Publications by authors named "Bernard D Frijling"

8 Publications

  • Page 1 of 1

Follow-up of mild alanine aminotransferase elevation identifies hidden hepatitis C in primary care.

Br J Gen Pract 2012 Mar;62(596):e212-6

Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands.

Background: Hepatitis C (HCV) and hepatitis B (HBV) virus infection can lead to serious complications if left untreated, but often remain undetected in primary care. Mild alanine aminotransferase (ALT) elevations (30-100 IU/l) are commonly found and could be associated with viral hepatitis; unfortunately, these findings frequently remain without follow-up.

Aim: To determine if and how mild ALT elevation can be used to identify hidden HCV and HBV infection in primary care.

Design And Setting: Primary care patients referred for liver enzyme testing were selected by a large primary care Diagnostic Centre (Saltro).

Method: First, 750 anonymous samples were collected in three categories of ALT elevation (30-50 IU/l, 50-70 IU/l, and 70-100 IU/l) and tested for HCV and HBV. Second, the national prevalence of each ALT elevation was estimated by analysing all annual ALT tests performed at Saltro.

Results: HCV prevalence was 1.6% and 1.2% in patients with an ALT of 50-70 IU/l and 70-100 IU/l respectively. In patients with an ALT of 30-50 IU/l, HCV prevalence was normal (≤0.1%). HBV prevalence was normal (≤0.4%) in all groups. The estimated number of ALT tests performed nationally each year in primary care was 1.1 million. An ALT of 30-50 IU/l was found in 21.1%, an ALT of 50-70 IU/l in 5.6%, and 2.6% had an ALT of 70-100 IU/l.

Conclusion: In primary care patients with an ALT level of 50-100 IU/l, HCV prevalence is tenfold the population prevalence, whereas HBV prevalence is not elevated. Therefore, diagnostic follow-up for HCV is indicated in these patients, even when other explanations for ALT elevation are present.
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http://dx.doi.org/10.3399/bjgp12X630115DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3289828PMC
March 2012

Out of hospital anticoagulant therapy in patients with acute pulmonary embolism is frequently practised but not perfect.

Thromb Res 2010 Dec;126(6):481-5

Department of Internal Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands.

Introduction: Traditionally, patients with pulmonary embolism (PE) are treated in-hospital until they reach an adequate international normalized ratio (INR). Analogous to patients with a deep venous thrombosis, therapy with low-molecular-weight heparin facilitates out of hospital treatment of PE. We retrospectively analysed the current practice of early anticoagulant therapy in 86 acute PE patients with emphasis on the occurrence and safety of outpatient treatment.

Methods: Data were collected from two large regional teaching hospitals and from a specialized anticoagulation clinical, where patients were followed in the period after hospital discharge. The course of hospitalization and LMWH transitioning therapy and the quality of treatment in the first three months after diagnosis were compared between patients discharged before and patients discharged after reaching adequate INR.

Results: Forty-four patients (51.2%) were discharged early, before reaching an adequate INR, and 42 patients (48.8%) were discharged after reaching adequate INR. Early discharged patients needed more time to reach adequate INR compared to other patients (13 versus 6 days). In 28 patients (32.6%), the LMWH transitioning therapy was stopped prematurely; 21 patients were from the early discharged group. During the first 3 months, the mean individual times below, in and above the INR range were equal between the two groups.

Conclusion: Enhanced compliance to existing guidelines and tools, and further development of guidelines, with focus on intensification of monitoring of INR values in an outpatient setting and preventing premature discontinuation of transitioning therapy, are warranted for a safe and early discharge of stable patients with PE.
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http://dx.doi.org/10.1016/j.thromres.2010.08.019DOI Listing
December 2010

Perceptions of cardiovascular risk among patients with hypertension or diabetes.

Patient Educ Couns 2004 Jan;52(1):47-53

Centre for Quality of Care Research, University of Nijmegen/Maastricht, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.

