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J van der Lei

Publications and source records attributed to J van der Lei.

At least 19 recordsLinked to original sources
PubMed2001

Assessment of decision support for blood test ordering in primary care. a randomized trial.

BACKGROUND: Different methods for changing blood test-ordering behavior in primary care have been proven effective. However, randomized trials comparing these methods are lacking. OBJECTIVE: To compare the effect of two versions of BloodLink, a computer-based clinical decision support system, on blood test ordering among general practitioners. DESIGN: Randomized trial. SETTING: 44 practices of general practitioners in the region of Delft, the Netherlands. PARTICIPANTS: 60 general practitioners in 44 practices who used computer-based patient records in their practices. INTERVENTION: After stratification by solo practices and group practices, practices were randomly assigned to use BloodLink-Restricted, which initially displays a reduced list of tests, or BloodLink-Guideline, which is based on the guidelines of the Dutch College of General Practitioners. MEASUREMENTS: Average number of blood tests ordered per order form per practice. RESULTS: General practitioners who used BloodLink-Guideline requested 20% fewer tests on average than did practitioners who used BloodLink-Restricted (mean [+/-SD], 5.5 +/- 0.9 tests vs. 6.9 +/- 1.6 tests, respectively; P = 0.003, Mann-Whitney test). CONCLUSIONS: Decision support based on guidelines is more effective in changing blood test-ordering behavior than is decision support based on initially displaying a limited number of tests. Guideline-driven decision support systems can be effective in reducing the number of laboratory tests ordered by primary care practitioners.

Decision Support Techniques↗
PubMed2001

Incidence of priapism in the general population.

OBJECTIVES: To assess the incidence of priapism in the general population. METHODS: We conducted a population-based retrospective cohort study within a general practitioners research database. Our study population comprised all male patients with permanent registration status with a general practitioner. All patients with an International Classification for Primary Care code for penile problems (Y01, Y04, Y08) were identified. In addition, a free text search on priapism and painful erection was conducted. The computerized medical records from all potential patients were reviewed, and we requested additional information from the general practitioner if priapism was suspected. RESULTS: The total study cohort comprised 145,071 men, with a total follow-up of 341,133 person-years. Five patients developed a first occurrence of priapism during the follow-up period, corresponding to an overall incidence rate of 1.5 per 100,000 person-years (95% confidence interval 0.2 to 2.8). The incidence rate in men 40 years old and older was 2.9 per 100,000 person-years (95% confidence interval 0.1 to 5.7). No cause of priapism was apparent in 2 patients, 2 cases occurred after intracavernous injection of vasodilators, and 1 patient experienced priapism because of sickle cell disease. CONCLUSIONS: The incidence of priapism is low but seems higher than was previously assumed.

Adult↗
PubMed2000

[Detailed analysis of the societal costs of diabetes mellitus].

OBJECTIVE: Estimation of the societal costs of diabetes and related complications in support of the revision of the diabetes guidelines. DESIGN: Retrospective and descriptive cross-sectional study. METHODS: Relative risks (RRs) of diabetes complications, by age, were determined by comparing patients with and without diabetes. Using existing 1994 General Practitioner registry data on prevalence, on costs of illnesses and on absenteeism, the contribution of diabetes to the costs of other illnesses was estimated on the basis of aetiological fractions calculated with the RRs found. Cost due to absenteeism by diabetes complications were calculated using the friction method. RESULTS: In 1994, the societal cost of diabetes were 1.67 milliard Dutch guilders (1.55-1.87; range determined by applying the 95% confidence intervals of the RRs; in Euro: 758 million (703-848). The costs due to absenteeism from work were almost 0.2 milliard. The medical costs of diabetes were 2.5% of the health care budget. The contribution of diabetes to the medical costs of cardiovascular diseases was 14%.

Cost of Illness↗
PubMed1999

A study of PROforma, a development methodology for clinical procedures.

Knowledge engineering has shown that besides the general methodologies from software engineering it is useful to develop special purpose methodologies for knowledge based systems (KBS). PROforma is a newly developed methodology for a specific type of knowledge based systems. PROforma is intended for decision support systems and in particular for clinical procedures in the medical domain. This paper reports on an evaluation study of PROforma, and on the trade-off that is involved between general purpose and special purpose development methods in Knowledge Engineering and Medical AI. Our method for evaluating PROforma is based on re-engineering a realistic system in two methodologies: the new and special purpose KBS methodology PROforma and the widely accepted, and more general KBS methodology CommonKADS. The four most important results from our study are as follows. Firstly, PROforma has some strong points which are also strong related to requirements of medical reasoning. Secondly, PROforma has some weak points, but none of them are in any way related to the special purpose nature of PROforma. Thirdly, a more general method like CommonKADS works better in the analysis phase than the more special purpose method PROforma. Finally, to support a complementary use of the methodologies, we propose a mapping between their respective languages.

