Chapter 4 Research in Evidence Based Medicine in Practice (EBM) Programme leaders head of the department of General Practice Prof dr FM Haaijer-Ruskamp, professor in Drug Medicine in Practice’ (EBM) is organised around The mission of the research programme is to two themes: strengthen the link between evidence and actual 1 Chronic diseases under the leadership of practice. A major part of our knowledge about prof dr B Meyboom-de Jong and 2 Rational drug use under the leadership of the value of diagnostic and treatment strategies becomes only available when these strategies are prof dr FM Haaijer-Ruskamp. used in actual practice. Starting date understand the doctor’s performance in terms Our principal goal is to evaluate and Within the faculty research institute NCH, the of quality of care, to develop tools to support predecessor of this programme was established optimal care, and improve the implementation in 1992 in order to concentrate a heterogeneous of scientific evidence in actual practice. The set of research activities into a well structured research focussed on EBM in chronic diseases, programme. in particular with cerebral and cardiovascular Three research themes were functioning Betty Meyboom-de Jong risks, diabetes mellitus, asthma, and palliative within the NCH, i.e. RUG HAG-1 Care for care for patients with cancer, and diseases of the patients with chronic diseases in general musculo-skeletal system. Pharmacotherapy is the practice, RUG NCH-1 Disorder, disability and most used treatment, emphasizing the relevance quality of life and RUG NCH-2 Medical decision of EBM in pharmacotherapy in everyday practice. making and evaluation of health care. In 1998 a Our research in this area focussed on rational reorganisation took place. An important part of drug use, and in particular on the understanding the programme (‘Medical Decision Making’) was and the decision making of doctors when they transferred to the University of Rotterdam with choose medication and the factors that drive the departure of the principal researcher (prof these decisions. dr M Hunink) as full professor to that university. For the Department of General Practice RUG HAG 1 and the group on Rational Drug Use involved in this programme, a second mission (part of RUG NCH-2) started to collaborate from is the professionalisation of general practice, 1998 onward and formed a new programme implying a focus of research done by general ‘Evidence Based Medicine in practice’. During practitioners (certified or during their training the period 1997-2002 the research programme period). was expanded. Now the time has come to focus Flora Haaijer-Ruskamp on a more limited number of topics to improve quality. Affiliations outside the programme Collaboration exists with general practitioners in the adherent region of the University Hospital Groningen (UHG) and regional pharmacists, with 113 Research in Evidence Based Medicine in Practice (EBM) Utilization Studies Research area and mission Chapter 4 Prof dr B Meyboom-de Jong, professor in and The programme ‘Research in Evidence Based other departments of the University Hospital 1 Leadership especially with the Hypertension service, and 114 Management style, means of motivation, communication and Northern Centre for Healthcare Research with the internists of the Isala Clinics in Zwolle. Programme leaders during the review period Further cooperation exists with the research were prof dr B Meyboom-de Jong, professor and The general programme policy is established school Behavioral and Cognitive Neurosciences head of the department of General Practice and in regular meetings of the two leaders (at least (BCN) and the research school Groningen prof dr FM Haaijer-Ruskamp, professor in drug four times per year, but usually more often) for University Institute for Drug Exploration (GUIDE), utilization studies. feedback, information exchange and planning division Pharmacoepidemiology and Drug Policy; Though organised around different themes, control of new activities. The management of the actual Self evaluation 1997 - 2002 part of the programme is also part of GUIDE. On the close collaboration of the two leaders, the programme activities can be characterised as a National level cooperation exists with the Dutch collaboration with the field, i.e. the general project management with frequent individual College of General Practitioners and the RIVM practitioners and pharmacists from practices and group meetings with programme leaders (see also research environment). The programme in the North of the Netherlands, as well as the and researchers. The group meetings are also has a clear international orientation, with collaboration between the department of general organised with a pragmatic approach, trying its European collaborative research, where we practice and drug utilisation’s studies/ clinical to fit in with the researchers’ activities. This coordinate different EU subsidized projects. pharmacology in several projects made the implies that group meetings do not always merging into one programme advantageous. comprise all researchers, since the programme Cooperation between the two leaders brings together young researchers, based in Evidence based medicine, quality of health care, has been fruitful and rewarding with prof dr the university and GPs (certified as well as in guidelines, family practice, chronic disease, B Meyboom-de Jong being more practice training) as well as people from other regions asthma, cardiovascular risk, diabetes, CVA, drug orientated and prof dr FM Haaijer-Ruskamp (Zwolle), who are actively involved in patient utilization, implementation, changing practice, being more theoretically driven. Both leaders use care. The latter prefer meetings after practice rational drug use. the national guidelines of the Dutch College of hours. Teamwork is encouraged. Teamwork General Practitioners and of the Dutch Institute is deemed very important in view of the for Health Care CBO (e.g. diabetes mellitus, multidisciplinary character of the programme, hypertension, shoulder complaints, chronic heart as well as in view of the collaboration between failure, asthma). Both leaders have close contacts university and the health care field. The with the field (doctors and pharmacists), as management can also be characterised as illustrated by the data collected by the 16 GPs being in close contact with the field (doctors, participating in the regional morbidity and pharmacists and patients), which is clear from medication Registration Network Groningen. the involvement of programme participants in Some members of their staff have been involved different local and national professional and in projects of both departments. policy organisations. Key words actual practice. At the same time new scientific by indicators. All studies and interventions knowledge challenges accepted strategies in targeted at improving quality of care need valid As stated before, the EBM programme is clinical practice often laid down in guidelines that and reliable indicators. What are the minimum organised around two themes, chronic diseases become more and more used. In order to use this data needed to draw conclusions on the quality in General Practice and Rational Drug Use. tension to the maximum benefit, it is essential to of treatment? How reliable is the use of existing evaluate accepted guidelines and develop new databases (GP, or pharmacist based). What is the diseases in General Practice deals in particular guidelines in the light of evidence and to develop relation between the question at hand and the with cerebro- and cardiovascular risks, diabetes tools and strategies for implementation of required sensitivity, and specificity? These are mellitus, asthma, palliative care for patients with changes needed. Most evidence is based on RCT, some of the questions that have to be answered cancer, and diseases of the musculo-skeletal i.e. a controlled situation and a patient population in order to progress in this field of study. system. that is usually different from the patients seen Research area and mission statement The theme focussing on EBM in chronic in General Practice. It is therefore important to Research goals The mission of the research programme is to evaluate patient outcome in the natural setting of Our principal goal is to evaluate and understand strengthen the link between evidence and actual the General Practice where patients have multiple doctors’ performance in terms of quality of practice. This is done by: disorders, where the social –economic situation care and develop tools to support optimal • Identifying, understanding and studying gaps may be taken into account, where patients do not care, and improve the implementation of between scientific evidence and medical always follow doctors orders. One of the fields scientific evidence in actual practice. As part practice. where there is ample evidence of a gap between of this process we want to know the impact of Developing and testing strategies to scientific evidence and actual performance is treatment according to evidence from RCTs on implement evidence in practice. the use of pharmacotherapy. Much effort is actual patient outcome in the natural setting of Implement new knowledge in practice. put into improving the situation with mixed General Practice, the use of dynamic databases For the department of General Practice results. In order to enable implementation, it is for identifying gaps between evidence and involved in this programme, a second mission important to understand why doctors do and do practice, understand underlying mechanisms and is the professionalisation of General Practice, not implement scientific evidence in practice. using our improved understanding for designing implying a focus of research done by general From the available evidence, it is clear that lack protocols and (innovative) strategies to optimise practitioners (certified or during their training of knowledge is not the main reason why we care. An important aspect is to develop valid period). By getting the PhD degree they can find a gap between evidence and actual practice. instruments for measuring quality of care. use the acquired knowledge to further the Other factors play a role. Barriers and facilitators development of the profession of General of changing practice according to (new) Practice. evidence may occur at different levels, doctors’ We selected subjects of investigation using characteristics, patients’ characteristics and the following criteria: the burden of illness, organisational characteristics. Understanding the significant scientific (new) evidence that requires barriers and the effect of the context in which implementation in practice, developments in changes have to be implemented is important health care organisation and societal impact. As There exists a continuous tension between new for developing innovative implementation a result we focussed on stroke, cardiovascular scientific developments and actual practice. A strategies. The effectiveness and feasibility of risk factors and diabetes, asthma and diseases major part of our knowledge about the value of such strategies have to be tested before they of the musculo-skeletal system and rational diagnostic and treatment strategies becomes can be implemented on a large scale. A specific drug use. Drug treatment is the most used • • Content of the research programme Research problems Subjects of investigation 115 Research in Evidence Based Medicine in Practice (EBM) problem is the measurement of quality of care Chapter 4 only available when these strategies are used in 2 Strategy and policy 116 Northern Centre for Healthcare Research form of