-West life expectancy gap, these results suggest that reducing differences in the effectiveness of medical care may be more important for narrowing the life expectancy gap than has hitherto been assumed.

Reclassifying causes of death to study the epidemiological transition in the Netherlands,1875-1992.

"This article describes a method for reclassifying causes of death in the Netherlands for the period 1875-1992....A method developed by Vallin and Mesle (1988), which involves ¿dual correspondence tables' and ¿fundamental associations', was used to create nosologically continuous categories. These categories were tested for statistical continuity during the transition years of one ICD-revision [International Classification of Diseases] to the next, using ordinary least squares regression analysis. The reclassification procedure resulted in a nested classification consisting of three levels of refinement of causes of death: 27 causes, 1875-1992; 65 causes, 1901-1992; and 92 causes, 1931-1992. On the basis of this classification, 43% of all deaths in 1875-79 and 98% of all deaths in 1992 could be allocated to either communicable diseases, non-communicable diseases or external causes." (SUMMARY IN FRE)