Once tired, always tired? Limitations in function over time of tired patients in Dutch general practice.

OBJECTIVE: To gain insight into limitations in function over time of general-practice patients who presented and were diagnosed with "tiredness". METHODS: In a routine family-practice electronic register based on use of the International Classification of Primary Care (ICPC), 684 patients were identified who presented (in 1997 or 1998) with the complaint tiredness, who were given the same symptom diagnosis, and who still had this diagnosis on 1 August 1999. A questionnaire (WONCA/COOP charts, HAD Scale, recent medical care, tiredness and attribution) was sent to these 684 "cases" and 858 controls. In a logistic regression analysis (16 dichotomous variables), we constructed five models for optimizing sensitivity and specificity for the detection of patients with an episode of care for "tiredness". RESULTS: We received 385 fully completed questionnaires of cases, on average 19 (7~31) months after the start of their episode of care for "tiredness". The results of the 1997 and 1998 cases were similar. Cases did considerably worse than did the 385 optimally matched controls: e.g., seriously limited by tiredness: 52% of cases vs 32% of controls; poor overall health: 35% of cases vs 20% of controls; HAD Scale scores indicating anxiety or depression: about 20% of cases vs about 10% of controls. Highest sensitivity (70%) was reached by including poor overall health, recent medical care and HAD Scale depression score >10 in the model; and highest specificity (65%) by including poor overall health and a HAD Scale anxiety score >7. CONCLUSION: Patients who present with tiredness and receive the same diagnosis have a high probability of suffering from substantial limitations in function in the years following diagnosis. Their limitations are more serious than those of controls, but no indication is found for a specific limitation. The indicators are strongly related and concentrate around "poor overall health".

[The clinical relationship between symptoms and the final diagnosis in general practice, determined by means of posterior probabilities calculated on the basis of the Transition Project]. / Het klinisch verband tussen klachten en uiteindelijke diagnosen in de huisartspraktijk, vastgesteld met achterafkansen berekend op grond van het Transitieproject.

OBJECTIVE: To determine how, with the aid of the database of the Transition Project (www.transitionproject.nl), one can calculate posterior probabilities for general practice that provide insight into the clinical significance of the simultaneous occurrence of two events (a symptom and a diagnosis, or two diseases) in general practice. DESIGN: Descriptive. METHOD: The use of the 'International classification of primary care' (ICPC) to code both the patient's reason for encounter and the diagnosis of the general practitioner in the Transition Project has resulted in a database for the period 1985-2002 with a total of 201,127 patient-years, in which the posterior probability of a diagnosis in the presence of a complaint or symptom is available in the form of an odds ratio. Also in the case of the simultaneous occurrence of 2 episodes of care (comorbidity) in a patient it is now possible to determine whether the ratio between the prior and the posterior probability indicates a clinically relevant relationship or that it is a chance finding. Such posterior probabilities have been calculated for the conditions otitis media, hypertension in diabetes mellitus, shortness of breath and heart failure. In the calculation ofthe prior and posterior probabilities, only 'certain' diagnoses were used. RESULTS: For the diagnosis 'otitis media' in the age group 0-4 years, otalgia had the highest posterior probability (odds ratio: 15.77), with discharge from the ear taking second place (odds ratio: 8.59). 'Fever' contributed almost nothing. The odds ratio for hypertension in 45-74-year-old women with diabetes mellitus was 3.42. When the symptom was 'shortness of breath', the prior probability of heart failure in the age group 45-64 years was relatively low (2.0) but the posterior probability was relatively high (24.2). In this way, the combination of prior and posterior probabilities can provide support for the clinical work of the general practitioner. As a predictive variable for heart failure in the age group 65-74 years, 'ankle oedema' played an important role while 'fatigue' contributed nothing to the diagnosis. It was apparent from the database that the care for patients with heart failure often coincided with that for chronic diseases such as diabetes mellitus, hypertension, ischaemic heart disease, chronic obstructive pulmonary disease and atrial fibrillation. But the question whether there is a clinically relevant relationship could only be answered on the basis of the posterior probabilities: the highest odds ratio's were found for 'atrial fibrillation/atrial flutter' (32.5), 'chronic obstructive pulmonary disease' (22.5) and 'chronic skin ulcer' (20.2). CONCLUSION: The calculation of prior and posterior probabilities on the basis of the database of the Transition Project makes it possible for general practitioners to determine the clinical relevance of their observations.