treatment. There exists much pressure complaints by Winters and Sobel (1995). the GP and the neurologist together, while one on doctors to change their prescribing on the The result of their descriptive study and RTC third was treated at home by the GP (Schuling). one hand because of new options coming on resulted in a new thoroughly revised guideline In the meantime, it became clear that stroke the market, and on the other hand from health (1998). Based on that model new projects were patients are better off, both in functional status insurance and policy makers to prescribe (more) developed: studies of the effect of additional and mortality, when they are admitted to a stroke efficient. manipulative therapy in shoulder complaints, of unit because of the more systematic care. The injection therapy, of (new) classification systems department shifted its attention to the long-term General Practice focussed on the acute phase of for shoulder complaints, carpal tunnel syndrome consequences of stroke in particular the mood stroke. Since it became clear that the care and and trigger finger, and low back pain. of patients especially depression, cognitive Originally research of the department of treatment in stroke units was superior, both for Our research in rational drug use has put disturbances, the quality of life and their mutual Self evaluation 1997 - 2002 mortality and functional status, we proceeded much effort in understanding the decision relationship. That is studied in the project to study the long-term effects of stroke, the making of doctors when they choose medication Cognitiva by two PhD researchers in cooperation wellbeing of caregivers, the effects of education and the factors that drive these decisions. with the department of neuro-psychology of patients and caregivers on the quality of life, Strategies to optimise therapy need to take into (BCN). Using the same cohort, the attention was and the cognitive and emotional problems and account the different types of decision made. focused on the main caregivers, mostly partners, quality of life post stroke. Decisions may be active, i.e during the doctor- of the stroke patients and on the problems they patient contact, or more general, i.e. to introduce experienced. One year post stroke, one third of studies was used in the studies of risk factors as a new drug in the standard set a doctor has in the partners experienced serious psychological hypertension and diabetes not only for stroke but his mind. We study the extent decisions are problems. They performed more (household) for the total domain of cardiovascular diseases. influenced by doctor characteristics (for example tasks, had a more limited marital relationship and As far as national guidelines of the Dutch knowledge and attitudes), patient characteristics less leisure time due to a lower degree of self- College, the so-called “Standaarden” existed, (clinical characteristics as well as patient esteem and a great need for help. The partners we used (parts of) them. The quality of care demand) and organisational factors (solo versus wished more attention and support from the GP for diabetes patients was tested according the group practice etc). Different tools for optimising (Schure). Based on these findings, a ‘care-trial’ new guidelines of the Dutch college published therapy are evaluated, such as the available study with home visits and a group intervention in 1998 both in Zwolle in a shared care model, information, formularies, and guidelines. Based for caregivers was started. Both interventions and on Urk. The improvement of the quality of on these results new strategies are designed or showed a small to medium result on knowledge care was studied, using task delegation to the existing strategies are adjusted, of which the about disease, resources and caring for the diabetes practice nurse. Palliative care proved a feasibility and effectiveness is tested. In the patient in particular among younger caregivers. new research field in which GPs were very much context of this research, indicators of prescribing In the long term, caregivers received more social interested and involved. This field is developing quality are developed and tested. support post intervention, especially women (Van The methods and expertise gained in these concerning the research focus already mentioned: developing of guidelines, longitudinal den Heuvel). As a consequence these strategies Results obtained care, shared care with specialists, and quality of In the programme Evidence Based Medicine care. in practice concerning chronic diseases, the where used in a research programme for caregivers of palliative oncology patients. The expertise gained in stroke research, both research started with studies of stroke in the in the descriptive longitudinal studies and quality and diseases of the musculo-skeletal system acute phase. In a cohort of stroke patients in the of care was used in research of cardiovascular started with the evaluation of the National adherent region of Groningen, two third of the diseases. A new method, the 24-hour ambulatory Guideline of the Dutch College on shoulder patients were admitted in hospitals or treated by blood pressure measurement, was studied in The development in research on complaints Summary of relevant projects (sorted by supporting institution) Research in Evidence Based Medicine in Practice 117 European Union Drug Education Project 1994 - 1998 NWO • Manipulative therapy in treatment of shoulder complaints 2000 - 2004 • MARGARIN: Mediterranean alpha-linolenic acid enRiched Groningen dietARy Intervention study 1997 - 2002 Dutch Heart Foundation (Hartstichting) • How to provide effective support to caregivers of stroke patients (co-project with DDQ-programme) 1998 - 2002 CVZ / VAZ • Evaluation and Implementation of Guidelines on Antimicrobial therapy: EGA study 2001 - 2004 CVZ • Patient and doctor factors explaining changes in prescribing of antihypertensive medication 2002 - 2004 Isala Clinics Zwolle • Shared care for patients with non-insulin-dependent Diabetes Mellitus; the effect of the diabetes nurse • Diabetes Specialist nurse Carrying Out Usual and Reasonable Schemes and Education (DISCOURSE-study). Possibilities for a new kind of diabetes specialist nurse 1998 - 2002 2000 - 2003 COPZ NN • How to provide effective support to caregivers of palliative oncology patients 2000 - 2002 NHG, Fund for Ordinary Diseases (Fonds allledaagse ziekten) • The Groningen HAWITT-trial: efficacy, safety and feasibility of steroid injection-therapy in general practice for tenosynovial diseases of the wrist and hand (Carpal Tunnel Syndrome) 2000 - 2004 University Hospital Groningen • Morbidity Registration Network Groningen (RNG) from 1992 on Faculty of Medical Sciences • Validation of disease specific indicators for assessing quality of prescribing in general practice 1998 - 2002 • Implementing transmural guidelines in general practice 1998 - 2003 • The consumption of non-prescribed antibiotics in Europe in relation to antimicrobial resistence patterns 2002 - 2006 • Can national differences in heart-failure treatment be explained by health system features? 2002 - 2007 Department of General Practice • Polypharmacy 1995 - 1999 • Empirical classification of shoulder problems by means of multidimensional scaling and cluster analysis on previously collected data 1999 - 2003 • Education for stroke patients 1999 - 2004 • A comparison of the effect of treatment by the GP or the specialist in sportsmedicine, concerning the treatment of not acute sportsinjuries of the lower extremity 1999 - 2005 Research in Evidence Based Medicine in Practice (EBM) Foundation for Preventive Medicine (Preventiefonds) Chapter 4 • 118 Northern Centre for Healthcare Research decreased dietary intake of (saturated) fat and lifestyles. In Zwolle according the guidelines increase intake of fish, fruit, poultry and bread. of T2DM of the Dutch College of General Alpha-linolenic acid (ALA) adversely affected the Practitioners the care was evaluated in a shared serum lipid profile, but this may be counteracted care model using diabetes specialist nurses by an anti-inflammatory impact (Bemelmans). based in the hospital, performing the yearly Effects on cardiovascular risks were moderate. control of T2DM patients in their own town or Predictive factors for the intention to increase village. Feedback about every patient by nurses physical activity were prior behaviour, attitude, and participating internists was send to the self-efficacy expectations and outcome efficacy. GP who remained responsible for the care of Alpha-linolenic acid was positively correlated to the patients (Ubink-Veltmaat). The support by diastolic blood pressure but not to the intima- diabetic nurses was favourable both concerning media thickness, an indicator for cardiovascular metabolic regulation and quality of life. At the disease. same time, protocols for sub-divisions of the The interest in unhealthy lifestyles and their guideline were elaborated (Houweling). Task Self evaluation 1997 - 2002 effect on disease will lead to more research delegation became a separate topic to be studied projects in this field. in a randomised controlled trial both in secondary In cooperation with dr HJM Bilo of the Isala Clinics in Zwolle, we focussed on diabetes and primary care (Houweling). A start was made using the same mellitus, an outstanding cardiovascular risk methodology with research in palliative oncology factor. We performed studies on patients care, because GPs are mainly responsible for with diabetes mellitus both in Zwolle, and providing care for these patients in the last phase in the adherent region, on Urk: Here, 1027 of their life. It appeared that 30-40% of cancer patients with type 2 Diabetes Mellitus (T2DM) patients reported moderate symptoms, 15-20% were followed: 46 patients died within 5 severe symptoms. About 60% of cancer patients years: 70% of cardiovascular diseases versus reported having pain, 20% severe. Of a control patients with high blood pressure together 37% of non diabetes patients. Of 271 T2DM group of non-cancer patients 18% reported pain with the effects in a therapy trial (Beltman). patients examined in 1996, 50% suffered from of the same severity. The knowledge of GPs The increased rate of cardiovascular mortality cardiovascular events and 28% had died after concerning palliative care increased, but their in Oost-Groningen appeared mainly due to a 5 years. A low score on the dimension physical prescription behaviour in practice did not change combination of unhealthy lifestyles (smoking, functioning of the Rand-36 was predictive accordingly. more obesity, higher serum cholesterol). for a cardiovascular event in the short term. Options for prevention involved the issue of Quality of life was mainly associated with hypo- provider in palliative oncology and most GPs smoking and nutrition (Broer). Based on these and hyperglycaemic symptoms experienced. have only little experience with palliative care, results, the Margarine study about influences of With the use of the genealogical data of the four GP advisers were appointed, one in each nutritional interventions on the cardiovascular isolated population of the former island Urk, it of the four northern provinces. Three of them risk profile of patients in Oost-Groningen with appeared that the relative risk for T2DM was will be involved in a study of psychological at least 3 risk factors including high cholesterol 5.1 for brothers and sisters, 2.8 for children and symptoms, among others, since the influence on was performed. Nutritional group education 3.4 for spouses. This implies an important role wellbeing and quality of life of psychological and established long term dietary changes with a for environmental factors, such as unhealthy social problems is impressive. Vice Chancellor prof dr F Zwarts presenting the PhD degree certificate to W Bemelmans. Since the GP is seen as the central care In 1994 the original national guideline of the Dutch College of General Practitioners Polypharmacy (PhD thesis L Veehof) concerning shoulder complaints first published in 1994 was changed and revised profoundly. 