Experience as a doctor in the developing world: does it benefit the clinical and organisational performance in general practice?

BACKGROUND: Many physicians have medical experience in developing countries early in their career, but its association with their medical performance later is not known. To explore possible associations we compared primary care physicians (GPs) with and without professional experience in a developing country in performance both clinical and organisational. METHODS: A retrospective survey using two databases to analyse clinical and organisational performance respectively. Analysis was done at the GP level and practice level.517 GPs received a questionnaire regarding relevant working experience in a developing country. Indicators for clinical performance were: prescription, referral, external diagnostic procedures and minor procedures. We used the district health insurance data base covering 570.000 patients. Explorative secondary analysis of practice visits of 1004 GPs in 566 practices in the Netherlands from 1999 till 2001. We used a validated practice visit method (VIP; 385 indicators in 51 dimensions of practice management) to compare having experience in a developing country or not. RESULTS: Almost 8% of the GPs had experience in a developing country of at least two years.These GPs referred 9,5% less than their colleagues and did more surgical procedures. However, in the multivariate analysis 'experience in a developing country' was not significantly associated with clinical performance or with other GP- and practice characteristics. 16% of the practices a GP or GPs with at least two years experience in a developing country. They worked more often in group and rural practices with less patients per fte GP and more often part-time. These practices are more hygienic, collaborate more with the hospital and score better on organisation of the practice. These practices score less on service and availability, spend less time on patients in the consultation and the quality of recording in the EMD is lower. CONCLUSIONS: We found interesting differences in clinical and organisational performance between GPs with and without medical experience in developing countries and between their practices. It is not possible to attribute these differences to this experience, because the choice for medical experience in a tropical country probably reflects individual differences in professional motivation and personality. Experience in a developing country may be just as valuable for later performance in general practice as experience at home.

Long-term prognosis of acute otitis media in infancy: determinants of recurrent acute otitis media and persistent middle ear effusion.

OBJECTIVES: Children under 2 years of age with acute otitis media are known to have a relatively poor prognosis. The objective of this study was to assess whether known determinants for recurrent acute otitis media and persistent middle ear effusion after an episode of acute otitis media during childhood also apply to children under 2 years. STUDY DESIGN: prospective study of 210 children under 2, with identification of potential prognostic determinants. Univariate and multivariate logistic regression analyses were applied to evaluate which parameters independently contributed to the prediction of both outcome measures (recurrent acute otitis media and persistent middle ear effusion). A prognostic function was developed, and the area under the receiving operating characteristic (ROC) was used to estimate the predictive ability of the prognostic models. POPULATION: children under 2 years of age with an episode of acute otitis media in family practice. OUTCOMES MEASURED: recurrent acute otitis media and persistent middle ear effusion. RESULTS: For the outcome recurrent acute otitis media data from 210 children were used and winter season, male sex, passive smoking and persistent symptoms for more than 10 days at presentation were independent prognostic determinants. For the outcome persistent middle ear effusion data from 190 children were used and winter season, bilateral disease at entry, a sibling history of recurrent acute otitis media, and a previous episode of acute otitis media independently predicted the outcome. No sufficiently discriminatory prognostic model could be constructed for either outcome measure. CONCLUSION: Prediction of recurrent acute otitis media or persistent middle ear effusion in individual young children remains poor.

Clinical efficacy of three common treatments in acute otitis externa in primary care: randomised controlled trial.

OBJECTIVE: To compare the clinical efficacy of ear drops containing acetic acid, corticosteroid and acetic acid, and steroid and antibiotic in acute otitis externa in primary care. DESIGN: Randomised controlled trial. SETTING: 79 general practices, Netherlands. PARTICIPANTS: 213 adults with acute otitis externa. PRIMARY OUTCOME: duration of symptoms (days) according to patient diaries. Secondary outcome: cure rate according to general practitioner completed questionnaires and recurrence of symptoms between days 21 and 42. RESULTS: Symptoms lasted for a median of 8.0 days (95% confidence interval 7.0 to 9.0) in the acetic acid group, 7.0 days (5.8 to 8.3) in the steroid and acetic acid group, and 6.0 days (5.1 to 6.9) in the steroid and antibiotic group. The overall cure rates at seven, 14, and 21 days were 38%, 68%, and 75%, respectively. Compared with the acetic acid group, significantly more patients were cured in the steroid and acetic acid group and steroid and antibiotic group at day 14 (odds ratio 2.4, 1.1 to 5.3, and 3.5, 1.6 to 7.7, respectively) and day 21 (5.3, 2.0 to 13.7, and 3.9, 1.7 to 9.1, respectively). Recurrence of symptoms between days 21 and 42 occurred in 29% (50/172) of patients and was seen significantly less in the steroid and acetic acid group (0.3, 0.1 to 0.7) and steroid and antibiotic group (0.4, 0.2 to 1.0) than in the acetic acid group. CONCLUSIONS: Ear drops containing corticosteroids are more effective than acetic acid ear drops in the treatment of acute otitis externa in primary care. Steroid and acetic acid or steroid and antibiotic ear drops are equally effective.

Outpatient antibiotic prescriptions from 1992 to 2001 in the Netherlands.

OBJECTIVES: Although Dutch outpatient antibiotic prescription rates are low compared with other European countries, continuing to scrutinize trends in outpatient antibiotic use is important in order to identify possible increases in antibiotic use or inappropriate increases in the use of particular classes of antibiotics. METHODS: We assessed the volume of Dutch outpatient antibiotic prescriptions from 1992 to 2001 by calculating the mean number of outpatient antibiotic prescriptions (indicating the number of times physicians decide to prescribe an antibiotic agent) per 1000 patients insured by the Dutch Sickness Fund per year, according to subgroups (narrow-spectrum penicillins, broad-spectrum penicillins, tetracyclines, macrolides, sulphonamides and trimethoprim, and quinolones). Data were obtained from the Dutch Drug Information Project/Health Care Insurance Board. RESULTS: The total volume of outpatient antibiotic prescriptions in 2001 was 394 prescriptions per 1000 patients insured by the Dutch Sickness Fund. Overall, the rates were stable between 1992 and 2001, with small variations across years, but with marked differences in volumes within antibiotic groups across these years: a decrease in prescribing of narrow-spectrum penicillins (-29%), amoxicillin (-23%), tetracycline (-24%), doxycycline (-19%) and trimethoprim and derivatives (-45%) was accompanied by an increase in prescribing of co-amoxiclav (+85%), macrolides (+110%) and quinolones (+86%). CONCLUSIONS: The international trend of a decline in the use of narrow-spectrum and older penicillins and prescribing more broad-spectrum and new chemotherapeutics was shown to exist in a low prescribing country, The Netherlands. Therefore, inappropriate antibiotic prescribing should remain prominent on the research agenda in intervention studies in order to improve the appropriate selection of antibiotic class and to reduce the prescription of antibiotics.