Artificial Intelligence↗
PubMed1999

An inventory of publications on electronic patient records.

This study describes an analysis of 1832 papers dealing with electronic patient records, and indexed in NLM's MEDLINE. Of each retrieved publication the country of origin and the journal in which it was published was determined. Furthermore, insight into the subjects of the publication was obtained by analysing the MeSH terms by which it was indexed. Since 1990 the number of publications on electronic patient records has increased. Publications originated from 43 different countries representing all continents. However, 75% stemmed from only 4 countries. The publications appeared in 379 different journals, of which 26 journals had 10 or more publications. Of all publications, 5.3% had appeared in journals with an impact factor of at least 4.5. The topics most often dealt with were: Hospital Information Systems, Computer Communication Networks, User-Computer Interface, Confidentiality and Computer Security. No obvious trends, other than an increased interest in confidentiality and computer security, were observed.

Abstracting and Indexing↗
PubMed1999

Postmarketing surveillance based on electronic patient records: the IPCI project.

Researchers claim that data in electronic patient records can be used for a variety of purposes including individual patient care, management, and resource planning for scientific research. Our objective in the project Integrated Primary Care Information (IPCI) was to assess whether the electronic patient records of Dutch general practitioners contain sufficient data to perform studies in the area of postmarketing surveillance studies. We determined the data requirements for postmarketing surveillance studies, implemented additional software in the electronic patient records of the general practitioner, developed an organization to monitor the use of data, and performed validation studies to test the quality of the data. Analysis of the data requirements showed that additional software had to be installed to collect data that is not recorded in routine practice. To avoid having to obtain informed consent from each enrolled patient, we developed IPCI as a semianonymous system: both patients and participating general practitioners are anonymous for the researchers. Under specific circumstances, the researcher can contact indirectly (through a trusted third party) the physician that made the data available. Only the treating general practitioner is able to decode the identity of his patients. A Board of Supervisors predominantly consisting of participating general practitioners monitors the use of data. Validation studies show the data can be used for postmarketing surveillance. With additional software to collect data not normally recorded in routine practice, data from electronic patient record of general practitioners can be used for postmarketing surveillance.

Family Practice↗
PubMed1999

Design of a decision support system for test ordering in general practice: choices and decisions to make.

The increased availability of tests in the past years has been accompanied by an increased number of blood tests ordered by general practitioners. Dutch investigators report a lack of general practitioners' knowledge concerning the indications for blood tests leading to inappropriate and inadequate use of diagnostic tests. Taking advantage of the use of electronic patient records by Dutch general practitioners, the authors replaced the traditional paper forms for test ordering by a decision-support system. The objective of the decision-support system is to change test-ordering behavior. Designing a system to change test-ordering behavior, however, required the selection of a method to provide support. To study different methods for changing test-ordering behavior, the authors developed two versions of the decision-support system BloodLink. The first version, BloodLink-Restricted, is based on the notion of restricting the number of choices presented to the general practitioners. The second version, BloodLink-Guideline, is based on the guidelines provided by the Dutch college of general practitioners.

Blood Chemical Analysis↗
PubMed1998

Skin reactions to antibacterial agents in general practice.

OBJECTIVES: To quantify the risk of skin reactions to antibacterial drugs under everyday circumstances in a large population with automated data from general practitioners (GP). DESIGN: A retrospective cohort study in a dynamic population. SETTING: Data came from the Integrated Primary Care Information (IPCI) database. The IPCI database consists of all data on consultations, morbidity, and prescriptions and other interventions, as registered by the GP in a source population of approximately 150,000 persons. METHODS: The study period started on April 1, 1994, and ended on September 30, 1995. All patients who were treated with an antibacterial drug were enrolled on the first day of starting treatment until the end of the study period or until the occurrence of one or more of the following diagnoses within the risk period: allergic reaction, rash, erythema, pruritus and urticaria, or a notification of a skin reaction in the free text. Subsequently, patient profiles were assessed by two authors who were blinded to exposure. The risk period was defined as the legend duration of the antibacterial drug plus 14 days to control for carry-over of drug effects and delay in patient presentation. Age, gender, and comedication were examined as potential confounders. RESULTS: In the study period 13,679 patients received 19,961 prescriptions of an antibacterial drug. It concerned 5330 men (39.0%) and 8349 (61.0%) women with a mean age of 41 and 42 years, respectively. One hundred thirty-five patients developed a skin reaction in the risk period. Rash, pruritus, urticaria, and miscellaneous skin reactions were encountered in 76 (56.3%), 18 (13.3%), 19 (14.1%), and 22 (16.3%) patients, respectively. The three most frequently reported causes of skin reactions were combinations of trimethoprim with sulfonamides (2.1% of users; incidence density [ID]: 2.1/1000 exposed days), fluoroquinolones (1.6% of users; ID: 1.5/1000 person days), and penicillins (1.1% of users; ID: 1.3/1000 person days). Compared to tetracyclines, the broad-spectrum penicillins showed an incidence density ratio (IDR) of 3.7, the combination of amoxicillin with clavulanic acid of 3.3, the fluoroquinolones of 2.8, and the combination of trimethoprim with sulphonamides of 4.4. The presence of infectious mononucleosis increased the risk of rash in amoxicillin users with a factor of 58. CONCLUSIONS: We found that the frequency of skin reactions to antibacterial drugs in general practice is around 1% and highest for the combination of trimethoprim with sulphonamides, penicillins, and fluoroquinolones. The outpatient incidence for skin reactions is probably lower than the incidence in hospitalized patients. Although this may be partly explained by negative misclassification, it is also likely that the actual incidence is lower as some hospitalized patient groups may be more prone to develop a skin reaction.

