Computed critiquing integrated into daily clinical practice affects physicians' behavior--a randomized clinical trial with AsthmaCritic.

OBJECTIVE: We developed AsthmaCritic, a non-inquisitive critiquing system integrated with the general practitioners' electronic medical records. The system is based on the guidelines for asthma and chronic obstructive pulmonary disease (COPD) as issued by the Dutch College of General Practitioners. This paper assesses the effect of AsthmaCritic on monitoring and treatment of asthma and COPD by Dutch general practitioners in daily practice. METHODS: A randomized clinical trial in 32 practices (40 Dutch general practitioners) using electronic patient records. An intervention group was given the use of AsthmaCritic, a control group continued working in the usual manner. Both groups had the disposal of the asthma and COPD guidelines routinely distributed by the Dutch College of General Practitioners. We measured the average number of contacts, FEV 1 (forced expiratory volume), and peak-flow measurements per asthma/COPD patient per practice; and, the average number of antihistamine, cromoglycate, deptropine, and oral bronchodilator prescriptions per asthma/COPD patient per practice. RESULTS: The number of contacts increased in the age group of 12-39 years. The number of FEV1 , peak-flow measurements, and the ratio of coded measurements increased, whereas the number of cromoglycate prescriptions decreased in the age group of 12-39 years. CONCLUSIONS: Our study shows that the guideline-based critiquing system AsthmaCritic changed the manner in which the physicians monitored their patients and, to a lesser extent, their treatment behavior. In addition, the physicians changed their data-recording habits.

Higher prevalence of depressive symptoms in middle-aged men with low serum cholesterol levels.

OBJECTIVE: Investigators from several studies have reported a positive relationship between low cholesterol levels and death due to violent causes (eg, suicide and accidents), possibly mediated by depressive symptoms, aggression or hostility, or impulsivity. We set out to establish whether middle-aged men with chronically low cholesterol levels (< or =4.5 mmol/liter) have a higher risk of having depressive symptoms, according to scores on the Beck Depression Inventory, compared with a reference group of men with cholesterol levels between 6 and 7 mmol/liter. A similar comparison was also made for measures of anger, hostility, and impulsivity. METHODS: Cholesterol measurements were obtained as part of a population-based cholesterol screening study in 1990-1991. These levels were remeasured in 1993-1994. Only those whose cholesterol level remained in the same range were included in the study. Depressive symptoms were assessed by using the Beck Depression Inventory; anger, by questionnaires based on the Spielberger Anger Expression Scale and State-Trait Anger Scale; hostility, by the Buss-Durkee Hostility Inventory; and impulsivity, by the Eysenck and Eysenck Impulsivity Questionnaire. RESULTS: Men with chronically low cholesterol levels showed a consistently higher risk of having depressive symptoms (Beck Depression Inventory score > or =15 or > or =17) than the reference group, even after adjusting for age, energy intake, alcohol use, and presence of chronic diseases. No differences in anger, hostility, and impulsivity were observed between the two groups. CONCLUSIONS: Men with a lower cholesterol level (< or =4.5 mmol/liter) have a higher prevalence of depressive symptoms than those with a cholesterol level between 6 and 7 mmol/liter. These data may be important in the ongoing debate on the putative association between low cholesterol levels and violent death.

Selecting subjects for ultrasonographic screening for aneurysms of the abdominal aorta: four different strategies.

BACKGROUND: We studied whether the effectiveness of ultrasound screening for abdominal aortic aneurysms could be increased by preselecting high-risk subjects, based on the presence of risk indicators for the disease. METHODS: In a population-based screening programme for abdominal aortic aneurysms among 5328 subjects living in Rotterdam, The Netherlands, we studied four different strategies to select subjects for ultrasound screening of the abdominal aorta, based on risk indicators for abdominal aortic aneurysm disease. Risk indicators used in each strategy were entered in a logistic regression model to predict the probability of an individual having an abdominal aortic aneurysm. Using several cutoff values for the probability of a subject having an aneurysm for each strategy, we estimated the proportion of subjects that should be referred for ultrasound screening and the proportion of aneurysms that would be diagnosed by each strategy (sensitivity). RESULTS: When a probability of 1.5% of having an aneurysm is chosen as the cutoff point above which ultrasound screening is indicated, the proportion of subjects that would be referred for screening ranged from 36% (first strategy) to approximately 50% (other strategies), while 80% (first strategy) to approximately 94% (other three strategies) of all aneurysms would be detected. CONCLUSION: Effectiveness in screening for abdominal aortic aneurysms can be increased by selecting subjects by means of a short medical questionnaire, filled out by the screening candidates, including questions on medical history.