We aimed to examine risk perceptions among patients at moderate to high cardiovascular risk. A questionnaire about perceived absolute risk of myocardial infarction and stroke was sent to 2424 patients with hypertension or diabetes. Response rate was 86.3% and 1557 patients without atherosclerotic disease were included. Actual cardiovascular risk was calculated by using Framingham risk functions. A total of 363 (23.3%) of the 1557 patients did not provide any risk estimates and these were particularly older patients, patients with a lower educational level, and patients reporting no alcohol consumption. The remaining 1194 patients tended to overestimate their risk. In 42.3% (497/1174) and 46.8% (541/1155) of the cases, patients overestimated their actual 10-year risk for myocardial infarction and stroke, respectively, by more than 20%. Older age, smoking, familial history of cardiovascular disease (CVD), and actual absolute risk predicted higher levels of perceived absolute risk. Male sex, higher scores for an internal health locus of control, lower scores for a physician locus of control, and self-rated excellent or (very) good health were positively related to higher accuracy. In conclusion, patients showed inadequate perceptions of their absolute risk of cardiovascular events and physicians should thus provide greater information about absolute risk when offering preventive therapy.
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http://dx.doi.org/10.1016/s0738-3991(02)00248-3DOI Listing
January 2004

Process evaluation of a multifaceted intervention to improve cardiovascular disease prevention in general practice.

Eur J Gen Pract 2003 Sep;9(3):77-83

Department of General Practice, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands.

Objectives: To perform a process evaluation of a multifaceted intervention to improve cardiovascular and diabetes care in general practice.

Methods: The feasibility of the intervention, carried out by outreach visitors in 62 practices, was addressed by evaluating whether the intervention programme was performed as planned and the extent to which it was accepted by the practice team. In addition, the costs of the programme were determined.

Results: The intervention was largely carried out as planned, although the intervention period had to be extended by three months. Of the 18 topics that could be addressed during the intervention period, 12 (mean) were addressed. The number of outreach visits per practice was 15.2 (mean), each visit lasted about one hour. Most practice members endorsed both the key recommendations for clinical decision-making and cardiovascular risk profiling. The majority of GPs (range 63-98%) agreed with the guidelines for clinical decision-making, and 29-97% had a positive opinion about the guidelines for practice organisation. According to practice staff members, the outreach visitor had sufficient knowledge and skills to support them in changing the practice organisation. GPs were less positive about the outreach visitor's knowledge and skills in optimising clinical decision-making; however 78% believed that the outreach visitor contributed to effecting change in their clinical decision-making. The total costs of the intervention per practice were Euro 4317.

Conclusions: This process evaluation demonstrated that the intervention was usually carried out as planned and achieved a high satisfaction rating from the participating practice members.
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http://dx.doi.org/10.3109/13814780309160409DOI Listing
September 2003

Organisational determinants of cardiovascular prevention in general practice.

Scand J Prim Health Care 2003 Jun;21(2):99-105

Department of General Practice, Erasmus University Rotterdam, Rotterdam, The Netherlands.

Objective: To assess organisational determinants in the prevention of cardiovascular disease.

Design: A cross-sectional study.

Setting And Subjects: 130 general practices in The Netherlands. Data were collected using questionnaires. A causal model was designed and analysed by path analysis.

Main Outcome Measures: Relationships between preventive activities, practice management and practice characteristics.

Results: Important differences between adequacy of equipment and practice organisation were found. Record-keeping was significantly better when working experience of the GPs was less than 15 years, when the practice consisted only of female GPs, and when the practice had written protocols for cardiovascular disease management and the staff held regular scheduled meetings (teamwork). Teamwork also showed a significant relation with follow-up activities. The influence of non-measured variables in the model was considerable.

Conclusion: In exploring the organisational setting as a barrier to prevention and disease management, the designed model showed no major effects. Despite the wide variety of practice organisational items investigated, a strong influence of non-measured variables was evident. Teamwork in the practices proved to be related to both follow-up and record-keeping. Younger and female GPs were further predictors of adequate record-keeping.
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http://dx.doi.org/10.1080/02813430310001707DOI Listing
June 2003

Organizing cardiovascular preventive care in general practice: determinants of a successful intervention.