119 Due to the results of the descriptive study Chapter 4 and the randomised controlled therapy trial of Winters and Sobel. The revised guideline was published in 1998 (first author Winters). Based centre NWO study into shoulder complaints was started. In Groningen, the study of additional manipulative therapy in persisting shoulder complaints is performed (Bergman under supervision of Winters). The favourable results of corticosteroid injections became also a central topic in other muskolo-skeletal disorders as trigger finger, carpal tunnel syndrome and low back pain. Moreover, with several clustering and multiscaling techniques the data of several general practice and mainly treated by GPs results indicate that computer support may be studies of shoulder complains are analysed themselves. an important tool to prevent errors, and help to study the best performing classification of shoulder complaints (Groenier). Our study of drug utilisation patterns will be to identify patients in need of adjustment of continued to identify current problem areas, their treatment. Elderly are often treated with on further understanding of how doctors make a combination of drugs, i.e. polypharmacy. National Guidelines exist, the effects of treatment their decisions and studying the relevance of Veehof showed that about a third of the elderly by GP and sports medicine specialist were different information sources, and on developing in General Practice are treated with more than compared. GPs treat preferably recent injuries an innovative approach to implement guidelines. one drug, light polypharmacy occurred in 23% while the specialist in sports medicine is treating In the review period the issues of repeat of the patients, 8% had moderate and 4% had older persisting problems. The GP uses a very prescribing and of polypharmacy in General extensive polypharmacy. Usually polypharmacy broad area of diagnostic labels and refers eight Practice were studied. A considerable part of is a slow process, taking several years before times more to the physiotherapist than the prescribing consists of repeating prescriptions high levels are reached. Cardiovascular drugs and specialist in sport medicine. without direct contact between patient and psychotropics are most used in combination with doctor, varying from 51% for psycholeptics other drugs, but the risk of adverse effects was will be expanded in the coming years, since to 13% for ear medication. Repeating without small (< 3%). The low risk of adverse effects was the problem for health status due to unhealthy doctor-patient contact increases the efficiency supported by our finding of a low incidence of lifestyles is evident and movement and exercises in General Practice, but it also increases the side effects in elderly treated with polypharmacy. could be favourable for people in general, but risk of errors, in particular administrative errors Moreover, most adverse effects were harmless. in particular for patients with chronic diseases. (Dijkers). Another problem is the chance of Our results suggested that polypharmacy was At the same time exercises can cause musculo- undertreatment because the doctor is unaware not a high priority area in need of improvement in skeletal problems, that are very prevalent in of the need to change the medication. Our general, but should be more focussed on specific In sport related injuries, for which not yet The research of movement and exercises Research in Evidence Based Medicine in Practice (EBM) on lacunas in these guidelines, a large multi- 120 Northern Centre for Healthcare Research Self evaluation 1997 - 2002 diseases. This was reported to the National GPs and their local pharmacist(s) in addition apart. While Belgians have a greater tendency council on health insurances (CVZ, College voor to feedback on actual drug prescribing. This to label their symptoms as ‘bronchitis’ (rather Zorgverzekeringen) based on our own results as approach was then tested in a ‘multicentre’ RCT serious), the Dutch labelled their symptoms as well as a thorough literature review. In the next trial in five European countries for improvement ‘a cold’, not serious at all, with the expected step, studies focussed on asthma and chronic of the treatment of asthma and of UTI. The consequences for antibiotic use. The lessons heart failure. The prevalence of both these method was well appreciated in all countries; learned from these international comparative diseases is increasing since the last decade. the effect varied for the different countries and studies indicate that one cannot implement an Knowledge about the underlying mechanisms for the topic discussed, asthma or UTI. Analysis intervention that has been proven successful in has resulted in new effective treatment options. of modifying factors revealed that there was one cultural and health care setting directly into In both these cases there is clear scientific little if any effect of attendance rates, quality of another context. Success factors are directly agreement on treatment recommendations, as the discussions, and duration of the meetings in linked to the context of the intervention. reflected in internationally accepted guidelines. which the feedback was discussed or age of the However, from our studies it became clear that doctor. More important seemed the impact of use on choosing drug treatment; this variation there was a clear gap between the scientific the culture and the health care setting, i.e. the appears within small groups, within countries knowledge and actual treatment in General differences between the countries. This varies en between countries. At the same time, much Practice indicating undertreatment for both from familiarity with small group learning to decision making on treatment is habitual, without diseases. acceptance of guidelines as a ‘gold standard’ active deliberating on the different aspects. This In qualitative studies we gained a better Doctors differ strongly in the criteria they for treatment choices. The programme failed in is in particular the case in more ‘simple’ diseases understanding of the barriers and facilitators Germany apparently because German GPs felt such as UTI, while for stomach complaints of change in these diseases. In the asthma threatened by changes in the health care system doctors weight more aspects before choosing. treatment, it appears that doctors are well aware and had little faith in small group learning. These are core aspects of drugs prescribing of the evidence and the guidelines, they think Unfortunately, these aspects were not evaluated (effectiveness, costs) as well as the context they treat their patients accordingly, but in actual systematically, but we learned that cultural and of the patient. Formularies are an important fact this is not the case. Therefore strategies national contexts may be very important for the tool to help doctors who are looking for extra to improve the implementation of the guideline impact of this type of intervention, an aspect information. However, adherence to these need to make doctors aware of this gap. Audit little studied. We did study different views on guidelines can be much improved, in particular and feedback is a strategy that has been widely asthma treatment in the countries involved, if drug choice is evaluated in relation to the used, and that fits in well with the existing which showed clear differences. The German indication. The latter can only be done when data infrastructure of FTO (quality circles of doctors GPs, for example, put much more weight on are available about the indication as is the case in patients). To address the lack of awareness of psychosocial aspects then GPs in the other the RNG data base. One problem which appeared their own decision making, we developed a countries, while the Scandinavian countries set when analysing the different formularies used in method to provide cognitive feedback, called high store at shared decision making between the Netherlands is the large variation, in content clinical judgement analysis. The method gave doctor and patient. The relevance of the as well as coverage of different therapeutic feedback on the value attached to different cultural aspect was underlined in a later study areas, between these formularies (Kamps). This patient characteristics when deciding on a looking at differences between Belgium and may create confusion, and point to the need drug, such as in asthma the age of the patient, the Netherlands in the use of antibiotics. These of a national formulary. On the other hand, symptoms, PEF-values, use of bronchodilators countries clearly differ in their view on disease local variations can often be well defended and and use inhaled corticosteroids. This type of as well as on their attitudes towards antibiotics, increase the likelihood of doctors adhering to the feedback was discussed in small groups of even between populations living only 40 km formularies. Indicators of (prescribing) quality are essential for implementation efforts and their evaluation. For prescribing indicators large datasets with prescribing data are widely available, that have been used to calculate such indicators. However, The joy of documentary research taken about the validity of these indicators. We If we want to examine a new subject we immerse same time. They felt that this practice was often Veninga et al. found a low correlation between ourselves in the scientific literature, of which used unnecessarily and could lead to medication- indicators that were supposedly measuring the there is no shortage. The problem is that different related problems. The results of the study showed same issue, suggesting that the validity of both publications tend to say slightly different things. that the use of several medicine combinations was was doubtful. These doubts were supported New researchers take fright and have difficulty a direct result of the condition of the patients’ when the validity of the indicators was tested seeing the wood from the trees. Practising doctors health and could not be defined as unnecessary or against clinical evaluation by Pont et al. The become weary if research first shows that treat- irrational. Polypharmacy is a broad term, which indicators concerned were disease specific ment X is very successful and then turns out to can cover a number of different problems, such indicators, trying to take into account the need have little effect. as not clearly indicated medication, side effects, for specific treatments in view of the severity of The joy of documentary research is found in specific undesirable combinations of medicines, the disease. As such the indicators had high face creating order out of chaos and extracting synthe- unnecessary costs and trueness of performance. value in particular for prescribers, but did not sis from all the available pieces of information. It would seem more appropriate to direct inter- stand up against critical assessment. Our results We are then left with a situation in which we can ventions to a specific problem. This study is indicate that great care should be taken about more easily see what we have learned and where an example of the importance of documentary the interpretation of such