Nutritional deficiency in Dutch primary care: data from general practice research and registration networks.

OBJECTIVE: To explore incidence and prevalence rates of nutritional deficiency in adults in general practice. METHODS: Six Dutch general practice research and registration networks supplied incidence and prevalence rates of nutritional deficiency by the International Classification of Primary Care (ICPC) or 'E-list' labels ('loss of appetite, feeding problem adult, iron, pernicious/folate deficiency anaemia, vitamin deficiencies and other nutritional disorders, weight loss'). In case of disease-related nutritional deficiency, we asked whether this was labelled separately ('co-registered') or included in the registration of the underlying disease. RESULTS: 'Iron deficiency anaemia' had highest incidence (0.3-8.5/1000 person years), and prevalence rates (2.8-8.9/1000 person years). Nutritional deficiency was mostly documented in the elderly. In two networks 'co-registration' was additional, two only documented the underlying disease and two did not specify 'co-registration'. No clear difference was found between networks considering the difference in 'co-registration'. CONCLUSION: Nutritional deficiency is little documented in general practice, and generally is not registered separately from the underlying disease.

Tiredness in Dutch family practice. Data on patients complaining of and/or diagnosed with "tiredness".

BACKGROUND: Research including patients from the entire tiredness spectrum in family practice is needed. OBJECTIVES: Our aim was to provide routine family practice data on (i) relationships between the RFE (reason for encounter) and the diagnosis "tiredness"; (ii) duration, number of encounters and family physician's (FP's) interventions in episodes of care of tiredness; and (iii) sex/age and co-morbidity of patients diagnosed with "tiredness". METHODS: Routine episode of care data from the Transition Project, coded comprehensively with the International Classification of Primary Care (ICPC), were used. (i) A 16 year database (1985-2000, 58 FPs, 504 145 episodes of care, 168 550 patient years) for calculating "prior probabilities" with (diagnostic) odds ratios. (ii) A "basic population" extracted from that 16 year database of patients listed for an entire 4 year period (1997-2000; n = 12 292). RESULTS: The RFE tiredness resulted in a variety of diagnoses, but most frequently (43%) in "tiredness". Most odds ratios were low or negative. Of episodes of care of tiredness, 90% started with the RFE tiredness; 72% required one encounter only, and 90% lasted <6 months. In the 4 year period, 21% of patients first presented with tiredness, and 12% were diagnosed with tiredness; both groups were skewed towards women. Average co-morbidity in tired patients (16.6) was higher than in other visiting patients (10.4), and contained more tiredness-related conditions. FPs' interventions were mainly blood test, physical exam and advice; few referrals occurred. CONCLUSIONS: For many diagnoses, the RFE tiredness hardly contributes to the Bayesian posterior probability. FPs react differently to the RFE tiredness in cases in which they diagnose the patient with "tiredness" from how they react in other cases. The characteristics of ICPC and the Dutch health care system resulted in a full integration of tiredness as an RFE and as a freestanding episode of care in the context of family practice.

The March 2002 update of the electronic version of ICPC-2. A step forward to the use of ICD-10 as a nomenclature and a terminology for ICPC-2.

The electronic version of the second edition of the International Classification of Primary Care, ICPC-2-E, available on the website of Family Practice since 2000, needed an update of the mapping with ICD-10 as a nomenclature and, consequently, of some of its criteria. This is now being made available, together with the full four-digit conversion structure between the two systems, in an electronic form, allowing the use of the alphabetical index of ICD-10 in several languages to be used as a terminology for ICPC-2. In this contribution, we discuss the considerations for preparing this new mapping structure, and its potential use in future electronic patient records in family practice.

