QUOTE-HIV: an instrument for assessing quality of HIV care from the patients' perspective.

BACKGROUND: An HIV-specific version of the QUOTE questionnaire was developed to measure the quality of care of patients infected with HIV from the patients' perspective. The consistency and validity of the questionnaire was assessed. METHODS: Focus group discussions were held to select aspects for inclusion in the questionnaire that are important to patients with HIV. Item and inter-item analysis, factor analysis, and reliability analysis were performed to test the internal consistency and validity of the questionnaire. RESULTS: Twenty seven items (13 generic and 14 HIV specific) were used in the QUOTE-HIV questionnaire. Separate factor analyses of the generic and HIV specific aspects indicated that each loaded onto a single factor. The internal consistency of the total questionnaire was good (Cronbach's alpha >/=0.80). Feasibility of the questionnaire was shown by the diversity of importance and performance scores for general practitioners as well as for HIV specialists and AIDS nursing consultants. CONCLUSION: The QUOTE-HIV questionnaire is a useful instrument for measuring the quality of care from the perspective of HIV infected patients.

Changing attitudes towards antiretroviral treatment of HIV infection: a prospective study in a sample of Dutch general practitioners.

This study investigated the attitude towards antiretroviral therapy (ART) for HIV infection over time, in a sample of Dutch general practitioners (GPs). Twenty-one GPs, of which 16 were practising in Amsterdam, completed multiple questionnaires on HIV-related topics between April 1995 and March 1997. In 1995, only 10% had a positive attitude towards treatment of asymptomatic persons with a CD4+ > 300 x 10(6)/l; at the end of the study 43% had. In 1995, 57% had a positive attitude towards treatment of asymptomatic persons with a CD4+ < or = 300 x 10(6)/l, and 52% towards treatment of symptomatic patients with a CD4+ < or = 400 x 10(6)/l; heterosexual GPs more often had a positive attitude as compared to homosexual GPs (p = 0.005 and p = 0.01, respectively). At the end of the study the proportions of GPs with a positive attitude had increased from 57 to 81% and 52 to 95%, respectively. The risk of adverse effects, strict dose regimens and medicalization were regarded as the main disadvantages of the current treatment strategy. The conclusion is that the attitude towards ART has become more positive since 1995. At the beginning of 1997, however, there still existed reservations about treatment of asymptomatic persons with CD4+ cell counts > 300 x 10(6)/l.

[Worldwide care of people with HIV-infection or AIDS; report of an international conference held in Amsterdam]. / Wereldwijde zorg voor mensen met HIV-infectie of AIDS; verslag van een internationale conferentie in Amsterdam.

Millions of people all over the world are HIV-infected; 90% of them are living in developing countries. Other heavily affected groups are homosexual males, drug addicts, workers in the sex industry and other fringe groups. Taking suitable care of these patients and their families is a major task. This was the subject of the third international conference on home and community care in HIV infection/aids, held in Amsterdam in May 1997. There is a world of difference between the rich West and developing countries in regard to number of patients and availability and accessibility of care. Moreover, in developing countries the inferior socioeconomic position of women and children substantially impairs effective care programmes. Drugs against HIV and against opportunistic infections, and means of palliative care are not available and not affordable in these countries. Local initiatives to improve this situation can only succeed given an infrastructure for the care that is supported by the authorities, so that continuity is guaranteed. Structural cooperation between these authorities and international bodies, and large-scale support by Western foreign aid services are indispensable.

When do HIV-infected persons start with antiretroviral therapy? A retrospective analysis of patients' monitoring and treatment status in general practice, as compared with the 1991 Dutch HIV treatment guidelines.