indicators. there are still gaps in our knowledge. Sound research: the research clarifies a problem and – in systematic documentary research is also useful this case, prevented the need for an intervention in order to avoid unnecessary research. With the study from which little success could have been Some of the results of the programme of EBM introduction of the Cochrane Collaboration and expected. And that is the joy of documentary in chronic diseases in General Practice will be evidence-based medicine, systematic documentary research. implemented in the guidelines of the Dutch research has been given a great deal of encourage- College of General Practitioners, such as the ment and is now considered to be just as valuable results of the effect of education of stroke as traditional empirical research. In our own field patients. of medical research more systematic documentary Strategies and plans for the future The studies of cardiovascular risk factors research of a higher quality is being carried out. and diabetes will be expanded. Besides the The RDU research group was recently asked by drug utilization studies, the implementation of the College of Healthcare Insurers to carry out a strategies to improve unhealthy lifestyles will be study into the increased efficiency that could be stimulated, as a continuation of the Margarine achieved with interventions to improve polyphar- study in which advises about healthy food habits, macy, the use of several medicines at the e.g. the Mediterranean diet were studied in a trial. In particular strategies to promote active lifestyle with sufficient exercise will be started Flora Haaijer-Ruskamp Follow-Up 2000, 4(1) Research in Evidence Based Medicine in Practice (EBM) started to go more deeply in this area, when Chapter 4 our results show that greater care should be 121 122 Northern Centre for Healthcare Research to reduce weight in order to improve functional clues for strategies to optimise the situation. status and quality of life of patients with chronic Shared care between primary and secondary disease, to reduce morbidity and if possible to care will be evaluated (in particular diabetes increase life expectancy. In practice, the context care), providing the necessary link between The research programme is at the crossroad of the patient both socially (life- and housing the different levels of care (see also above). between science and medical practice. situation, ethnicity) and medically (co-morbidity, Moreover we will know more about strategies for The nature of the research is inherently co-medication and medical history and risk improving drug therapy in the hospital situation, multidisciplinary, where insights from medicine, factors including genetic disposition) will be and we expect to increase our understanding of clinical pharmacology, epidemiology and the focused upon. the impact of cultural context and health care social sciences are needed to answer the system on drug therapy by comparing therapy in research questions. Therefore the group works different countries. with people from these different backgrounds. The start and expanding of studies of the musculo-skeletal system, a prevalent problem in 3 Processes in research, internal and external collaboration general practice will be helpful, since more and The actual collaborators change with the clinical more experience is gained in that field. Mobility problem studied. Another characteristic is the is a way to improve health, but musculo-skeletal close collaboration with professionals in the field diseases may limit mobility. and their professional organisations. Practising Self evaluation 1997 - 2002 In the nearest future, a programme of shared GPs are stimulated to do studies within the care studies will be developed, facilitated by the research programme. To date the collaboration establishment of an academic group practice of between the two research lines occurs primarily 9 general practitioners with ca. 15000 patients at the leadership level, together with senior on their list, using the database of the morbidity researchers. At the level of junior researchers, and medication Registration Network Groningen the two groups only meet on a project base. (RNG). In this shared care programme, topics Junior researchers are supervised directly by from the above described studies, using the their supervisor (usual the PhD supervising expertise of the aforementioned programme will professor (the promotor), and a senior be developed. researcher) and discuss progress in weekly or Considering the subprogramme RDU, in biweekly meetings. Moreover, journal clubs, the coming years we will continue with the and monthly and biweekly group discussions research as described above, and add more on a research problem are held. PhD students focus on cardiovascular risk factors in diabetes are supported by training in courses, provided (see above). We anticipate to developing more by NCH as well as other organisations, since effective tools supporting pharmacotherapy schooling programme are tailored to the PhD in actual practice, adjusted to the specific students needs. context they are intended for. Indicators of prescribing quality are further developed and Methodological safeguarding validated. Problems in the choice of drugs (for The programme uses the established quantitative example anti-hypertensives), and in adherence and qualitative study designs, sometimes in to a guideline (for example the treatment of triangulation. Quantitative approaches include cardiovascular risks in patients with diabetes RCT, cohort studies, (interrupted) time series mellitus type 2) will become clear, providing analyses depending on the problem studied, departments of Cardiology, Internal Medicine, University Nijmegen, prof dr R Grol), University studies are faced with data on several levels of General Practice, and the laboratory for general of Nijmegen (dr C Witteman), with Erasmus aggregation, each with their own characteristics; practice, and the department of Public Health University Rotterdam (prof dr AF Caspari, for example the level of the doctor, the patient, of the Community of Groningen take part. In dept of epidemiology dr M Sturkenboom), the diagnosis, or the drug. In this case multilevel- particular studies of cardiovascular risk factors and with the research school UIPS (Utrecht), analyses is used. Qualitative approaches are are realized with this Hypertension Service. pharmacoepidemiology prof dr HGM Leufkens. used primarily to identify particular barriers Further collaboration exists with the research At the European level, the group is involved school BCN, the GUIDE Research Institute of in several projects 1) prof dr FM Haaijer-Ruskamp understand decision making by doctors. The Cardiovascular Diseases, the department of and dr P Denig were international coordinators programme makes extensive use of large Social Psychiatry of Groningen University, and of DEP (Drug Education Programme), funded existing databases. First of all data on morbidity the research Institute of Oncology. In the field by BIOMED programme of the EU, in which and prescribing from the Registration Network of oncology also collaboration exists with the researchers from Sweden (Karolinska Institute, Groningen (RNG). This is an episode-based Comprehensive Cancer Centre North Netherlands Stockholm, prof dr V Diwan, C Stålsby Lundborg, database, covering 16 GPs since 1994 in the (IKN, Integraal Kankercentrum Noord Nederland). R Wahlström), Norway (Univ of Oslo dr M North of the Netherlands with 30.000 patients on Since 2001 joint research is also undertaken with Andrew, P Lagerløv), Germany (E Hummers- their list that cooperated in the Second National the department of Internal Medicine (prof dr Pradier, prof dr M Kochen), Slovakia (Univ Survey and the LinH (NIVEL). Other databases ROB Gans) and the pharmacy of the University of Bratislava, M Muskova). 2) The group also used are IPCI, a GP database coordinated by the Hospital (dr J Kosterink). participated in ENDEP (European Network University of Rotterdam covering 150 doctors, The EBM research on rational drug use partic- Drug Evaluation and Price) with researchers pharmacy records, and data from the public ipates in the research school GUIDE (Groningen from France (Univ Paris, C Huttin), UK (Univ health insurance. Internationally comparative University Institute of Drug Exploration), section of Manchester, prof dr P Noyce), Italy (Univ studies enable the study of the impact of cultural Pharmacoepidemiology and Drug Policy with of Rome, V Atella), Finland (Univ of Helsinki, context and the health care system on the uptake prof dr LTW de Jong-van den Berg. MB Hedvall), and Austria (Univ of Linz, dr R of evidence in actual practice. In the field of the musculo-skeletal Mechtler) funded by BIOMED. 3) Since 2002 diseases, collaboration with the departments prof dr FM Haaijer-Ruskamp is the international Objectives and results of internal of Rehabilitation and Beatrixoord, Orthopedic coordinator of SAR (Self-medication with collaboration Surgery and Anaesthesiology exist and is antibiotics and resistance in Europe), funded by expanding. EU/ SANCO in which 19 countries participate. There is an intensive collaboration with about one third to one fifth of the circa thousand This project closely collaborates with two other general practitioners in the adherent region of Objectives and results of external European networks ESAC (European Study the UHG. This is important since the research collaboration Antibiotics Consumption, coordinated by prof dr programme wants to base the results of the On a national level collaboration exist with H Goossens) and EARSS (European Antimicrobial studies on patients from real practice, so that the Dutch College of General Practitioners in Resistance Surveillance System, coordinated by guidelines and implementation strategies can be particular concerning the implementation of dr H Grundman). Dr P Denig has been involved used in real practice. Further collaboration exists evidence in new or revised guidelines, and with in the Cochrane EPOC review group, in particular with different departments: with the Isala Clinics the RIVM (Rijksinstituut voor Volksgezondheid en Manual paper reminders: effects on professional in Zwolle (dr HGM Bilo) in particular in shared Milieu). practice and health care outcomes (See: Rowe R, care activities for diabetes patients and with the Hypertension Service, Groningen, in which the Collaboration exists with the WOK (Workgroup Research Quality of Care, Wyatt J, Grimshaw J, Gordon R, Hicks N, Altman D, Durieux P, Haaijer F, Denig P, Gill P. (Protocol Research in Evidence Based Medicine in Practice (EBM) for evidence based performance, but also to 123 Chapter 4 as well as cross sectional studies. Many of our for a Cochrane Review). In: The Cochrane Library, Issue 2, 2000. Oxford: Update Software). Strong 124 And the impact factors of the journals in 4 Academic reputation which the publication are realised are increasing Northern Centre for Healthcare Research ties exist with the Department of Palliative Care The programme Evidence Based Medicine too. We ourselves, assess the programme as in Cardiff, UK (prof Ilora Finlay) in practice (EBM) is a programme in a programme in progress that is evaluating in development. It is built on the expertise of the right direction. The research porgramme on both leading professors and their staff. Certain rational drug use provides a unique contribution subprogrammes, started in the EBM programme, to the field of health services research in The have been ‘moved’ to another programme. For Netherlands, with its focus on quality of care and example the stroke research (that