Adolescent↗
PubMed1997

The availability of unavailable information.

Currently, developers of decision-support systems try to integrate these systems with the electronic medical record. The drawback is a limited amount of recorded medical data. System developers who face the choice between designing an integrated 'non-inquisitive' system and an integrated 'inquisitive' system need insight into the availability of information that is being missed by the support system. Therefore, we have investigated in a simulation study, the reasons why information that was being missed from the electronic medical records of patients with asthma/COPD by reviewers, had not been recorded by general practitioners. Important reasons were: the physicians had not recorded the information explicitly, they assumed the requested information to be common knowledge, and the information was available elsewhere in the electronic medical record. Also, we investigated the reasons why information that was being missed, could not be made available by the physicians. Important reasons were: the decision had been made by another decision maker, or the physician had not recorded the information at the time of the encounter. In addition to insight into the availability of missing information, system developers need to have insight into the significance of this information for the quality of the decision support, before the final choice between a non-inquisitive and an inquisitive design can be made.

Asthma↗
PubMed1996

Cough due to ACE inhibitors: a case-control study using automated general practice data.

OBJECTIVES: To determine the risk of coughing as an adverse reaction to ACE inhibitors under everyday circumstances in a large population, and to study whether this adverse effect was duration or dose dependent. DESIGN: A population-based case-control study. SETTING: Ten general practices of 14 Dutch general practitioners (GP), in which all consultations, morbidity and medical interventions, including drugs prescribed, were registered over the 18 month period from 1st September, 1992 to 1st March, 1994. SUBJECTS: 1458 patients with incident coughing and up to four controls per case were obtained (total 4182 controls), matched for GP. All cases and controls were 20 years or older and had no record of respiratory infection, influenza, tuberculosis, asthma, chronic bronchitis, emphysema, congestive heart failure, sinusitis, laryngitis, haemoptysis or respiratory neoplasms during the study period. RESULTS: Cases were 2.1-times more likely than controls to have been exposed to ACE inhibitors (95% CI 1.5-3.1), but after adjustment the odds ratio was 1.4 (95% CI 0.9-2.1). The crude odds ratio for captopril was 1.3 (95% CI 0.7-2.5), for enalapril 2.6 (95% CI 1.6-4.2) and for lisinopril 2.0 (95% CI 0.5-9.3). The adjusted odds ratio for captopril was 0.9 (95% CI 0.4-1.7), for enalapril 1.7 (95% CI 1.03-2.8) and for lisinopril 1.7 (95% CI 0.4-7.9). For patients who had been on ACE inhibitor treatment for no longer than 2 months the odds ratio was 4.8 (95% CI 1.7-13.3). The odds ratio declined to 2.0 (95% CI 1.1-3.8) for those who had taken an ACE inhibitor for 2-6 months, and to 1.6 (95% CI 0.9-2.7) for those on ACE-inhibitors for more than 6 months. CONCLUSION: The risk of coughing was increased twofold among ACE inhibitor users, but the odds ratios were no longer significant after controlling for several confounding factors. The risk of developing cough due to ACE-inhibitors declines with the duration of treatment, possibly due to depletion of susceptible persons.

Adult↗
PubMed1995

Laboratory services utilization: a survey of repeat investigations in ambulatory care.

BACKGROUND: Earlier studies have shown that repeat investigations are a common cause of unnecessary duplication of laboratory test procedures. Most of the interventions aimed at reducing the number of repeat investigations have not resulted in long-term improvements. None of these studies, however, assessed utilization of laboratory services by physicians, simultaneously treating the same patient. METHODS: For a random sample of 1500 patients, we examined laboratory services utilization by physicians during an 8-month period. We counted the number of patients for whom more than one physician ordered laboratory test procedures simultaneously, and to what extent these procedures overlapped. RESULTS: For 28% of the patients more than one physician had ordered tests. Of all 41,655 tests, 5536 (13%) were repeated by a physician other than the physician who ordered the initial test: 1527 (4%) of the tests were repeated within 5 days. Patients between 70 and 90 years had the highest average number of tests, the highest number of involved physicians, and the smallest mean time between similar tests. CONCLUSIONS: There is a need for better coordination of care. Improved communication among physicians simultaneously treating a patient may lead to a reduction of repeat investigations.

