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Publications and source records attributed to R A de Melker.
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OBJECTIVE: The aim of this study was to assess the competence of Polish primary care physicians in diagnosing and managing patients with transient ischaemic attacks (TIAs) in the carotid territory. METHOD: A written questionnaire was distributed to all first-contact physicians (n = 100) in one of the seven health care districts of Warsaw (response rate 89%). The questionnaire included three pairs of TIA cases. In each of the pairs, only the age and type varied. Three cases were characterized by transient monocular blindness and the other three by symptoms of hemispheral ischaemia. RESULTS: Physicians confronted with TIA cases had difficulties in diagnosing it. In the cases of monocular blindness, only 20-44% of cases were diagnosed correctly, and hemispheral ischaemia was diagnosed correctly in 46-78% of cases. Patients with no history of non-specific symptoms and with the first attack would have a higher percentage of correct diagnoses in comparison with those with recurrent attacks and a history of non-specific symptoms. Patients with hemispheral ischaemia frequently would be referred to neurologists, and about two-thirds of doctors would refer patients with monocular blindness to ophthalmologists, and fewer than half to neurologists. Antiplatelet therapy would be prescribed by <22% of physicians, while peripheral vasodilatators would be prescribed by up to 60% of them. CONCLUSION: The results of this study indicate that Polish primary care physicians when confronted with TIA cases would have basic difficulties, especially in diagnosis and management. These results underline the need for changes in the vocational training of primary care physicians, with special attention to frequent family medicine problems.
Of the reports issued by a general practice expert for disciplinary and malpractice cases in the period 1994 to August 2000, 76 were analysed, with the emphasis on the more serious cases. Infectious diseases and cardiovascular diseases together formed 42% of the cases judged. The starting point of the analysis was the practice of an 'average general practitioner'. On the basis of jurisprudence and general practice literature, failure to diagnose a rare illness was not automatically regarded as reproachable but failing to estimate the seriousness of a situation was. In the first place it was checked whether or not general practitioner had adequately estimated the seriousness of the situation by paying due attention to the alarm signals and risk factors and in the case of diagnostic doubts by ensuring adequate follow-up. According to the analysis, 41% of the cases clearly exhibited reproachable conduct. This figure was twice as high when a locum was working at a practice. Two-thirds of the primary errors were due to the seriousness of the situation not being adequately estimated as a result of too little attention being paid to alarm signals and risk factors as well as a failure to ensure adequate follow-up. On the basis of the analysis it is advised that the use of a locum should be regarded as a risk situation: better information can be made available by means of an electronic patient file and unequivocal agreements for drawing up reports. For each consultation, the GP must systematically check whether there are alarm signals or risk factors. In the case of diagnostic doubts the clinical picture should be actively followed up by means of clear follow-up appointments at definite times. In the guidelines of the Netherlands Society for General Practitioners, explicit attention should be given to alarm signals and risk factors. In medical training and ongoing professional education, systematic training should be provided in the recognition of serious situations and rare diseases/complications.
OBJECTIVE: To derive and evaluate diagnostic determinants of gastro-oesophageal malignancy as a means of helping family physicians select patients for 'open-access' gastroscopy. In this multicenter study, 861 consecutive patients were investigated with first-time gastroscopy (study population). Another 1153 patients were studied during the next 6 years (validation population). General practitioners registered symptoms relevant to malignancy and patient histories; the results of gastroscopies were received from the endoscopists. METHODS: Univariate and multivariate analyses resulted in four relevant symptoms that were then compared with 'alarm symptoms' previously published in the literature. Receiver-operating characteristic analysis was used to evaluate the probability of finding malignancy using these two sets of symptoms. RESULTS: Positive answers regarding the symptoms, weight loss and dysphagia, together with negative answers on pain during the night and heartburn, predicted malignancy in the study population with an AUC (area under the curve) of 0.90. 'Alarm symptoms' performed less well in the study population (AUC 0.85), although reproducibility was better in the validation population (0.71 versus 0.63). If exclusion of malignancy had been chosen as the only valid reason for requesting gastroscopy, then pre-selection with the help of these symptoms would have reduced the number of requests by 10%. CONCLUSION: Thorough evaluation of 'classical' alarm symptoms in dyspeptic patients might help minimize unnecessary gastroscopy requests by GPs seeking a safe treatment decision.