led to a new implementation of new evidence in practice. NWO grant), is now integrated in BCN, where it fits better, and can benefit from integration with Previous peer reviews of the similar research. This illustrates an important programme Self evaluation 1997 - 2002 challenge for the leaders and the programme— The predecessor of this programme received the which is to keep coherence in the programme. value 4 in 1996 (see also chapter 1, section 7), as After the first years of expanding the research part of the NCH evaluation. As said before, the focus, the time has come now to focus and to programme was reorganised after this evaluation achieve excellence. but kept many of its constituents. Research on cardiovascular diseases, musculo-skeletal diseases and rational drug Rewards and Prizes use has promises for the near future. The Prof dr B Meyboom-de Jong: rational drug use programme will focus more • on cardiovascular diseases, leading to a more focussed research programme. The academic Honorary professor National Medical University of Mongolia. (5-10-2002) • reputation is good; both leaders and post-docs KNMG silver medal for great merit in the field of health care. are regularly invited as referee for research programmes and articles, and they know how Dr W Kasje to attract national and European research funds. • Since the start of the programme, the number of Poster prize at 16th ICPE (International Conference on PharmacoEpidemiology). publications in international journals and in Dutch scientific journals is increasing over the years. Editorships in academic journals, and memberships in scientific boards Prof dr B Meyboom-de Jong • Chairwoman of the board of the Vereniging het Nederlands Tijdschrift voor Geneeskunde 1998-2003. Prof dr FM Haaijer-Ruskamp • • 6 External validation Research and Policy, Editorial Advisory Board, In a mailed questionnaire, we asked 14 Relations are primarily with non-profit 1995-1999. researchers involved in the programme, how they organisations in public health care. The most Editorial board International Journal of Risk evaluated the management, the support received, important are National council on health and Safety, Advisory Board, 1990 - today. the research climate and the available resources insurances, CVZ (A Schuurman and dr Y Editorial board Dukes MNG, Haaijer-Ruskamp on a scale from 1 (very bad) to 7 (very good). Waterreus), Health Insurance Company (Geove/ FM, de Joncheere CP, Rietveld AH. (eds) The different aspects were judged to be ‘good’ RZG, dr H Schildkamp), and Het Groene Land/ Drugs and money: prices, affordability and ranging from 5.4 for support, 5.6 for resources, Achmea. At the international level WHO (dr H cost containment. International Journal of 5.7 for management to 6.1 for climate. Hogerzeil, dr C de Joncheere). Editorial board Journal of Health Services • • Three of the responders made a remark, ‘I’m The increasing societal relevance of Member Advisory Committee VTV very satisfied about the supervision’; ‘I did with research in EBM in practice is expressed by the (Volksgezondheid Toekomst Verkenning, much pleasure research during my PhD study’; development of national and regional databases Public Health Scanning the Future) Drugs now ‘I had not much contact with the NCH or the on various aspects of care, based on Health and in the future (published in 2002) 1999- department because my study was situated Information Systems of GPs (HIS) or drug 2000. outside Groningen’, respectively. utilisation in pharmacy records and in health Member ZonMw (Zorg Onderzoek Nederland) insurance data bases (GIP). Staff members working Group Scientific Quality of Health participate in such networks and programmes Services Research 1999 - today. both in scientific advisory roles, as managerial Member ZonMw (Zorg Onderzoek Nederland) board members or as actively contributing data Effective Implementation 1999 - today. (for example in LINH, the Landelijk Informatie • Member Gezondheidsraad 2002 - today. Systeem Huisartsen). Staff members are actively • Chair executive committee EURODURG involved in professional organisations. • (European Drug Utilisation Research Group) 1994-2000. Dr J Schuling • • Gezondheidsraad 1994-2002. • Raad voor de Volksgezondheid en Zorg 1994- Chair editorial board ‘Geneesmiddelenbulletin’ from 1996. • Prof dr B Meyboom-de Jong has been involved in: 1997. • Member committee Groninger Formularium since 1994. KNMG/ VSNU committee ‘Arts van straks’ 2001-2002. • Chair NWO Committee Chronische Neurologische Psychiatrische Aandoeningen Dr GTh van der Werf • Editorial board Huisarts en Wetenschap. • Member supervisory board KITTZ, het (Chronic neurological and psychiatric disorders (1992- today). • Joint European Project to Develop a New KwaliteitsInstituut voor Toegepaste Medical Curriculum for the National Medical ThuisZorgvernieuwing. University of Mongolia. 1997 - today. Research in Evidence Based Medicine in Practice (EBM) Risk and Safety in Medicine. 2002: 15:1-151. 125 Chapter 4 • 5 Internal evaluation Interview with Betty Meyboom - de Jong 126 Main themes Northern Centre for Healthcare Research The implementation of standards in general practice is one of the main themes of the General Medical Practice Discipline Group’s research programme ‘Implementation of Evidence Based Medicine in the Medical Practice’. This theme has been studied since 1996 and is now a large study subsidised by the Netherlands Organisation for Scientific Research, NWO. Self evaluation 1997 - 2002 Other main research themes within the institute The basis of the research themes described by are cardiovascular risk prevention and interdisci- the General Medical Practice Discipline Group plinary implementation of the diabetes standard. is socially relevant general practice research and Although it is not easy to combine the research as an extension of this, professionalisation of the themes under one general heading, we do try GP. This is reflected in the research output of the to give them a common thread. One continuous Discipline Group. An increasing number of dis- source of research data is the Registratie Netwerk sertations and publications find their way to GP Groningen (RNG). Sixteen general practitioners colleagues and researchers. Until a few years ago, the institute as a whole. The research themes must be participate in this network, which comprises socially relevant research did not meet with the clearly defined so that they can be handed over in one three group practices and 3 solo practices. These same recognition as pure scientific research, but piece. In other words, Betty wants to make sure that GPs register the diagnosis, medication prescribed it is now seen in a different light, both within the when she leaves everything has been tidied up. With a and associated referrals for each patient. This university and elsewhere. Since her appointment total staff of 55, including 15 PhD students, a sizeable means that the Discipline Group has a sizeable Betty Meyboom-de Jong has pushed for this and teaching commitment, the imbedding of the research pro- database at its disposable, enabling it to respond regards the change in attitude as a positive deve- gramme in the NCH and the future partnership within directly to the GPs with information and carry lopment which does justice to the nature and con- the University Medical Centre, it would seem that the out patient-based and epidemiological research. tent of her own discipline. (…) continuity of General Medical Practice has been secured. Since 1999 the RNG has been financed by the Before she hands over she would like to be University Hospital Groningen (UHG) and works sure that her institute is soundly imbedded in the in close collaboration with it. The UHG and the university structures. Future themes within gene- Faculty of Medical Sciences are planning to form ral medical practice, such as chronic disease, pal- a University Medical Centre to include GPs in a liative and informal care will be further examined group practice as part of an Academic Care Chain and provided with a theoretical framework. This in the north of the Netherlands. will require reflection and careful consideration, not only from the programme director, but from Follow-Up 2001, 5(1) • • Peer Review Committee of Danish Primary Two of our members are participating in National Our ability to attract resources, grants and funding Care Research Units of Copenhagen, Aarhus, Guidelines of the Dutch Society of General is another indicator for the appreciation from the Odense and Frederiksborg. 2000 - today. Practice: external world. On a national level no separate Peer Review Committee of Danish post-doc section exists for research on rational drug use, Dr J Schuling or pharmaco epidemiology within the Netherlands today. • Transient Ischemic Attack Organisation for Scientific Research (NWO). Thus • Stroke the group has had to attract funds from other Prof dr FM Haaijer-Ruskamp is involved in Dr JC Winters to non-profit organisations, of which the most rational drug use, such as: • important are: Board of the Geneesmiddelenbulletin (Drug Shoulder complaints • Bulletin) 1992 - today. • Klankbordgroep Farmaceutische Zorg SANCO. • (Sounding Board Pharmaceutical care), • CVZ (National council on health insurances) antihypertensives). • cost-effective health care’) of CVZ and VAZ WHO Collaborating Centre for (Academic Hospitals Council) - improvement of Pharmacotherapy teaching and training, 1988- use of antibiotics in hospital, implementation of Consultant for Yemen Drug Action Program shared care in pharmacotherapy. • (YEMDAP) 1996-1999. • pharmacotherapy. • for Pharmacotherapy in Groningen), 2000 - Drugs and Money. • De Stichting DGV (Dutch Institute for Responsible Drug Use). WHO (dr H Hogerzeil, dr C de Joncheere) – interventions to improve rational drug use, today. Dr P Denig is involved in: Health Insurance Company (Geove/ RZG), implementation of shared care in Implementatie committee Proeftuin Farmaceutische Zorg Groningen (Shared care • Doelmatigheidsfonds (‘fund for research on Consultant for Pharmacy program, 2002. 2000. • CVZ (National council on health insurances) for research on polypharmacy, trends in the use of Ministry of Health: 1999-2001. • European Union BIOMED funding, and from DG Ministry of Health (Dutch part of the DEP study). Research in Evidence Based Medicine in Practice (EBM) • sources regarding RDU research. This was limited committees and organisations that promote 127 Chapter 4 fellowships for general practitioners. 