Severity of episodes of care assessed by family physicians and patients: the DUSOI/WONCA as an extension of the International Classification of Primary Care (ICPC).

OBJECTIVES: The DUSOI/WONCA is included in the second edition of the International Classification of Primary Care (ICPC-2), as an extension to assess the severity of episodes of care. We studied (i) family physician's (FPs') assessment of three DUSOI/WONCA parameters per episode of care; (ii) how these relate to patient and episode of care characteristics, and to the interventions that occur; and (iii) how FPs' and patients' assessment of severity compare. METHODS: Twelve FPs participated and coded patient and encounter data with ICPC. Also, they answered three DUSOI/WONCA questions, that were also answered (after the consultation) by 300 patients. Odds ratios were calculated for the relationships of the severity elements to patient and episode characteristics, and interventions. The relative agreement between FPs' and patients' ratings of severity was assessed. RESULTS: In 2033 consultations, 2860 episodes of care were documented, with a subset of 411 with a paired assessment by patient and FP. Patients appeared to be less hindered by symptoms/ complaints than the FPs thought, and less optimistic about the prognosis without care than the FP. Clear relationships existed between the FPs' assessment of severity and the patient, encounter and episode of care characteristics. Substantial agreement existed between FPs' and patients' assessment of severity. CONCLUSIONS: This study confirms the feasibility for FPs routinely to code the separate elements of severity for episodes of care, simultaneously using ICPC and DUSOI/WONCA. The studied elements of severity all provide relevant information: the interventions that occurred all related to them in a logical fashion. The FP-patient agreement on severity is satisfactory, also in the sense that it seems realistic to include these elements of severity as a topic in the communication with the patient.

The probability of specific diagnoses for patients presenting with common symptoms to Dutch family physicians.

OBJECTIVE: Our goal was to develop reliable data on the probability of specific diagnoses among patients of family physicians (FPs) presenting with common symptoms. STUDY DESIGN: A group of 54 Dutch FPs recorded the reasons for encounter, diagnoses, and interventions for all episodes of care between 1985 and 1995. Diagnoses could be modified during the episode of care, and a modified diagnosis was applied to all episode data. POPULATION: We used the listed patient populations of the 54 Dutch FPs, representing 93,297 patient years, 236,027 episodes of care, and 267,897 patient encounters. OUTCOMES MEASURED: The top 20 diagnoses related to 4 selected presenting symptoms (cough, shortness of breath, general weakness/tiredness, and low back symptom/complaints without radiation), per 100 patients, with 95% confidence intervals, stratified by age. In the standard tables, age-specific cells with fewer than 10 observations were excluded. RESULTS: The availability of an accurate estimate of prior (pretest) probabilities for common symptoms/complaints has great potential value for family practice as an academic discipline and for family physicians in that it can support their medical decision making. Stratifying data by age groups increases the clinical relevance of the prior probabilities. CONCLUSIONS: Though collected by Dutch FPs, the data in our study have a high face validity for other clinicians. Still, FPs in other countries should give priority to collecting their own probability databases.

Advantages of long observation in episode-oriented electronic patient records in family practice.

From 1985-2000, 58 Dutch family physicians (FPs) of the Transition Project collected ICPC-coded data on 47, 2451 episodes of care, first in paper records for direct encounters only, later with a complete electronic patient record (EPR) for all (direct and indirect) encounters. Based on these data, the effects of a long observation period and the inclusion of all encounters (both direct and indirect) in the EPR were studied. Long observation periods in EPRs appear to have important advantages for patient documentation and the assessment of the content of family practice. Comparison of data from a one-year versus a four-year observation period showed a shift in utilization rates. In a long observation period, visiting patients appeared to make less demand on care, while the content of the FP's care for selected chronic diseases was reflected more realistically. The inclusion of all indirect encounters in an EPR (as compared to the previous inclusion of direct encounters only) resulted in more than twice the number of coded entries per listed patient, and thus led to a major shift in perspective on the FP's involvement in patient care.