Differences in observer variability of ultrasound measurements of the proximal and distal abdominal aorta.

OBJECTIVE: To assess the observer variability of ultrasound measurements of the abdominal aorta and to study whether observer variability is influenced by the site of measurement or cardiovascular risk factors. SETTING: Population based screening programme for abdominal aortic aneurysms. METHODS: For 135 subjects taking part in a screening programme for abdominal aortic aneurysms, two of the three ultrasonographers measured the distal and proximal ultrasound diameter of the abdominal aorta, using B-mode ultrasound, according to the Rotterdam study scanning protocol. RESULTS: The mean difference between two different observers was 0.06 mm (95% CI-0.15 to 0.27) for measurements of the distal aorta and 0.32 mm (95% CI 0.09 to 0.55) for the proximal aorta. Maximal differences between observers for measurements of both the distal and proximal aortic diameter were 4.0 mm. Interobserver variability in the proximal and distal measurements of the abdominal aorta was not related to the level of the major cardiovascular risk indicators. However, interobserver variability in ultrasound measurements of the proximal aorta increased with increasing waist circumference and increasing diameter of the proximal aorta. CONCLUSION: Ultrasonographic readings of the distal and proximal aortic measurements can be interpreted within a range of plus or minus 3 mm. Ultrasound measurements are more accurate for the distal than for the proximal measurement. Definition of the aortic diameter based on a combination of both distal and proximal measurement may be more accurate.

Withdrawal of long-term diuretic medication in elderly patients: a double blind randomised trial.

OBJECTIVES: About 20% of elderly people use long-term diuretic medication, but there is doubt whether prolonged diuretic medication on such a large scale is necessary. We performed a study to assess what proportion may successfully be withdrawn from diuretic therapy. DESIGN: Double blind randomised controlled trial with six month follow up. SETTING: General practice. SUBJECTS: 202 patients taking long-term diuretics without manifest heart failure or hypertension. INTERVENTIONS: Patients were allocated to either placebo (withdrawal group, n = 102) or continuation of diuretic treatment (control group, n = 100). MAIN OUTCOME MEASURE: Occurrence of clinical conditions requiring diuretic therapy based on fixed criteria. RESULTS: During follow up diuretic therapy was required in 50 patients in the withdrawal group and 13 in the control group (risk difference 36%; 95% confidence interval 22% to 50%). Heart failure was the most frequent cause of prescribing diuretic therapy (n = 25). Cessation of diuretic therapy caused a mean increase in systolic blood pressure of 13.5 (9.2 to 17.8) mm Hg and in diastolic pressure of 4.6 (1.9 to 7.3) mm Hg. CONCLUSION: Withdrawal of long-term diuretic treatment in elderly patients leads to symptoms of heart failure or increase in blood pressure to hypertensive values in most cases. Any attempt to withdraw diuretic therapy requires careful monitoring conditions, notably during the initial four weeks.

Continuity of information in cancer care: evaluation of a logbook.

A logbook, or patient-dossier, was developed, to improve continuity of information in the treatment and care of head-and-neck cancer patients. It contained information modules on different aspects of care, as well as forms to facilitate communication both between patient and care-professional and between the various care-professionals. The logbook's effectiveness was evaluated in two hospitals in Rotterdam, by comparing outcomes for trial and comparison groups of, respectively, 71 and 54 patients and 59 and 35 care-professionals. Trial patients proved to be better informed, to receive more support and to experience fewer psychosocial problems. Professionals who used the logbook were better informed about their patients, and about the care-activities of fellow-professionals than those who did not. They recognised an improvement in their contact with colleagues and in the harmonisation of their respective care-activities.

Implementation of a pre-hospital decision rule in general practice. Triage of patients with suspected myocardial infarction.