2001 - 7 Researchers and other personnel Table 1 Research staff attached to the programme 1997 1998 1999 2000 2001 2002 Haaijer-Ruskamp, F 0.15 0.15 0.15 0.15 0.15 0.15 Hunink, MGM 0.26 0.15 There is no specific programme personnel policy. Recruitment, selection, training, personal 128 Full professors development opportunities, mobility and Northern Centre for Healthcare Research 0.3 0.3 0.3 0.3 0.3 0.3 and faculty level. For recruitment use is made Associate professors Meyboom-de Jong, B Werf, GTh van der 0.12 0.12 0.12 0.12 0.12 0.12 of the different networks in which the group Assistant professors Denig, P 0.06 0.06 0.06 0.06 0.06 0.07 Groenier, KH 0.15 0.15 0.3 0.3 0.3 0.3 0.24 0.3 0.3 0.3 1.17 1.23 1.23 1.54 0.6 0.72 0.72 0.72 0.06 0.18 0.18 0.18 0.9 0.45 0.45 0.45 0.7 0.7 0.7 0.27 0.27 0.27 exchange policies are regulated at the central participates. During the period of this report (1997-2002) at times it has been difficult to find Schuling, J researchers and technical support personnel, Winters, JC because of scarcity on the labour market. Table 1 Total tenured staff provides an overview of the research staff Non tenured staff members, attached to the programme. PhD students 0.3 1.04 0.93 Veen, WJ van der Baarveld, F Bemelmans, WJE 0.9 0.9 Self evaluation 1997 - 2002 Bergman, G Boendermaker, PM 0.27 Bosch, JL 0.58 Grand, A le 0.18 Greving, JP 0.75 Grigoryan, L 0.35 Houweling, B 0.35 0.7 Jansma, F 0.36 0.36 0.7 0.7 0.7 Mol, P 0.0 0.0 Nannan Panday, PV 0.0 0.0 0.18 0.18 0.18 0.7 0.7 0.35 0.36 0.36 Kamps, GB 0.0 Kasje, W Loor, HI 0.0 0.0 0.29 0.7 0.18 Peters – Veluthamaningal, C Pont, L 0.29 0.7 Stewart, RE Sturm, H 0.64 Ubink – Veltmaat, L Note: The following guidelines were followed in the computation Veehof, L of research time: Tenured staff, 0.3 of a FTE (full time equivalent) Veninga, CCM Vries, SO de 0.9 0.18 0.18 0.18 0.7 0.7 0.7 0.35 0.9 0.45 0.45 0.9 0.9 0.3 0.7 0.35 0.09 0.09 0.09 Total non tenured staff 4.12 3.61 5.55 6.40 6.61 7.34 Total research staff 5.16 4.54 6.72 7.63 7.84 8.88 Post docs, 0.9 of a FTE; PhD students, 0.7 of a FTE; Furthermore Wachters – Kaufman, CSM research input is proportionate to the size of the appointment, and to the part of the year 0.9 Visser, CL de (staff with an appointment at the University hospital: 0.1 of a FTE); 0.7 0.09 Table 2 provides additional information with 8 Resources, funding and facilities respect to research staff. First the number of Coordination Centre at the University Hospital) has provided the necessary support. PhD students is presented for each year. This Research facilities number then is divided by the fte research input Special reference should be made to the hard of tenured staff. This gives an impression of the and software infrastructure of the Registration Table 3 provides an overview of the sources of workload of tenured staff members. Finally the Network Groningen (RNG), a database funding, divided in direct funding and contract proportion between fte research input of tenured comprising data on morbidity, medication and funding. Since 1999, due to the substantial staff and direct funding supporting staff is given. consultation flow of 16 GPs. The data base exists increase in PhD students from that year on, the since 1994. The RNG database is important proportion direct funding / contract funding Table 2 shows a steady growth in the number of for research on GP quality of care; the dataset fluctuates round 50%. PhD students. This growth is partially matched is linked to the nationally representative LINH by an increase in tenured staff. Over the last (Landelijk Informatie Netwerk Huisartsen). The years the tenured staff is assisted by well over research group is adequately supported with With the departure of prof dr Hunink a dip 1 fte supporting staff. This means that for every computer facilities (including software) and occurred in staff and PhD students as well as four employees tenured staff, one employee has adequate online access to literature, both output. Since then the situation has improved. supporting staff is available. provided by the faculty. However, structural The staff, tenured as well as non-tenured staff ICT support targeted to the research of this and PhD students increased over the review programme can be improved. To date for period. We have been increasingly effective in other projects collaboration with the TCC (Trial attracting funds from third parties. The increased Funding at programme level (publications), although as is to be expected with Table 2 Fte analyses a certain lag time. 1997 1998 1999 2000 2001 2002 8 8 11 13 15 16 Number of PhD students / fte tenured staff 7.69 8.60 9.40 10.57 12.20 10.39 Fte tenured staff / fte direct funding supporting staff 1.04 0.93 1.17 1.23 1.23 1.28 Future funding targets Number of PhD students We intend to at least remain constant in our efforts to attract funds, and attract 1 or 2 new PhD students per year for our research programme. Although 4 year study grants are preferred, we also aim for grants of shorter Table 3 Funding at programme level in O : personnel funding Funding duration. However, in view of the cutting in 1997 1998 1999 2000 2001 2002 Average 133.742 116.049 145.783 154.237 161.529 211.165 153.751 public grant opportunities this may meet more obstacles in the near future. Direct funding (1st moneyflow) Contracts (3rd moneyflow) Total 83% 71% 57% 50% 48% 53% 57% 27.238 46.802 111.242 156.365 172.469 185.109 116.538 50% 52% 47% 43% 310.602 333.998 396.274 270.288 17% 29% 43% 160.980 162.851 257.025 100% 100% 100% Note: See chapter 1 for explanation of computation of personnel funding 100% 100% 100% 100% Research in Evidence Based Medicine in Practice (EBM) input is reflected in an increase in output Chapter 4 Explanation of trends 129 Table 4 Key publications Authors/Titles Source 1 Veehof LJG, Stewart RE, Meyboom-de Jong B, Haaijer-Ruskamp FM. Eur J Clin Pharmacol IF RIF Times cited 130 Northern Centre for Healthcare Research Adverse drug reactions and polypharmacy in the elderly in general practice. 2 Winters JC, Sobel JS, Groenier KH, Arendzen JH, Meyboom-de Jong B. Comparison of physiotherapy, manipulation, and corticosteroid injection for treating shoulder complaints 1999; 55:533-536 Self evaluation 1997 - 2002 1.771 71 13 4.994 94 37 5.491 100 19 5.021 96 15 1.078 67 7 5.143 94 7 2.590 79 20 2.070 88 4 2.075 86 4 BMJ 1997; 314:1320-1325 in general practice. 3 Veninga CCM, Lagerlov P, Wahlstrom R, Muskova M, Denig P, Berkhof J, Kochen MM, Haaijer-Ruskamp FM. Evaluating an educational intervention to inprove the treatment of asthma in four European countries. 4 Bemelmans WJ, Broer J, Feskens EJ, Smit AJ, Muskiet FA, Lefrandt JD, Bom VJ, May JF, Meyboom-de Jong B. Effect of an increased intake of alpha-linolenic acid and group nutritional education on cardiovascular risk factors: Am J Respir Crit Care Med 1999; 160:1254-1262 Am J Clin Nutr 2002; 75:221-227 the Mediterranean Alpha-linolenic Enriched Groningen Dietary Intervention (MARGARIN) study. 5 Veehof LJG, Stewart RE, Haaijer-Ruskamp FM, Meyboom-de Jong BM. The development of polypharmacy. A longitudinal study. 6 Winters JC, Jorritsma W, Groenier KH, Sobel JS, Meyboom-de Jong B, Arendzen JH. Treatment of shoulder complaints in general practice: long term results of a randomised, single blind study Family Practice 2000; 17:261-267 BMJ 1999; 318:1395-1396 comparing physiotherapy, manipulation, and corticosteroid injection. 7 Lagerløv P, Veninga CCM, Muskova M, Hummers-Pradier E, Haaijer-Ruskamp FM, Andrew M, DEP-group. Asthma management in five European countries: doctor’s knowledge, attitudes and prescribing behaviour. 8 Veninga CCM, Denig P, Pont LG, Haaijer-Ruskamp FM. Comparison of indicators assessing the quality of drug prescribing for asthma. 9 Veninga CCM, Denig P, Zwaagstra R, Haaijer-Ruskamp FM. Improving drug treatment in general practice. Eur Respir J 2000; 15:25-29 Health Serv Res 2001; 36:143-161 J Clin Epidemiol 2000; 53:762-772 9 Overview of the results Table 5 Programme results: outcome numbers 1997 1998 1999 2000 2001 2002 Total 15 21 13 20 13 23 105 3 4 6 11 13 7 44 Key publications To review our impact in the scientific Academic publications a. in refereed journals b. in other journals environment, we selected and analysed nine key 2 2 2 0 1 10 27 21 33 26 31 159 Monographs 0 1 0 1 3 2 7 PhD theses 7 3 5 4 3 3 25 1997 1998 1999 2000 2001 2002 Mean Total overview of these publications is given in table 4. The key publications have been limited to the research groups that participate in EBM after the reorganisation of 1998. Almost half of these publications appear in journals of an impact Table 6 Output analyses factor > 4. To have a better understanding of the 97-02 value of the absolute impact factor, we added the relative impact factor, which is derived from the IF <1 3 3 6 7 1 1 positions of the journal within a certain SSCI field IF 1<2 2 3 3 5 10 14 of research. Our average relative impact factor IF 2<3 3 9 0 3 1 1 of these nine key publications is 86, indicating IF 3+ 5 5 2 0 1 4 that these journals belong to the top 14% in their Mean IF 3.520 3.084 1.845 1.341 1.736 2.522 RIF <50 2 1 1 3 0 0 RIF 50<75 2 4 5 6 9 9 RIF 75<90 3 4 2 6 2 5 Table 5 provides an overview of outcome RIF 90+ 6 11 2 1 2 6 numbers of the programme. In table 6 additional Mean RIF 78.2 81.1 65.0 65.5 71.0 79.9 74.4 1997 1998 1999 2000 2001 2002 4.05 2.389 field. On average our key publications were 10.9 times cited, excluding self citations. Programme results figures are presented. In this table publications in journals with an impact factor are given. The journals are divided into four categories, with Table 7 Output-fte analyses respect to absolute impact factor (IF) as well as relative impact factor (RIF). This table clearly shows that after the relapse due to the departure Number of publications / fte research staff 5.43 6.83 3.87 5.24 4.08 of prof dr Hunink both the absolute and relative Number of publications with IF>=1 / fte research staff 1.94 3.74 0.74 1.18 1.53 2.14 impact factors show a steady increase. Number of PhD theses / fte tenured staff 6.73 3.23 4.27 3.25 2.44 1.95 Note: For research staff and tenured staff the proportion of appointment to be dedicated to research is used. In table 7 the programme output is linked to the input. The number of publications, in total and with Impact Factor of at least 1.0 is given per fte research staff. In addition the number of finished PhD theses per fte tenured staff is given. See note table 1 for and explanation Research in Evidence Based Medicine in Practice (EBM) 3 21 of both themes within the programme. An Chapter 4 c. book chapters publications in order to give a good impression 131 It can be seen that the number of publications 10 Analysis, perspectives and • per fte research staff is rather stable. The number expectations for the research the core interest of the group, though to date of publications in journals with an impact factor programme adequate support was provided by the TCC of at least 1.0 is increasing since 1999. A slight 132 Lack of structural ICT support specialised in (Trial Coordinating Centre) of the University decrease in the number of PhD theses (table 5) Northern Centre for Healthcare Research and number of PhD theses per tenured staff • (table 7) is noticeable. Synergy in different parts of the programme (assessing performance, and implementing the results in guidelines and programmes to Opportunities • improve health care). Full list of publications The full list of publications can be found at the Hospital. Strengths • end of this chapter. Structural collaboration with the research collaboration with university hospital. • school GUIDE and research groups within the University Hospital. • Self evaluation 1997 - 2002 • • • Start of University General Practice (i.e. is formalised in collaboration within the RNG within the University Hospital organisation), database but is also clear from the large consisting of 9 GPs covering approx 15 000 number of dissertations from GPs outside the patients. university. • Motivated and ambitious staff. Close collaboration with national and regional • Increasing number and impact of publications. public health organisations. • Increased international exchange. Research programme meets public health Threats Rational drug use research programme • Departure of prof dr Meyboom-de Jong. providing a unique contribution to the field of • Dwindling funding opportunities from public quality of care research in The Netherlands. • Start of network for shared care on diabetes in Northern Netherlands. needs. • Improving the network with daily medical practice. • Very intensive collaboration and integration with practising GPs in the region; the input Collaboration with GUIDE, and more International collaboration in joint funds. • international research projects. Dependency on financial means from