OBJECTIVE: We aimed to compare, in a sample of Amsterdam general practices, the monitoring and treatment status of HIV-infected patients according to the 1991 Dutch consensus guidelines for antiretroviral treatment of HIV-infection, which advise that therapy be started at a peripheral blood CD4+ cell count of < or = 300 x 10(6)/l in asymptomatic patients, or < or = 400 x 10(6)/l in symptomatic patients. METHOD: In 1994, data were collected from the records of all 511 HIV-infected patients registered in 14 Amsterdam general practices (20 doctors). The main outcome measures were the antiretroviral treatment status of all patients who were eligible for treatment, and the disease stage and CD4+ cell counts at the onset of therapy for patients who started treatment after publication of the 1991 guidelines. RESULTS: For 472 patients, data were available on CD4+ cell measurement status and disease stage. For 15.9% of patients, CD4+ cells had never been measured; most of them were asymptomatic. In 84.1 % of patients, CD4+ cells had been measured. Of the 8.9% of patients whose results were not known to GPs, 93% were treated by a specialist and 76% were symptomatic. Of the remaining 355 (75.2%) patients whose CD4+ count and disease status were known, 201 (56.7%) met the guideline criteria for treatment. Of these, 53.7% received treatment, 27.4% were never treated and 18.9% had discontinued treatment. Of the 67 patients who started treatment after publication of the guidelines, 36.2% of asymptomatic patients and 92.8% of symptomatic patients started later than the guidelines advised. CONCLUSION: In the population studied, we found a discrepancy between the 1991 treatment guidelines and the actual situation. In a substantial proportion of eligible patients, antiretroviral treatment was either not administered at all or was administered at a (very) late disease stage. This can only be attributed to physicians' and/or patients' attitudes towards antiretroviral treatment. Other studies confirm that a number of psychological factors may influence treatment decisions. The new combination treatment of HIV-infection requires an early start and compliance with the guidelines. The degree to which doctors and patients are willing and able to comply with the guidelines is an important factor to be taken into account, both in research and in the development of guidelines.

Deliberate departures from good general practice: a study of motives among Dutch general practitioners.

BACKGROUND: When general practitioners (GPs) act contrary to their own standards of good practice, they usually cite patient demands as the main reason. However, up until now, studies have relied on doctors' recollections of departures from their own norms, which may be unreliable. AIM: To systematically explore GPs' motives for deliberate departures from their own conception of good practice. METHOD: Forty-nine GPs, over five days, registered to what extent they had deviated from their own norms, and recorded the motives underlying any deviation. RESULTS: Of the 6087 consultations registered, 10% contained some departure from 'good' general practice, the majority (75%) of which was perceived by the doctor concerned as 'slight'. Doctors underpinned their departures mostly by referring to the doctor-patient relationship: the wish to be nice was used, on average, in 42% of deviations, and the wish to prevent a conflict in 30%. The most important non-relational motive was clinical uncertainty, which doctors used in 11% of their cases. DISCUSSION: Contrary to common belief, GPs often comply with patient requests because they wish to, and not because they feel forced to. Whether or not this behaviour affects the quality of care is largely dependent on the model of 'good' general practice used.

[AIDS; new developments. IV. Changes in primary medical care due to new possibilities of treating HIV-infected patients]. / AIDS; nieuwe ontwikkelingen. IV. Veranderingen van huisartsgeneeskundige zorg door nieuwe behandelingsmogelijkheden van patiënten met HIV-infectie.

A combination treatment has recently become available for HIV-infected patients; it consists of two reverse transcriptase inhibitors and one protease inhibitor. This combination therapy has consequences for primary medical care as regards diagnostics, treatment, follow-up and counselling of patients with HIV and AIDS, education of patients requiring the HIV test, information of seropositive patients not yet being treated and the cooperation and task distribution between GPs and AIDS specialists. The new combination method creates new problems for patients, such as medicalization of their lives, side effects and compliance; it also affects their prospects (social reintegration, resumed occupational activity). In the medical management, the focus shifts to early start of treatment, stimulating compliance, monitoring of effect and side effects, if any, of the treatment and coping with the patients' uncertainty about durability of the effect. If the new treatment proves to be successful in the long run as well, HIV infection/AIDS will become a chronic disease, so that the needs of care and the care methods will increasingly resemble those of other chronic diseases. There will be a growing need of extramural care, leading to new requirements regarding the study of medicine and postgraduate instruction of GPs.

[Family practice management in urethritis. II. Comparison of clinical management to the protocol]. / Het huisartsgeneeskundig handelen bij urethritis. II. Toetsing van het medisch handelen aan het protocol.