[Post-traditional medicine. Negotiating about the complaint, diagnosis and therapy]. / Posttraditionele geneeskunde. Onderhandelen over klacht, diagnose en therapie.

Dutch health care is developing in the direction of posttraditional medicine: a dynamic system of demand and supply, in which the media, information technology and a more active attitude of the patient play a part. The nature of the complaint/diagnosis combination affects the degree to which therapy is or is not evidence-based and can be medically justified. Randomized studies and guidelines in itself do not lead to a more purposeful application of treatment. Patients persistently request interventions that are not medically justified, but rather have various non-medical aims. Physicians can regard demands of this nature as an encroachment on their authenticity and find it difficult to decide whether or not to comply with them.

[Patients with fatigue in family practice: prevalence and treatment]. / Prevalentie en behandeling van vermoeide patiënten in de huisartspraktijk; gegevens uit het transitieproject.

OBJECTIVE: To gain insight into the prevalence and treatment of severe fatigue in general practice. DESIGN: Secondary data analysis. METHOD: By means of an episode-oriented morbidity registration by 54 GPs throughout the Netherlands over the period 1985-1994 it was established how often in the course of one year 'fatigue' was listed as the reason for consultation, what diagnoses were then made, how long episodes of care because of 'fatigue' lasted and what interventions took place (n = 93,297). Of the patients with a care episode because of 'fatigue' lasting at least 6 months, age, sex, comorbidity and consumption of care were established; for this purpose use was also made of a file containing data on 4 years in succession (n = 9630). RESULTS: Per annum, 92 per 1000 listed patients consulted the GP because of fatigue. Somatic or psychic diagnoses were made in 27.7 per 1000 patients listed. The episode of care lasted 4 weeks at most in 86% and at least 6 months in approximately 4%. The GPs' management of patients with 'fatigue' included physical examination in 63% and blood testing in 34%, conversation in 35%, prescription of medication in 24% and referral to a specialist in 3%. Of the 97 patients with fatigue lasting longer than 6 months, 61% had a chronic disease or psychic problems. CONCLUSION: Fatigue is frequently encountered in general practice, but the estimate that one per 1000 listed patients meets the criteria of the chronic fatigue syndrome looks a little high. It appears that GPs, in accordance with recommendations, mostly adopt a policy of wait and see.

[Is the difference between the educational requirements and the final standards of medical studies a problem?]. / Is het verschil tussen opleidingseisen en eindtermen van de artsopleiding een probleem?

Last year a ministerial order was issued concerning the requirements of the study of medicine, stating the general end terms and listing health problems as a starting point for this study. The end terms have been made less specific than they were in the first draft, to achieve compatibility between existing European guidelines and Dutch education legislation. The list of problems is not in keeping with this, however. Furthermore, problem-oriented education that meets the end terms requires information about the age and sex-specific distribution of diseases. Owing to the continuous morbidity registration by general practitioners, part of this information is already present and more is expected to become available.

[Mood disorders in daily practice; the North American consensus statement on the undertreatment of depression]. / Stemmingsstoornissen in de dagelijkse praktijk; de Noord-Amerikaanse consensusverklaring over de onderbehandeling van depressie.

The American National Depressive and Manic-Depressive Association consensus statement on the undertreatment of depression may have consequences for the treatment of patients in the Netherlands. It is concluded that Dutch clinicians, also, can be expected to play a more active role in cases of mood disorders than formerly. A comparison of the definitions of depressive disorder in the available classification system results in the recommendation to be strict about the distinction between severe and moderate depressive disorders on the one hand and subthreshold or mild conditions on the other. It is expected that this will limit the anticipated shift towards a more general willingness to use pharmacotherapy for mood disorders in patients in whom this can be expected to be efficacious.

[Variable rates of diseases in health survey and family practitioners' registries]. / Verschillende frequentiecijfers van aandoeningen bij gezondheidsenquête en huisartsregistraties.