pharmaceutical industry, threatening independent research. Weaknesses • Limited recruitment of well trained PhD • Limited potential for further development and growth of non-tenured tracked staff. students with a clinical of pharmacy background. • • The programme is rather new; as described in Difficulty in remaining focussed because of the beginning of this chapter. During the period orientation on professionalisation of GPs, and 1997-2002 the research programme was formed because of funding opportunities. and expanded. The time has come to focus on a Merely adequate size of the research group. more limited number of topics to improve quality and reach excellence. The research on chronic pulmonary diseases was originally part of the research programme. It is now further developed In the future the focus will be primarily rational drug use in this field), disorders of the and moved to the Groningen Research Institute musculo-skeletal system and optimising rational of Asthma and COPD (GRIAC). The studies in pharmacotherapy. More effort will be given to stroke patients will not be continued since no implementation of results of scientific research in clear topics for general practitioners emerge practice. In the future, the total programme will at the moment. The last study of cognitive have greater attention for shared care between disturbances and quality of life are performed primary and secondary care as well as hospital within the research school of Behavioral and based care. Collaboration will be increased with Cognitive Neurosciences (BCN). In the period the University Hospital. This is facilitated by of this report, the affiliation of the staff- the upcoming establishment of the Academic members studying rational drug use changed General Practice Oostersingel of 9 GPs covering from the department of Health Sciences to the approximately 15 000 patients within the department of Clinical Pharmacology in order University Hospital grounds. The development to ensure a better embedding in the network of of a separate research line on shared care is at pharmacotherapy researchers. This has resulted present considered, that will focus on shared in a strengthening of the focus on cardiovascular consultations of GPs and specialists, the impact problems and diabetes. The programme has of secondary care on changes in treatment stimulated collaboration between researchers in primary care based on RNG data, and on from the department of General Practice and implementation of shared care on diabetes care, Clinical Pharmacology in the study of rational care for disorders of the musculo-skeletal system drug use, as is clear from 3 collaborative and palliative care. Moreover, the research on dissertations and 9 articles in refereed journals. rational drug use will extend to optimisation This trend of collaborative effort will be of pharmacotherapy within the hospital, with continued and intensified in the near future. special attention for patient safety issues. The collaboration with GUIDE will be intensified, in We plan to continue on the lines described particular in the field of a long term follow-up although one of the leaders of this programme study of the treatment of cardiovascular risks will retire in 2004 (prof dr B Meyboom-de Jong). in diabetes patients in relation to the planned The strengths of the programme and the positive interventions to improve treatment of these risks, development, coupled to the strong ties with and study the impact of these improvements on the field warrant continuation. This continuation morbidity and mortality. of the research programme described here will play an important role in attracting a successor. The scientific director of the Northern Centre of Health Care Research is involved in this process. 133 Research in Evidence Based Medicine in Practice (EBM) on cardiovascular risk factors (including Groningen and professor at Aberdeen University, Chapter 4 by dr T van de Molen, associate-professor in Full list of publications Academic publications in international refereed journals 1997 PhD theses 134 Northern Centre for Healthcare Research Beltman FW. Ambulatory blood pressure monitoring. 1997. Proefschrift Faculteit der Medische Wetenschappen Rijksuniversiteit Groningen Promotores: prof dr B Meyboom-de Jong, prof dr KI Lie. Bosch JL. Outcome assessment of the percutaneous treatment of iliac artery occlusive disease. 1997. Proefschrift Faculteit der Medische Wetenschappen Rijksuniversiteit Groningen Promotores: prof dr MGM Hunink, prof dr WPThM Mali, prof dr L Koopmans. Self evaluation 1997 - 2002 Dijkers FW. Repeat prescriptions; a study in general practice in the Netherlands. 1997. Proefschrift Faculteit der Medische Wetenschappen Rijksuniversiteit Groningen Promotores: prof dr B Meyboom-de Jong, prof dr FM Haaijer-Ruskamp, prof dr AF Caspari. Goddijn PPM. Improving metabolic control in NIDDM patients referred for insulin therapy. 1997. Proefschrift Faculteit der Medische Wetenschappen Rijksuniversiteit Groningen Promotores: prof dr B Meyboom-de Jong; Referenten: dr HJG Bilo, dr ir EJM Feskens. Joosten AR. Psychosociale verklaringen voor klachten in huisarts-patiëntgesprekken: een gespreksanalystische studie. 1997. Proefschrift Faculteit der Medische Wetenschappen Rijksuniversiteit Groningen Promotores: prof dr AJM van der Geest, prof dr B Meyboom-de Jong; Referent: dr MJ Maasland. Tetteroo E. The Dutch Iliac Stent Trial; results from a randomized multicenter study. 1997. Proefschrift Faculteit der Geneeskunde Promotor: prof dr MGM Hunink. van der Molen Th. Asthma treatment in general practice. 1997. Proefschrift Faculteit der Medische Wetenschappen Rijksuniversiteit Groningen Promotores: prof dr B Meyboom-de Jong, prof dr DS Postma. Baay MF, Duk JM, Groenier KH, Burger MP, de Bruijn HW, Hollema H, Stolz E, Herbrink P. Relation between HPV-16 serology and clinico-pathological data in cervical carcinoma patients: prognostic value of anti-E6 and/or anti-E7 antibodies. Cancer Immunology, Immunotherapy 1997; 44:211-215. Boerkamp EJC, Reuijl JC, Haaijer-Ruskamp FM. The pharmacist as a drug information supplier in hospitals: a view from services marketing. Journal of Business Research 1997; 40:207-218. Bosch J, Hunink MGM. Meta-analysis of the results of percutaneous transluminal angioplasty and stent placement for aortoiliac occlusive disease. Radiology 1997; 204:87-96. de Vries SO, Hunink MG. Results of aortic bifurcation grafts for aortoiliac occlusive disease: a meta-analysis. Journal of Vascular Surgery 1997; 26:558-569. Goddijn PM, Bilo HJG, Feskens KH, VanderZee KI, Meyboom-de Jong B. Longitudinal study on glycemic control and quality of life in referrred NIDDM patients. Diabetologica 1997; 40:A13. van der Molen T, Postma DS, Schreurs AJ, Bosveld HE, Sears MR, Meyboom-de Jong B. Discriminative aspects of two generic and two asthma-specific instruments: relation with symptoms, bronchodilator use and lung function in patients with mild asthma. Quality of Life Research 1997; 6: 353-361. van der Molen T, Postma DS, Turner MO, Meyboom-de Jong B, Malo JL, Chapman K, Grossman R, de Graaff CS, Riemersma RA, Sears MR. Effects of the long acting beta agonist formoterol on asthma control in asthmatic patients using inhaled corticosteroids. The Netherlands and Canadian Formoterol Study Investigators. Thorax 1997; 52: 535-539. Weeda G, Hutter AW, Groenier KH, Schuling J. The workload of trainees in general practice. Medical Education 1997; 31:138-143. Winters JC, Groenier KH, Sobel JS, Arendzen HH, Meyboom-de Jong B. Classification of shoulder complaints in general practice by means of cluster analysis. Archives of Physical Medicine and Rehabilitation 1997; 78:1369-1374. Winters JC, Sobel JS, Groenier KH, Arendzen JH, Meyboom-de Jong B. Comparison of physiotherapy, manipulation, and corticosteroid injection for treating shoulder complaints in general practice. BMJ 1997; 314: 1320-1325. Heesen WF, Beltman FW, May JF, Smit AJ, de Graeff PA, Havinga TK, Schuurman FH, van der Veur E, Hamer JP, Meyboom-de Jong B, Lie KI. High prevalence of concentric remodeling in elderly individuals with isolated systolic hypertension from a population survey. Hypertension 1997; 29:539-543. Winters JC, Sobel JS, Groenier KH, Arendzen JH, Meyboom-de Jong B. The course of pain and the restriction of mobility in patients with shoulder complaints in general practice. Rheumatology International 1997; 16:219-225. Hunink MGM, Goldman L, Tosteston ANA, Mittleman MA, Goldman PA, Williams LW, Tsevat J, Weinstein MC. The recent decline in mortality from Coronary Heart Disease, 1980-1990: the effect of secular trends in risk factors and treatment. JAMA 1997; 277:535-542. Dijkema J, de Haan J, Meyboom-de Jong B. Onvrede over de werkdruk van huisartsen en assistentes. Tijdschrijven in een huisartspraktijk. Huisarts en Wetenschap 1997; 40:6-8. Sobel JS, Winters JC, Groenier KH, Arendzen JH, Meyboom-de Jong B. Physical examination of the cervical spine and shoulder girdle in patients with shoulder complaints. Journal of Manipulative and Physiological Therapeutics 1997; 20:257-262. Tosteston ANA, Weinstein MC, Hunink MGM, Mittleman MA, Williams LW, Goldman PA, Goldman L. Costeffectiveness of population-wide educational approaches to reduce serum cholesterol levels. Circulation 1997; 95: 24-30. Academic publications in other journals Kamps GB, Meyboom-de Jong B. Regionale formularia voor huisartsen vergeleken. Nederlands Tijdschrift voor Geneeskunde 1997; 141:1002-1007. Veehof LJG, Schuling J. Polyfarmacie bij ouderen met chronische ziekten: tegenstrijdige belangen. Nederlands Tijdschrift voor Geneeskunde 1997; 141:177-179. Book chapters Denig P. The decision process of the physician. In: Bakker A, Hekster YA, Leufkens HG (eds.). Drug consumption in the Netherlands. Noordwijk, Amsterdam Medical Press, 1997: pp. 23-36. Haaijer-Ruskamp FM. Acquiring medicines, the Netherlands in a European context. In: Bakker A, Hekster YA, Leufkens HG (eds.). Drug consumption in the Netherlands. Noordwijk, Amsterdam Medical Press, 1997: pp. 9-22. 1998 Buis J. Thirteen chronic diseases, in particular stroke. 1998. Proefschrift Faculteit der Medische Wetenschappen Rijksuniversiteit Groningen Promotor: prof dr B Meyboom-de Jong; Co-promotor: dr J Schuling. Heesen WF. Pathophysiology and effects of treatment. 1998. Proefschrift Faculteit der Medische Wetenschappen Rijksuniversiteit Groningen Promotores: prof dr KI Lie, prof dr B Meyboom-de Jong, prof dr PA de Graeff; Co-promotores: dr JF May, dr AJ Smit. Loor HI. Leven na een beroerte. Een drie jaar durend observatie-onderzoek vanuit de huisartspraktijk, naar de gevolgen van een cerebrovasculair accident. 