Adolescent↗
PubMed1995

Postmarketing surveillance with computer-based patient records.

Postmarketing Surveillance (PMS) concerns the investigation of side-effects of drugs after they are introduced into the market. Traditionally, data collection for PMS-studies has been paper-based. The increasing number of general practitioners (GP) that use Computer-Based Patient Records (CBPR) and the central role these general practitioners in the Netherlands play in the delivery of care makes the use of CBPRs as a resource of data for PMS studies possible. Analysis of the current available CBPRs, however, proved them insufficient for PMS studies, because too much data is available only in free text, and other necessary data for PMS is lacking. To make the CBPR suitable for PMS, we had to build a software-module that could be plugged into the computer system of the GP. The module checks the data immediately after they it has been entered into the system, and missing data is requested. Initial filed studies have shown that, with this module, the collection of PMS data is feasible.

Medical Records Systems, Computerized↗
PubMed1995

The separation of reviewing knowledge from medical knowledge.

The developers of reviewing systems that rely on computer-based patient-record systems as a source of data need to model reviewing knowledge and medical knowledge. We simulate how the same medical knowledge could be entered in four different systems: CARE, the Arden syntax, Essential-attending and HyperCritic. We subsequently analyze how the original knowledge is represented in the symbols or syntax used by these systems. We conclude that these systems provide different alternatives in dealing with the vocabulary provided by the computer-based patient records. In addition, the use of computer-based patient records for review poses new challenges for the content of that record: to facilitate review, the reasoning of the physician needs to be captured in addition to the actions of the physician.

Artificial Intelligence↗
PubMed1994

The contents of free-text endoscopy reports: an inventory and evaluation by peers.

Insight into the current status of endoscopy reports is needed for a discussion on the desirability and feasibility of (more) standardized endoscopy reporting. We collected, from ten endoscopists, 181 reports in two diagnostic and two indication categories. An inventory was made of the subjects dealt with in the reports, such as: indication, premedication, therapy plan, and descriptive aspects of ventricular ulcers and lower tract polyps. To assess endoscopists' opinions on their reports, 16 randomly selected reports were reviewed by the ten endoscopists, using the Delphi method. The reports varied enormously in content and detail; 19 of the 28 subjects were not explicitly described in more than 50% of the studied reports. Such variation in the contents of reports may decrease the quality of care. The large number of topics that endoscopists indicate to be missing in their reports (on average 14 topics per report) suggests that more detail should be given in endoscopy reports. The current method of reporting causes endoscopists to omit information that they consider important. Due to the low overall consensus among endoscopists on which specific topics to include (eight or more endoscopists agreed on 15% of topics) we conclude that general criteria for the contents of reports cannot yet be formulated. However, the fact that the endoscopists agreed with more than one-third of the remarks made by colleagues opens a perspective towards identifying criteria for the formalization of certain report categories.

Delphi Technique↗
PubMed1994

A model for structured data entry based on explicit descriptional knowledge.

Clinical narratives in patient records are usually recorded in free text, limiting the use of this information for research, quality assessment, and decision support. This study focuses on the capture of clinical narratives in a structured format by supporting physicans with structured data entry (SDE). We analyzed and made explicit which requirements SDE should meet to be acceptable for the physician on the one hand, and generate unambiguous patient data on the other. Starting from these requirements, we found that in order to support SDE, the knowledge on which it is based needs to be made explicit: we refer to this knowledge as descriptional knowledge. We articulate the nature of this knowledge, and propose a model in which it can be formally represented. The model allows the construction of specific knowledge bases, each representing the knowledge needed to support SDE within a circumscribed domain. Data entry is made possible through a general entry program, of which the behavior is determined by a combination of user input and the content of the applicable domain knowledge base. We clarify how descriptional knowledge is represented, modeled, and used for data entry to achieve SDE, which meets the proposed requirements.

Artificial Intelligence↗
PubMed1994

A standardized message for supporting shared care.

As health care becomes more complex, interest in the benefits of coordination of care has increased. Especially patients that are being treated jointly by more than one physician (shared care), are vulnerable to adverse effects resulting from inadequate coordination and communication. We describe a study in which care providers support shared care by using computer-based patient records for data storage, and structured electronic data interchange as a means of communication. In this study, we are aiming at the development and implementation of protocols for shared care.

Computer Communication Networks↗
PubMed1993

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.

Database Management Systems↗