BACKGROUND: While dyspeptic patients in primary care often receive empirical treatment with antisecretory drugs, a substantial number suffer from motility disturbances which may be associated with their complaints. We aimed to compare the effectiveness of treatment with antisecretory treatment with a prokinetic agent in uninvestigated dyspepsia. METHODS: 563 patients presenting dyspeptic complaints to the general practitioner with a low likelihood of organic (ulcer, reflux or malignant) disease, i.e. absence of alarm symptoms or a history of peptic ulcer disease or gastro-oesophageal reflux disease were included. They entered a randomized, double-blind trial of 4 weeks of ranitidine 150 mg bid compared with 4 weeks of cisapride 10 mg bid, with 3 months follow-up. Treatment failure was defined as no response to treatment or a relapse of symptoms within the follow-up period. Also studied were the effect on dyspepsia severity, response to treatment after 4 weeks, and time to relapse. RESULTS: For all randomized patients, the incidence of overall treatment success after 3 months follow-up with antisecretory treatment was 107/271 (39.5%) and with a prokinetic agent 122/282 (43.3%); the risk difference was 3.8% (95% CI -4.4% to 12.0%); the difference in symptom severity score after 4 weeks of treatment was 0.3; 95% CI -0.4% to 1.0%. For patients responding to 4 weeks of treatment, relapse-free time was 86 days in the prokinetic group and 79 days in the acid suppression group (P = 0.005). CONCLUSIONS: Antisecretory and prokinetic therapies are equally effective in primary care patients with uninvestigated dyspeptic complaints, though relapse rates are lower in patients treated with prokinetic treatment.
T serotyping and M and exotoxin genotyping were performed on strains from 367 streptococcal pharyngitis patients in Dutch general practice. Potentially virulent strains of group A beta-haemolytic streptococci, such as T1M1 and T3M3 subtypes and strains expressing speA and speC, and a high number of colony counts did not occur more frequently in the 166 (45%) more seriously ill patients, defined as those who showed a delayed recovery or a complication.
OBJECTIVE: To determine the effect of antibiotic treatment for acute otitis media in children between 6 months and 2 years of age. DESIGN: Practice based, double blind, randomised, placebo controlled trial. SETTING: 53 general practices in the Netherlands. SUBJECTS: 240 children aged 6 months to 2 years with the diagnosis of acute otitis media. INTERVENTION: Amoxicillin 40 mg/kg/day in three doses. MAIN OUTCOME MEASURES: Persistent symptoms at day four and duration of fever and pain or crying, or both. Otoscopy at days four and 11, tympanometry at six weeks, and use of analgesic. RESULTS: Persistent symptoms at day four were less common in the amoxicillin group (risk difference 13%; 95% confidence interval 1% to 25%). The median duration of fever was two days in the amoxicillin group versus three in the placebo group (P=0.004). No significant difference was observed in duration of pain or crying, but analgesic consumption was higher in the placebo group during the first 10 days (4.1 v 2.3 doses, P=0.004). In addition, no otoscopic differences were observed at days four and 11, and tympanometric findings at six weeks were similar in both groups. CONCLUSIONS: Seven to eight children aged 6 to 24 months with acute otitis media needed to be treated with antibiotics to improve symptomatic outcome at day four in one child. This modest effect does not justify prescription of antibiotics at the first visit, provided close surveillance can be guaranteed.
OBJECTIVE: To assess whether treatment with penicillin for three days and the traditional treatment for seven days were equally as effective at accelerating resolution of symptoms in patients with sore throat compared with placebo. DESIGN: Randomised double blind placebo controlled trial. SETTING: 43 family practices in the Netherlands. PARTICIPANTS: 561 patients, aged 15-60 years, with sore throat for less than seven days and at least three of the four Centor criteria-that is, history of fever, absence of cough, swollen tender anterior cervical lymph nodes, and tonsillar exudate. 142 patients were excluded for medical reasons and 73 needed penicillin. INTERVENTIONS: Patients were randomly assigned to penicillin V for seven days, penicillin V for three days followed by placebo for four days, or placebo for seven days. MAIN OUTCOME MEASURES: Resolution of symptoms in the first week, eradication of bacteria after two weeks, and recurrences of sore throat after two, four, and six months. RESULTS: Symptoms resolved 1.9 and 1.7 days earlier in patients taking penicillin for seven days than in those taking penicillin for three days or placebo respectively. Symptoms resolved 2.5 days earlier in patients with group A streptococci and 1.3 days earlier in patients with high colony counts of non-group A streptococci. 23 (13%) of the placebo group had to be given antibiotics later in the week because of clinical deterioration; three developed a peritonsillar abscess. The eradication rate for group A streptococci was 72% in the seven day penicillin group, 41% in the three day penicillin group, and 7% in the placebo group. Sore throat recurred more often in the three day penicillin group than in the seven day penicillin or placebo groups. CONCLUSION: Penicillin treatment for seven days was superior to treatment for three days or placebo in resolving symptoms of sore throat in patients with group A streptococcal pharyngitis and, possibly, in those with non-group A streptococcal pharyngitis.