OBJECTIVE: To improve pre-hospital triage of patients with suspected acute cardiac disease. DESIGN: Prospective study. SUBJECTS. Patients with symptoms suggestive of acute cardiac pathology, who were seen by a general practitioner, for whom acute admission into hospital was requested, and in whom a pre-hospital electrocardiogram was recorded by the ambulance service. METHODS: The study consisted of two phases. In the first phase, a decision rule was developed based on clinical characteristics and electrocardiographic findings in 1005 patients with suspected acute cardiac pathology. In the second phase, the decision rule was prospectively validated. Symptoms were recorded by a standardized questionnaire by the general practitioner and a computerized electrocardiogram was made by the ambulance nurses at the patient's home. Three electrocardiographic outcomes were available: 'normal electrocardiogram', 'possible myocardial infarction' or 'extensive myocardial infarction'. By use of the predictive model, the general practitioner could decide if hospitalization was necessary or not. MAIN OUTCOME MEASUREMENTS: Identification of patients at low (stable angina, atypical chest pain, other pathology) and high (myocardial infarction, unstable angina) probability of acute cardiac pathology. RESULTS: Among 977 patients with a complete pre-hospital evaluation in the validation phase of the study, the decision rule recommended 'no hospitalization' in 227 patients (23%). The general practitioner followed this advice in 44% of these patients. Although seven of them developed a non-Q wave myocardial infarction, no complications occurred in patients not admitted. In addition, the general practitioner did not hospitalize 19 (2%) of 750 patients for whom the decision rule recommended admission. Pre-hospital triage by the general practitioner resulted in a 12% (118 of 977 patients) reduction of the number of patients admitted to the Coronary Care Units. CONCLUSIONS: Pre-hospital triage by the general practitioner was facilitated using a standardized questionnaire and pre-hospital electrocardiography, and resulted in a reduction in the number of patients admitted to the Coronary Care Unit, and proved to be safe.

Aneurysms of the abdominal aorta in older adults. The Rotterdam Study.

To assess the age- and sex-specific prevalence and risk factors for aneurysms of the abdominal aorta, the authors performed a population-based study in 5,419 subjects (42% men, 58% women) aged 55 years and over. The proximal and distal diameter of the abdominal aorta were measured by ultrasound. An aneurysm was defined as a distal aortic diameter of 35 mm or more or a dilatation of the distal part of the the abdominal aorta of 50% or more. The mean distal and proximal aortic diameter increased 0.7 mm and 0.3 mm, respectively, with every 10 years of age. In 2.1% (95% confidence interval (CI) 1.7-2.5) of the study population, an aneurysm was present, or in 4.1% (95% CI 3.2-4.9) of the men and 0.7% (95% CI 0.4-1.0) of the women. Subjects with an abdominal aneurysm were more likely to be smokers and they had higher serum cholesterol levels and higher prevalence of cardiovascular disease compared with subjects without an aneurysm. The authors conclude that the ultrasound diameter of the abdominal aorta clearly increases with age in both men and women and that the prevalence of aneurysms of the abdominal aorta in older adults in relatively high, especially in men.

Pre-hospital thrombolytic therapy with either alteplase or streptokinase. Practical applications, complications and long-term results in 529 patients.

OBJECTIVE: To assess the practical application, safety and long-term outcome of pre-hospital thrombolytic intervention with either alteplase or streptokinase in patients with extensive myocardial infarction. DESIGN: Prospective study. SUBJECTS: Patients with chest pain of more than 30 min duration, presenting within 6 h of symptom onset and with electrocardiographic evidence of extensive evolving myocardial infarction. METHODS: Eligibility of patients was established by the general practitioner or the ambulance nurse using a standardized questionnaire with (contra-) indications for thrombolytic therapy. Computerized ECG was recorded by ambulance nurses. In the presence of extensive ST segment elevation (sum ST deviation of at least 1.0 mV), eligible patients received either 100 mg alteplase (n = 246) or 50 mg alteplase in the ambulance followed by 0.75 x 10(6) IE streptokinase in hospital (n = 90), or 1.5 x 10(6) IE streptokinase intravenously (n = 193). MAIN OUTCOME MEASUREMENTS: Death and life-threatening complications (ventricular fibrillation, cardiac arrest) and side effects (hypotension, allergic reactions) during transportation to hospital and in the first 24 h following hospitalization, and survival up to 5 years follow-up. RESULTS: From 1988-1993, 529 patients received thrombolytic treatment initiated pre-hospital. The time gained by pre-hospital administration of thrombolysis amounted to 50 min. The rate of complications during transportation and during the first 24 h after hospitalization was low. Hospital mortality was 2% and 1-year mortality 3%. Cumulative survival at 5 years was 92%. This was superior to the 84% 5-year survival observed in a matched group of 239 patients with similar baseline characteristics treated with alteplase in hospital. CONCLUSIONS: Pre-hospital administration of either alteplase or streptokinase is feasible and safe and results in significant time gain. The long-term prognosis is excellent in spite of extensive evolving myocardial infarction upon admission.