OBJECTIVE: To describe general practitioners' approach to and management of urethritis in men, and to compare this with a general practice protocol for urethritis. DESIGN: Descriptive. SETTING: General practices in Amsterdam. PATIENTS AND METHODS: In 13 general practices in Amsterdam (23,510 patients, of whom 11,627 men) all episodes of urethritis in men (n = 55) were recorded during one year (complaints, medical management, diagnosis, medication, follow-up). OUTCOME MEASURES: Description of the diagnostic and therapeutic approach and the course of episodes; rough comparison with the urethritis protocol. RESULTS: In 25% the urine sediment was examined; other office tests were rarely performed. In 30 to 40% out of office microbiological tests were performed. In 50% of new diagnoses medication was underdosed, in some cases medication was wrong or not broad enough. In 25% explicit education was offered. In 22% new medication was given in the follow-up encounter. CONCLUSIONS: (Comparison with protocol.) Urine sediment examination as an effective test is performed insufficiently often. Other office tests are rarely performed, in accordance with the protocol. Out of office microbiological tests are performed too often, judged by the few changes of diagnosis and the character of new medication in the follow-up. First treatment is often underdosed and sometimes wrong. First treatment should preferably be broad, adequately dosed and independent of out of office microbiology. Too little education is given concerning the risks of ascending infections in female partners and of HIV infection. The referral rate is very low. It is important to pay attention to the outcome of this study in (postgraduate) education for general practitioners, as they treat the vast majority of urethritis patients.

[Relationship between the use of postgraduate educational material on human immunodeficiency virus and the number of HIV consultations in family practice]. / Samenhang tussen het gebruik van nascholingsmateriaal over het humaan immunodeficiëntievirus en het aantal HIV-consulten in huisartspraktijken.

An enquiry using a structured questionnaire was conducted among all 6300 GPs in the Netherlands in order to assess the distribution of HIV-related problems over general practices in the Netherlands and the influence on it of the use of the 'HIV-wijzer voor de huisarts', a loose-leaf handbook on HIV, distributed since 1988 among all Dutch general practitioners. The enquiry was conducted one year after its publication. The 2156 respondents (34%) appeared to be reasonably representative of all GPs. The results show minor imperfections because a small proportion of the questionnaires was filled out incompletely. Almost 90% of respondents mentioned HIV-related consultations, 24% had HIV-seropositive patients and 18% had AIDS patients. These numbers were correlated mainly with municipality size, less with region. The use of the 'HIV-wijzer' was related to occurrence of HIV-related consultations and AIDS patients in a practice. GPs who do not encounter these problems are little motivated to read the 'HIV-wijzer'. For them, other means of education have to be developed or HIV has to be included in existing education programmes on other subjects.

[Consultations concerning venereal diseases and AIDS at the weekend outpatient clinic for homosexual men: developments 1983-1987]. / Hulpvragen inzake geslachtsziekten en AIDS in de weekendpolikliniek voor homoseksuele mannen: ontwikkelingen 1983-1987.

In the Amsterdam gay weekend clinic the trends in numbers and sorts of sexually transmitted diseases (STD) and reasons for consultation about AIDS from 1983 till 1988 were assessed. A strong decrease in STD consultations and diagnoses was seen, especially concerning urethral and anorectal gonorrhoea. At the same time, consultations about AIDS strongly increased. These data support the hypothesis that gay men have changed their sexual behaviour.

[Whom the condom fits: mechanical and mental barriers]. / Wie het condoom past. Mechanische en psychische barrieres.

PIP: Latex condoms of good quality offer protection against pregnancy and many sexually transmitted diseases including human immunovirus (HIV) infection if used consistently and properly. Addition of a paste containing nonoxynol-9 spermicide increases the protective effect and even seems (in vitro) to give consistent protection with leaking or torn condoms. The greatest disadvantage for effective prophylaxis by means of condoms are then: the unsatisfactory quality of a proportion of the product; the lack of popularity; improper use; and unsatisfactory fitting. The first 2 factors are important considerations for the manufacturers, the authorities, and the retailers; the other factors may be ascribed to understandable resistance, doubt, and/or ignorance on the part of the potential users.^ieng