As beta-haemolytic streptococci can be cultured in people with and in those without a sore throat, a case-control study was set up in 43 family practices in The Netherlands. The association was tested between the number of colony counts, specific T/M types and exotoxin genes and an acute sore throat. Duplicate throat swabs were taken from 663 sore-throat patients, selected by clinical criteria, and from 694 healthy controls. They were cultured for beta-haemolytic streptococci by combining several updated laboratory methods. Approximately 40% of the controls and 80% of the patients had beta-haemolytic streptococci-positive cultures. When focusing on cultures with high colony counts, not only group A (46%), but also non-group A streptococci (20%), predominated significantly in adult patients compared with controls. No T/M or exotoxin gene type was significantly more prevalent in patients than in controls. Thus, semiquantitative analysis, but not T/M and exotoxin gene typing, showed an association between beta-haemolytic streptococci and active disease. Groups A, C and G streptococci were found to be potentially pathogenic in adult sore-throat patients, and should be included in the discussion on the use of rapid antigen detection tests and penicillin treatment in primary care.
In a population-based cross-sectional survey conducted in the Netherlands of 7,200 people aged 65 years and older (with a response rate of 79%), 20% of the respondents were found to have nontraumatic foot complaints of more than 4 weeks' duration, often involving the forefoot. Female sex, joint disease, and multimorbidity were found to be risk factors for the presence of foot complaints; older age and obesity were not. Respondents with these complaints had limited mobility and poor perceived well-being.
BACKGROUND: Approximately 10% of patients presenting with dyspepsia to the general practitioner have peptic ulcers; the large majority of which are related to infection with Helicobactor pylori. Office-based tests for H. pylori detection are generally validated and evaluated in selected patient groups. AIM: To evaluate the clinical effectiveness of a whole-blood serology test for infection with Helicobacter pylori in detecting peptic ulcer disease (PUD) in daily general practice. METHOD: A descriptive study of 171 primary care dyspepsia patients selected for open-access endoscopy in primary care and aged between 18 and 75 years, in 92 general practices in central, southern, and eastern parts of the Netherlands. H. pylori status was assessed using the BM-test Helicobacter pylori, which is identical to the Helisal test. Dyspepsia severity score was measured using a validated symptom score. Symptom characteristics and probability of relevant disease were assessed by the general practitioner. Endoscopy was carried out in local hospitals. Diagnostic outcome of both endoscopy and H. pylori reference test was supplied by local specialists. The BM-test was evaluated against endoscopic results. RESULTS: A high number (61.8%) of false-negative BM-tests resulted in a low sensitivity (95% confidence interval [CI] = 48-75%) for detection of H. pylori infection. Only 12 out of 32 patients with PUD had a positive BM-test, resulting in a positive likelihood ratio (LR) for PUD of 1.41 and a negative LR of 0.85. CONCLUSIONS: This study confirms the relatively poor performance of the BM-test in daily general practice, and shows the limited diagnostic value of H. pylori office-tests for detecting PUD in primary care. The discriminative value of the test result is too small to support either a 'test-and-endoscope' of a 'test-and-treat' strategy in general practice.
This study describes the prescription of antimicrobial agents in cases of lower respiratory tract infections in Dutch general practice. A secondary analysis of data from the National Study of Illness and Procedures of The Netherlands Institute of Primary Health Care (a nationwide group of 161 general practitioners with data from 334,449 patients) had been carried out. Antimicrobial agents were prescribed in 30% of all contacts: in about half of the first contacts and contacts for recurrences, and in one out of six repeat contacts. The prescription rates were associated with diagnosis and reason for encounter but rarely with older age or comorbidity. Amoxycillin and doxycycline were most frequently prescribed. While most lower respiratory tract infections are virus-induced and antibiotics are not effective in most cases, antimicrobial agents might still be overprescribed.