Diuretics, beta-blockers, and the risk for sudden cardiac death in hypertensive patients.

OBJECTIVE: To determine whether the use of non-potassium-sparing diuretics and beta-blockers is associated with an excess risk for sudden cardiac death in hypertensive patients. DESIGN: Case-control study. SETTING: Rotterdam, the Netherlands. PATIENTS: 257 case-patients who had died suddenly while receiving drug therapy for hypertension and 257 living controls also receiving drug therapy for hypertension. MEASUREMENTS: Detailed information on medication use and clinical characteristics of all case-patients and controls was collected from the files of general practitioners. Additional information on medication use was obtained from computerized pharmacy records. RESULTS: Patients receiving non-potassium-sparing diuretics had an increased risk for sudden cardiac death (relative risk, 1.8 [95% CI, 1.0 to 3.1]) compared with a reference group treated primarily with potassium-sparing diuretics. The corresponding relative risk for beta-blocker use was 1.7 (CI, 1.1 to 2.6). The use of non-potassium-sparing diuretics without beta-blockers was associated with a higher risk for sudden death (relative risk, 2.2 [CI, 1.1 to 4.6]) than was concomitant use of non-potassium-sparing diuretics and beta-blockers (relative risk, 1.4 [CI, 0.6 to 3.0]). The risk for sudden cardiac death among recipients of non-potassium-sparing diuretics was more pronounced in those who had been receiving the diuretic for less than 1 year and in those aged 75 years or younger. CONCLUSIONS: The use of non-potassium-sparing diuretics and beta-blockers is associated with an increased risk for sudden cardiac death. This association may offset part of the mortality benefit of these drugs in the treatment of hypertension.

Interobserver agreement on iliac crest pain syndrome in general practice.

OBJECTIVE: To investigate the degree of interobserver agreement on the iliac crest pain syndrome (ICPS) in patients with nonspecific low back pain in general practice. METHODS: Sixty-one patients with nonspecific low back pain were recruited by 11 general practitioners. All patients answered a questionnaire and underwent a standard examination. Each patient was examined by 2 independent observers. RESULTS: Kappa for ICPS was 0.57 (95% CI: 0.34-0.79). For the "localized tenderness" and "typical pain" criteria, kappa was 0.57 (95% CI: 0.40-0.73) and 0.66 (95% CI: 0.48-0.83), respectively. CONCLUSION: The presence of ICPS can be judged with good interobserver agreement. Clear definition of the diagnostic criteria and examining techniques, and multiple training sessions before and during the study are prerequisites. ICPS represents a group of patients with low back pain with the same symptoms and signs. A homogeneous group facilities studies on natural history, prognosis, and therapy.

Optimal use of coronary care units: a review.

Patients at a low probability of acute cardiac pathology constitute a considerable proportion in many coronary care units (CCUs), such that physicians should consider more effective alternatives than CCU admission "to rule out myocardial infarction." In this article, strategies to increase the efficiency of managing patients with acute chest pain are reviewed. Algorithms aiming to improve the diagnostic accuracy of the general practitioner have been developed but require an electrocardiogram recorded at the home of the patient. Another method of triage encompasses the identification in the emergency room of the hospital of patients at a low probability of acute cardiac pathology by using predictive models that include laboratory assessments. A third strategy includes alternatives to CCUs for patients at a low risk of acute cardiac pathology, such as the creation of a simple observation unit. Finally, some investigators have sought to identify patients with good prognosis for early transfer from the CCU to lower levels of care. It is concluded that a combination of these approaches will be most efficient, and that the most appropriate choice will be determined by local circumstances.

Patient and doctor delay in acute myocardial infarction: a study in Rotterdam, The Netherlands.