OBJECTIVE: To compare the data from the health survey of the Central Bureau for Statistics (CBS: about episodes of chronic diseases experienced by those questioned) and from general practice registration projects (regarding episodes of care). DESIGN: Descriptive. SETTING: Department of General Practice, Academic Medical Centre, Amsterdam, the Netherlands. METHOD: Frequency figures from the CBS health survey regarding chronic diseases for 1992 were compared with data from three large continuous general practice registration projects: the Amsterdam Transition Project, the Nijmegen Continuous Morbidity Registration and the fourth British National Morbidity Study. From the Transition Project not only one-year data were used but also data referring to a four-year period (1989/'93). RESULTS: Incidence and prevalence figures concerning illness and care were in good agreement regarding cardiovascular diseases, uterine prolapse, diabetes mellitus, thyroid disorders, epilepsy and cancer. The health survey had higher frequencies than the GP registration for respiratory disorders, hypertension (both mostly in the age group 25-44 years) gastrointestinal disorders, articular disorders and migraine. With regard to a number of diseases, the four-year registration was in better agreement with the health survey than the one-year registration (e.g. joint disorders): with other disorders the reverse was true (e.g. stroke). CONCLUSION: There were similarities as well as differences between the frequencies from the health survey and the general practice registration projects. Regarding a number of these differences interpretation was possible by using not only one-year data from the GP practice but also data concerning a longer period (4 years) and by comparing the information for different age groups.

Defensive dental behaviour: illusion or reality?

Defensive medicine or defensive behaviour of physicians is considered a major problem in contemporary health care. It seems reasonable to assume that defensive behaviour also occurs in dental practice, although so far very little has been published in the dental literature on this subject. The main objective of this study was to investigate whether defensive behaviour occurs in dentistry. As a survey study 38 dentists were interviewed: 30 men and 8 women, mainly general dental practitioners with an average of 20.9 years in practice. The results of this pilot-study indicate that it is very likely that defensive behaviour occurs in dental practice, despite the fact that there is hardly any evidence of fear for malpractice claims and lawsuits among the respondents. The majority of the dentists interviewed stated that they carried out some treatments at their patient's request although they did not believe the treatment to be necessary from a professional point of view. A motive for deliberately refraining from treatment is lack of dental motivation by the patient and poor oral hygiene. According to some respondents patients are sometimes referred unnecessarily to specialists. Also 'difficult' patients run the risk of unwarranted referral to specialists, and, moreover referrals because of insurance reasons are mentioned. The financial situation of the patient and the defensive behaviour of dental practitioners seem to be closely connected.

[Perspective of a patient in the general practitioners office and in the dental office]. / Het perspectief van de patiënt in de huisarts- en tandartspraktijk.

Both general practitioners and dentists acknowledge the importance of the patient's perspective and the demand for care, and, consequently, of good communication with their patients. In general practice, the concept of reason for encounter has proved to be very useful for gaining more insight in the nature and the importance of the patient's perspective. Data from the Amsterdam Transition project show that the general practitioner understands the patient's reasons for encounters very well, and that the nature of the patient's reasons for encounter clearly affect the subsequent interventions. In this article, 260 letters concerning people's experiences with their dentist are used in order to provide an impression of communication problems in dentist practice in the Netherlands. Three major problem areas are identified, with a total of ten subcategories. Several of these are well known to the general practitioner as well. In addition, some problems are characteristic for the dentist practice. It is suggested to incorporate the concept of reason for encounter in dental care as an essential part of the description and analysis of the communication between dentists and their patients.

The International Classification of Primary Care (ICPC): new applications in research and computer-based patient records in family practice.

The international Classification of Primary Care (ICPC) has now been available to the family medicine community for a decade as the main ordering principle of its domain. Research data and practical experiences with ICPC, as well as the development of new concepts in family medicine, have resulted in new applications. The structure of episodes of care to be included in a computer-based patient record has been further developed and refined. ICPC as the ordering principle of patient data is now available in 19 languages. Its conversion structure with the International Classification of Diseases (ICD-10) allows the highest possible level of specificity in a patient's problem list necessary in patient care, while the compatibility of the ICPC drug codes with the Anatomic Therapeutic Chemical Classification Index allows the systematic inclusion of data on prescription.