BACKGROUND: Otitis media with effusion (OME) has a high rate of spontaneous resolution, and a policy of waiting and watching for 3 months is justified. The decision about further treatment should be individualized, depending on duration and symptoms. Knowledge of the determinants for persistent OME would be helpful for identifying patients with a need for active treatment or increased monitoring for complications. METHODS: A total of 433 children aged 6 months to 6 years were monitored for 3 months in the offices of 57 family physicians. A questionnaire pertaining to determinants was completed. The outcome measures were: presence of unilateral or bilateral OME or bilateral OME after 3 months. The outcome was determined on the basis of tympanometry results. We performed bivariate and multivariate analyses. RESULTS: The presence of an upper respiratory tract infection (URTI) at the follow-up visit was associated with finding OME at that visit. When a URTI was present, no other determinants for persistent OME were found. When absent, the determinants for persistent bilateral OME were: no history of adenoidectomy, an episode of acute otitis media (AOM) in the first year of life, and month of entry into the study (June-November). For persistent unilateral or bilateral OME, the only significant determinant was an episode of AOM in the first year of life. CONCLUSIONS: Childrenwith 1 or more of the following factors need special attention for prevention of the sequelae of persistent OME: no history of adenoidectomy, AOM in the first year of life, and the presence of bilateral OME in the period between June and November.
BACKGROUND: The accuracy of data gathered by primary care clinicians in practice-based research networks (PBRNs) has been questioned. Tympanometry, recently recommended as a means of improving accuracy of diagnosing acute otitis media, was included as an objective diagnostic measure in an international PBRN study. We report the level of agreement of interpretations of tympanograms between primary care physicians in PBRNs and experts. METHODS: Primary care physicians in PBRNs in the Netherlands, United Kingdom, United States, and Canada enrolled 1773 children aged 6 to 180 months who contributed 6358 tympanograms during 3179 visits. The physicians were trained in the use and interpretation of tympanometry using the Modified Jerger Classification. We determined the level of agreement between physicians and experts for interpretation of tympanograms. One comparison used the 6358 individual ear tracings. A second comparison used the 3179 office visits by children as the unit of analysis. RESULTS: The distribution of expert interpretation of all tympanograms was: 35.8% A, 30% B, 15.5% C1, 12% C2, and 6.8% uninterpretable; for visits, 37.8% were normal (A or C1), 55.6% abnormal (B or C2), and 6.6% could not be classified. There was a high degree of agreement in the interpretation of tympanograms between experts and primary care physicians across networks (kappa=0.70-0.77), age groups of children (kappa=0.69-0.73), and types of visits (kappa=0.66-0.77). This high degree of agreement was also found when children were used as a unit of analysis. CONCLUSIONS: Interpretations of tympanograms by primary care physicians using the Modified Jerger Classification can be used with confidence. These results provide further evidence that practicing primary care physicians can provide high-quality data for research purposes.
OBJECTIVES: The importance of professional attitudes in medical care has long been recognized; however, medical training has not stressed attitude development until recently. In previous studies among medical students, we found that gender and specialty preference are important factors in attitudes. In this study, patient-centredness of trainees in general practice and surgery and of final-year clerks preferring one of these specialties was assessed in one medical school in The Netherlands. The effect of gender, specialty and training level on attitude was investigated. DESIGN: In 1995, attitudes of 37 general practice trainees, 31 surgery trainees and 120 clerks were measured anonymously using questionnaires containing the Doctor-Patient Scale. This attitude scale measures patient-centredness vs. doctor-centredness. Response rates were 78%, 58% and 84%, respectively. SETTING: University of Utrecht. SUBJECTS: Medical students. RESULTS: Attitudes were related to specialty. General practice trainees showed more patient-centredness than surgery trainees. In accordance with previous findings among younger students, no differences were found between final-year clerks and vocational trainees. In contrast to previous studies, gender was not related to patient-centredness. CONCLUSIONS: Professional attitudes, in particular patient-centredness, seem to be related to specialty preference in the final year of graduate medical training and specialty as a career choice. It remains unclear whether professional socialization reinforces existing attitudes or whether existing attitudes result in specialty preference.