Prev Med 2002 Nov;35(5):430-6

Department of General Practice, Erasmus University Rotterdam, The Netherlands.

Background: Although outreach visitor interventions have proven to be effective, more detailed studies are needed to understand what elements of interventions work and why. In this study we investigate the determinants of success of an intervention for optimizing cardiovascular preventive care in general practice.

Methods: After baseline measurements and randomization, 62 general practices received a comprehensive intervention program, by means of outreach visitors, lasting 21 months. Data on practice management and preventive activities were gathered at baseline and at postintervention measurements. Key characteristics of the intervention considered possible determinants of success were gathered by questionnaire. The difference between ideal and actual practice in each aspect of organizing cardiovascular preventive care was calculated as a deficiency score. The difference between deficiency scores before and after the intervention were the main outcome measures.

Results: The key characteristic, duration of exposure to an aspect (in months), was positively related to the change in availability of separate clinics and in the amount of teamwork. The improvement in instruments and materials was positively related to the general practitioner's opinion about the given feedback. No relations were found between the key characteristics and changes in record-keeping or follow-up routines.

Conclusions: Although implementation of a comprehensive prevention program is effective, we could not fully disentangle the "black box" of the intervention. The duration of exposure to an aspect of organizing cardiovascular care was the key determinant to success.
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http://dx.doi.org/10.1006/pmed.2002.1094DOI Listing
November 2002

Improving quality of organizing cardiovascular preventive care in general practice by outreach visitors: a randomized controlled trial.

Prev Med 2002 Nov;35(5):422-9

Department of General Practice, Erasmus University Rotterdam, The Netherlands.

Background: Adequate care for patients with cardiovascular risks requires an adequate practice organization. Educational outreach visits are a promising approach to modifying professional behavior. We aimed to assess whether the quality of cardiovascular preventive care in general practice can be improved through a comprehensive intervention implemented by an educational outreach visitor.

Methods: After baseline measurements, general practices (n = 124) in the southern half of The Netherlands were randomly allocated to either intervention or control group. The intervention, based on the educational outreach model, comprised 15 practice visits over a period of 21 months and addressed a large number of issues around task delegation, availability of instruments and patient leaflets, record-keeping, and follow-up routines. Twenty-one months after the start of the intervention, postintervention measurements were performed. The difference between ideal and actual practice in each aspect of organizing preventive care was defined as a deficiency score. Primary outcome measure was the difference in deficiency scores before and after the intervention.

Results: All practices completed both baseline and postintervention measurements. The difference in change between intervention and control group adjusted for baseline was statistically significant (P < 0.001) for each aspect of organizing preventive care. The largest absolute improvement was found for the number of preventive tasks performed by the practice assistant.

Conclusions: This study showed that a comprehensive intervention implemented by outreach visitors was effective in improving organization of cardiovascular preventive care in general practice.
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http://dx.doi.org/10.1006/pmed.2002.1095DOI Listing
November 2002

Provision of information and advice in cardiovascular care: clinical performance of general practitioners.

Patient Educ Couns 2002 Oct -Nov;48(2):131-7

Centre for Quality of Care Research, University of Nijmegen, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.

The aim of this study was to assess the provision of information and advice by general practitioners (GPs) with respect to patients with hypertension, hypercholesterolaemia, or cardiovascular disease. The study relied on the prospective recording of patient encounters by GPs. Performance indicators were selected from the Dutch national guidelines for general practice. The GPs (n=195) completed 5330 encounter forms. High levels of performance were found with regard to advice on smoking cessation and the provision of information (e.g. information about alarm symptoms or the aim of treatment). Low levels of performance were found with regard to advice on salt consumption, alcohol consumption, weight reduction and physical exercise for patients with hypertension. Discussion of compliance with the therapy in case of hypercholesterolaemia, advice on physical exercise in case of angina pectoris and advice on foot care in case of peripheral arterial disease also showed a substantial gap between recommended and actual care. Performance rates varied considerably across GPs. The patient and GP characteristics examined in this study contributed very little to the clinical performance.
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http://dx.doi.org/10.1016/s0738-3991(02)00013-7DOI Listing
February 2003