BACKGROUND: Early thrombolytic therapy for patients having a myocardial infarct size and improves survival. AIM: A study was undertaken to examine the components of pre-hospital delay in patients with retrospectively proven myocardial infarction. METHOD: Data were gathered from 300 patients with a documented myocardial infarction admitted to three hospitals in Rotterdam, the Netherlands. Interviews were carried out with patients, questionnaires were given to their spouses or significant others, medical information was provided by cardiologists, and logbook information was gathered from the ambulance service. RESULTS: Half of all patients (51%) called for medical help within 30 minutes of symptom onset. General practitioners arrived within 11 minutes in half of the 257 cases to which they were called. However, in half of the 257 cases, decision making by the general practitioner before the patient was sent to a hospital took more than 82 minutes. The ambulance arrived within 15 minutes in 90% of all 242 cases, while the time required for stabilization of the patient by the ambulance staff and transport to the hospital took a median of 15 minutes. CONCLUSION: Compared with earlier studies, patients with a myocardial infarction called for help sooner. However, it may take a considerable time before the general practitioner refers the patient to hospital. Further research is needed to design measures which will improve the diagnostic power of the general practitioner in order to further reduce pre-hospital delay.

Pre-hospital triage of patients with suspected myocardial infarction. Evaluation of previously developed algorithms and new proposals.

OBJECTIVE: To evaluate previously developed algorithms for the improvement of pre-hospital triage of patients with suspected acute cardiac disease. DESIGN: Prospective study. SUBJECTS: Patients with symptoms of possible cardiac origin, who were seen by a general practitioner and subsequently referred to hospital in the municipality of Rotterdam. METHODS: Prior to hospital admission, patients with suspected acute coronary disease recorded their symptoms by standardized questionnaire and a computerized ECG was made. All patients were hospitalized and a final diagnosis was established. Algorithms proposed by other investigators to distinguish patients with, from those without, acute cardiac disease were tested. MAIN OUTCOME: Identification of patients whose likelihood for acute cardiac pathology was low (stable angina, atypical chest pain, other pathology) or high (myocardial infarction, unstable angina). RESULTS: A total of 1005 patients were studied. Forty-two percent had myocardial infarction or unstable angina pectoris. Evaluation of previously developed algorithms showed that their diagnostic accuracy was poor in the pre-hospital setting. In a separate multivariate analysis, six characteristics from the clinical history and an electrocardiogram appeared to be independently and significantly associated with acute cardiac pathology. The presence of an abnormal ECG proved to be the most important predictor. CONCLUSIONS: The hospital-based algorithms were unsuitable as a predictor for pre-hospital acute cardiac pathology. A new practical hospital admission model was developed, based on six clinical predictors, including analysis of an electrocardiogram. Following appropriate validation, this out-of-hospital protocol may lead to better triage decisions by the general practitioner.

Accuracy of an oscillometric automatic blood pressure device: the Omron HEM403C.

The purpose of this study was to assess the accuracy of the Omron HEM403C blood pressure (BP) device and to study whether this accuracy was affected by subject-related factors such as BP level and age. A comparison was made with a Hawksley random zero sphygmomanometer. BP was measured with both meters connected to one arm-cuff by means of a T-connector. To assess the level of agreement of the Omron HEM403C with the random zero meter, BP was measured in 212 subjects. Systolic and diastolic readings with the Omron HEM403C were on average 1 mmHg (s.d. 9, 95% CI 0.4-2.2) and 4 mm Hg (s.d. 8, 95% CI 3.6-5.1) respectively, higher than those with the random zero meter. The Omron HEM403C underestimated SBP compared with the random zero at higher SBP levels and overestimated SBP at lower SBP levels. The Omron meter overestimated the diastolic pressure at all DBP levels and the diastolic difference was not related to the DBP level. A multiple linear regression analysis demonstrated that the SBP level and not age was the factor that independently influenced the systolic difference between the meters. According to the criteria of the British Hypertension Society the Omron HEM403C is accurate enough to be recommended for those clinical and research purposes that are in need of automatic measurements.

The introduction of computer-based patient records in The Netherlands.

Computer-based patient records, although an area of active research, are not in widespread use. In June 1992, 38% of Dutch general practitioners had introduced computer-based patient records. Of these, 70% had replaced the paper patient record with a computer-based record to retrieve and record clinical data during consultations. Possible reasons for the use of computer-based patient records include the nature of Dutch general practice and the early and active role of professional organizations in recognizing the potential of computer-stored patient records. Professional organizations issued guidelines for information systems in general practice, evaluated available systems, and provided postgraduate training that prepares physicians to use the systems. In addition, professional organizations successfully urged the government to reimburse general practitioners part of the expenses related to the introduction of computer-based patient records. Our experience indicates that physicians are willing and able to integrate information technology in their practices and that professional organizations can play an active role in the introduction of information technology.