BACKGROUND: Appropriate use of antibiotics is a major issue in today's medicine. The increasing worldwide bacterial resistance to antimicrobial agents is forcing us to prescribe antibiotics more rationally. It is known that overuse of antibiotics for upper respiratory tract infections exists. Little is known about the reasons for actual prescribing of antibiotics. In order to be able to implement strategies to restrict inappropriate antibiotic prescriptions, insight into the reasons for the actual prescribing could be important. OBJECTIVE: We aimed to explore the reasons, other than those stated in the guidelines of the Dutch College of GPs, for prescribing antibiotics for acute otitis media. METHOD: Seventy antibiotic prescriptions for acute otitis media, prescribed by 22 Dutch GPs, were evaluated to see whether they followed the guidelines on acute otitis media of the Dutch College of General Practitioners. Non-guideline-based antibiotic prescriptions were discussed in stimulated recall interviews with the prescribing GPs regarding their prescribing behaviour of antibiotics for acute otitis media. RESULTS: In total, 77% of the antibiotic prescriptions did not follow the guidelines of the Dutch College of General Practitioners. Medical reasons for prescribing antibiotics were mentioned most often for non-guideline-based antibiotic prescriptions; however, in a substantial number of cases doctors gave non-medical reasons as well. CONCLUSIONS: Appropriate use of antibiotics might not be reached by focusing only on the efficacy of these drugs. The impact of doctors' awareness of their non-medical motives for prescribing antibiotics on more rational antibiotic prescribing should be investigated further.
BACKGROUND: In theory, a positive relationship is expected between the quality of a consultation and a patient's subsequent health status. However, such a relationship has not yet been firmly established in daily practice. OBJECTIVE: We aimed to study the relationship between the quality of the first consultation in a new episode of non-acute abdominal complaints and subsequent health status of patients in general practice. METHODS: Quality scores for 743 consultations were calculated on the basis of review criteria developed by expert panels. Functional health status was measured by the SIP (Sickness Impact Profile) at baseline, and at 1 and 6 months after the consultation. Multilevel regression analysis was used to examine the relationship between the quality of consultations and health status, and to identify factors of influence on this relationship. RESULTS: In the majority of these patients (97%) health status improved regardless of consultation quality. In patients with malignant disease, and chronic colitis, however, an association between consultation quality and subsequent health status was found: in those with a high consultation quality score (>66-percentile) the health status deteriorated in the first month but improved over the following 5 months; in those with a low consultation quality score (<33-percentile) it deteriorated continuously. CONCLUSION: For the great majority of patients we found no relation between the quality of consultation and health status. However, for a very small subgroup of patients there is proof of benefit from better quality consultations.
OBJECTIVE: To investigate what factors influence the quality of general practitioner performance in consultations for non-acute abdominal complaints and to establish the extent to which performance quality differs between general practitioners (GPs). DESIGN: Explorative study in two parts: (i) detection of variables influencing quality scores of consultations; and (ii) comparison of mean quality scores of the consultations, selected by each GP. SETTING: Sixty-two family practices across The Netherlands. SUBJECTS: Eight-hundred and forty consultations concerning non-acute abdominal complaints, first encounters; 62 GPs. METHOD: Multilevel analysis was carried out to detect factors that influence quality. After correction for the effect of significant factors the mean quality scores of individual GPs were calculated and compared. RESULTS: Eighty-eight per cent of the total variance in quality scores was located at the consultation/patient level, and 12% at the GP level. One consultation characteristic had significant influence on quality: quality scores were higher in consultations of longer than average duration (>15 minutes). Several patient characteristics were of significant influence. Consultation quality scores were higher in consultations for patients with upper abdominal or non-specific abdominal complaints. Quality scores were lower in consultations with female patients and with patients aged >40 years. Together these characteristics explained 20% of the variance at the GP level. None of the GP characteristics investigated in this study appeared to have significant influence on the quality of their performance. After correction of the scores for the effect of significant factors the differences in performance quality between GPs remained significant. CONCLUSIONS: Quality of performance is far more influenced by consultation and patient characteristics than by GP characteristics. After correction for influencing factors, the mean quality scores of GPs still differed considerably and significantly. For many GPs the quality scores varied substantially between different consultations; to a large extent this variation remained unexplained. Consultation quality can be improved by booking more time per patient and by giving more medical/technical attention to female and older patients.