1998. Proefschrift Faculteit der Medische Wetenschappen Rijksuniversiteit Groningen Promotores: prof dr B Meyboom-de Jong; Co-promotor: dr J Schuling. Academic publications in international refereed journals Bosch JL, Tetteroo E, Mali WPTM, Hunink MGM. Iliac arterial occlusive disease: cost-effectiveness analysis of stent placement versus percutaneous transluminal angioplasty. Radiology 1998; 208:641-648. Bult JR, Hunink MG, Tsevat J, Weinstein MC. Heterogeneity in the relationship between the time tradeoff and Short Form-36 for HIV-infected and primary care patients. Medical Care 1998; 36:523-532. de Vries SO, Donaldson MC, Hunink MG. Contralateral symptoms after unilateral intervention for peripheral occlusive disease. Journal of Vascular Surgery 1998; 27: 414-421. de Vries SO, Fidler V, Kuipers WD, Hunink MG. Fitting multi-state transition models with autoregressive logistic regression: supervised exercise in intermittent claudication. Medical Decision Making 1998; 18:52-60. de Vries SO, Kuipers WD, Hunink MG. Intermittent claudication: symptom severity versus health values. Journal of Vascular Surgery 1998; 27:422-430. Fleischmann KE, Hunink MGM, Kuntz KM, Douglas PS. Exercise echocardiography or exercise SPECT imaging? - a meta-analysis of diagnostic test performance. JAMA 1998; 280:913-920. Beltman F, Heesen W, Smit A, May J, de Graeff P, Havinga T, Schuurman F, van der Veur E, Lie K, Meyboom-de Jong B. Two-year follow-up study to evaluate the reduction of left ventricular mass and diastolic function in mild to moderate diastolic hypertensive patients. Journal of Hypertension Suppl 1998; 16:S15-S19. Heesen WF, Beltman FW, Smit AJ, May JF, de Graeff PA, Havinga TK, Schuurman FH, van der Veur E, Meyboomde Jong B, Lie KI. Effect of quinapril and triamterene/ hydrochlorothiazide on cardiac and vascular end-organ damage in isolated systolic hypertension. Journal of Cardiovascular Pharmacology 1998; 31:187-194. Beltman FW, Heesen WF, Smit AJ, May JF, de Graeff PA, Havinga TK, Schuurman FH, van der Veur E, Lie KI, Meyboom-de Jong B. Effects of amlodipine and lisinopril on left ventricular mass and diastolic function in previously untreated patients with mild to moderate diastolic hypertension. Blood Pressure 1998; 7:109-117. Hunink MGM. Outcomes research and cost-effectiveness analysis in radiology. European Journal of Radiology 1998; 27:85-87. Hunink MGM, Bult JR, DeVries J, Weinstein MC. Uncertainty in decision models analyzing costeffectiveness: the joint distribution of incremental costs and effectiveness evaluated with a nonparametric bootstrap method. Medical Decision Making 1998; 18:337346. Kolkman PM, Luteijn AJ, Nasiiro RS, Bruney V, Smith RJ, Meyboom-de Jong B. District nursing in Dominica. International Journal of Nursing Studies 1998; 35:259-264. Schuit KW, Sleijfer DT, Meijler WJ, Otter R, Schakenraad J, van den Bergh FC, Meyboom-de Jong B. Symptoms and functional status of patients with disseminated cancer visiting outpatient departments. Journal of Pain and Symptom Management 1998; 16:290-297. Tetteroo E, van der Graaf Y, Bosch JL, van Engelen AD, Hunink MGM, Eikelboom BC, Mali WPTM. Randomised comparison of primary stent placement versus primary angioplasty followed by selective stent placement in patients with iliac-artery occlusive disease. Lancet 1998; 351:1153-1159. van der Kam WJ, Branger PJ, van Bemmel JH, Meyboomde Jong B. Communication between physicians and with patients suffering from breast cancer. Family Practice 1998; 15:415- 419. van der Molen T, Sears MR, de Graaff CS, Postma DS, Meyboom-de Jong B. Quality of life during formoterol treatment: comparison between asthma-specific and generic questionnaires. Canadian and the Dutch Formoterol Investigators. European Respiratory Journal 1998; 12:3034. van der Molen T, Meyboom-de Jong B, Mulder HH, Postma DS. Starting with a higher dose of inhaled corticosteroids in primary care asthma treatment. American Journal of Respiratory and Critical Care Medicine 1998; 158:121-125. van Wijck EEE, Bosch JL, Hunink MGM. Time-tradeoff values and standard-gamble utilities assessed during telephone interviews versus face-to-face interviews. Medical Decision Making 1998; 18:400- 405. Academic publications in other journals Denig P, Haaijer-Ruskamp FM. Descriptief besliskundig onderzoek op het gebied van voorschrijfgedrag. Huisarts en Wetenschap 1998; 41:274-279. Goddijn PP, Meyboom-de Jong B, Feskens EJ, van Ballegooie E, Bilo HJ. Verschillen tussen patiënten met diabetes mellitus type 2 bij wie wel en bij wie niet wordt overgeschakeld op insulinetherapie in de tweede lijn. Nederlands Tijdschrift voor Geneeskunde 1998; 142:10231026. 135 Research in Evidence Based Medicine in Practice (EBM) PhD theses Bosch JL, Hammitt JK, Weinstein MC, Hunink MGM. Estimating general-population utilities using one binarygamble question per respondent. Medical Decision Making 1998; 18:381-390. Jansen RMG, de Vries SO, Cullen KA, Donaldson MC, Hunink MGM. Cost-identification analysis of revascularization procedures on patients with peripheral arterial occlusive disease. Journal of Vascular Surgery 1998; 28:617-623. Chapter 4 Haaijer-Ruskamp FM. The decision process of the physician. In: Bakker A, Hekster YA, Leufkens HG (eds.). Drug consumption in the Netherlands, Vol 2. Utrecht, Rijksuniversiteit: Faculteit Farmacie, 1997: pp. 9-22. Bijl D, van Sonderen E, Haaijer-Ruskamp FM. Prescription changes and drug costs at the Interface between primary and specialist care. European Journal of Clinical Pharmacology 1998; 54:333-336. Veehof LJG, Stewart R, Haaijer-Ruskamp FM, Meyboom-de Jong B. Door geneesmiddelen veroorzaakte problemen bij ouderen. Nederlands Tijdschrift voor Geneeskunde 1998; 142:1409. 136 Veninga CCM, Denig P, Heyink JW, Haaijer-Ruskamp FM. Denkbeelden van huisartsen over de behandeling van astma. Huisarts en Wetenschap 1998; 41:236-240. Northern Centre for Healthcare Research Book chapters Denig P, Bradley CP. How doctors choose drugs. In: Hobbs R, Cradley CP (eds.). Prescribing in general practice. Oxford, Oxford University Press, 1998: pp. 79-94. Haaijer-Ruskamp FM. L’apport de la sociologie. In: Durieux P (ed.). Les dossiers de l’ Institut d’ Etudes des Politiques de Sante, Flammarion Medicine-Sciences, 1998: pp. 41-43. Books (monographs) Self evaluation 1997 - 2002 van der Werf GT, Smith RA, Stewart RE, Meyboomde Jong B. Spiegel op de huisarts; over registratie van ziekte, medicatie en verwijzingen in de geautomatiseerde huisartspraktijk. Groningen, Disciplinegroep Huisartsgeneeskunde, Rijksuniversiteit Groningen, 1998. 1999 PhD theses Kamps GB. Formularia en het voorschrijven door huisartsen. 1999. Proefschrift Faculteit der Medische Wetenschappen Rijksuniversiteit Groningen Promotores: prof dr B Meyboom-de Jong; Co-promotor: dr J Schuling. Luteijn AJ. Primary health care in Dominica. 1999. Proefschrift Faculteit der Medische Wetenschappen Rijksuniversiteit Groningen Promotores: prof dr B Meyboom-de Jong, prof dr GAC Grell, prof dr D Picou. Schuit KW. Palliative care in general practice. 1999. Proefschrift Faculteit der Medische Wetenschappen Rijksuniversiteit Groningen Promotores: prof dr B Meyboom-de Jong, prof dr DT Sleijfer; Referenten: dr R Otter, dr WJ Meyler. Veehof LJG. Polypharmacy in the elderly. 1999. Proefschrift Faculteit der Medische Wetenschappen Rijksuniversiteit Groningen Promotores: prof dr B Meyboom-de Jong, prof dr FM Haaijer-Ruskamp. Verhoeven AAH. Information-seeking bij general practitioners 1999. Proefschrift Faculteit der Medische Wetenschappen Rijksuniversiteit Groningen Promotor: prof dr B Meyboom-de Jong. Academic publications in international refereed journals Bouma J, Broer J, Bleeker J, van Sonderen E, Meyboom-de Jong B, DeJongste MJL. Longer pre-hospital delay in acute myocardial infarction in women because of longer doctor decision time. Journal of Epidemiology and Community Health 1999; 53:459-464. Gill P, Freemantle N, Makela M, Vermeuen K, Bond C, Thorsen T, Ryan G, Haaijer-Ruskamp FM. Changing doctor prescribing behaviour, a systematic review. Pharmacy World & Science 1999; 21:159-167. Groen HW, Groenier KH, Schuling J. Comparative study of a foam mattress and a water mattress. Journal of Wound Care 1999; 8:333-335. Hummers-Pradier E, Denig P, Oke T, Lagerløv P, Wahlström R, Haaijer-Ruskamp FM. GP’s treatment of uncomplicated urinary tract infections - a clinical judgement analysis in four European countries. Family Practice 1999; 16:605-607. Joosten A, Mazeland H, Meyboom-de Jong B. Psychosocial explanations of complaints in Dutch general practice. Family Practice 1999; 16:245-249. Kok RH, Beltman FW, Terpstra WF, Smit AJ, May JF, de Graeff PA, Meyboom-de Jong B. Home blood pressure measurement: reproducibility and relationship with left ventricular mass. Blood Pressure Monitoring 1999; 4:65-69. LeGrand A, Hogerzeil H, Haaijer-Ruskamp FM. Intervention research in rational use of drugs: a review. Health Policy and Planning 1999; 14:89-102. Loor HI, Groenier KH, Limburg M, Schuling J, Meyboomde Jong B. Risks and causes of death in a communitybased stroke population: 1 month and 3 years after stroke. Neuroepidemiology 1999; 18:75-84. Veehof LJG, Stewart RE, Meyboom-de Jong B, HaaijerRuskamp FM. Adverse drug reactions and polypharmacy in the elderly in general practice. European Journal of Clinical Pharmacology 1999; 55:533-536. Veen-de Vries NR, Luteijn AJ, Nasiiro RS, Meyboom-de Jong B. Health status of the elderly in the Marigot Health District, Dominica. West Indian Medical Journal 1999; 48: 73-80. Veninga CCM, Lagerløv P, Wahlström R, Muskova M, Denig P, Berkhof J, Kochen MM, Haaijer-Ruskamp FM. Evaluating an educational intervention to improve the treatment of asthma in four European countries. American Journal of Respiratory and Critical Care Medicine 1999; 160:12541262. Winters JC, Sobel JS, Groenier KH, Arendzen JH, Meyboom-de Jong B. The long-term course of shoulder complaints: a prospective study in general practice. Rheumatology 1999; 38:160-163. Winters JC, Jorritsma W, Groenier KH, Sobel JS, Meyboom-de Jong B, Arendzen JH. Treatment of shoulder complaints in general practice: long term results of a randomised, single blind study comparing physiotherapy, manipulation, and corticosteroid injection. BMJ 1999; 318: 1395-1396. Academic publications in other journals Lagro-Jansen ALM, van der Werf GT. Hoe spreken huisartsen en hun patiënten over ziekte? Een zoektocht in de medische literatuur naar het ziektebegrip van huisartsen en patiënten. Huisarts en Wetenschap 1999; 42:539-544. Loor HI, Groenier KH, Schuling J, Meyboom-de Jong B. Depressiviteit na een cerebrovasculair accident: het oordeel van de huisarts. Huisarts en Wetenschap 1999; 42: 299-302. Meyboom-de Jong B. Feminisering van de geneeskunde. Nederlands Tijdschrift voor Geneeskunde 1999; 143:11341136. Meyboom-de Jong B, van der Kam WJ, Pierik EG, Bosveld HP. Geen vrijdagmiddagpiek in de patiëntenstroom naar de afdeling Spoedeisende Hulp van Ziekenhuis De Weezenlanden te Zwolle, mei/juni 1997. Nederlands Tijdschrift voor Geneeskunde 1999; 143:2562-2566. Veehof LJG, Stewart R, Haaijer-Ruskamp FM, Meyboomde Jong B. Chronische polyfarmacie bij eenderde van de ouderen in de huisartspraktijk. Nederlands Tijdschrift voor Geneeskunde 1999; 143:93-97. Wachters-Kaufmann CS. Ervaringsverhalen over een beroerte; profiel van de lezers. TSG: Tijdschrift voor Gezondheidswetenschappen 1999; 77:282-284. Book chapters Haaijer-Ruskamp FM, Denig P. Voorschrijven van geneesmiddelen. In: Buurma H, de Jong-van den Berg LTW, Leufkens HGM (eds.). Het geneesmiddel. Maarssen, Elsevier/Bunge, 1999. PhD theses Bremer GJ. Hora est. Proefschriften van huisartsen 19001995. 2000. Proefschrift Erasmus Universiteit Rotterdam. Promotores: prof dr MJ van Lieburg, prof dr B Meyboomde Jong. Broer J. Oversterfte aan hartziekten in Groningen. Achtergronden en preventiemogelijkheden. 2000. Proefschrift Faculteit der Medische Wetenschappen Rijksuniversiteit Groningen. Promotores: prof dr B Meyboom-de Jong, prof dr JP Mackenbach; Co-promotor: dr JF May. Veninga CCM. Improving prescribing in general practice. 2000. Proefschrift Faculteit der Medische Wetenschappen Rijksuniversiteit Groningen. Promotor: prof dr FM Haaijer-Ruskamp. Visser S. Hypochondriasis. Assessment and treatment. 2000. Proefschrift Faculteit der Medische Wetenschappen Rijksuniversiteit Groningen. Promotores: prof dr PMG Emmelkamp, prof dr B Meyboom-de Jong; Co-promotor: dr TK Bouman. Academic publications in international refereed journals Bemelmans WJE, Muskiet FAJ, Feskens EJM, de Vries JHM, Broer J, May JF, Meyboom-de Jong BM. Associations of alpha-linolenic acid and linoleic acid with risk factors for coronary heart disease. European Journal of Clinical Nutrition 2000; 54:865-871. Kamps GB, Stewart RE, van der Werf GT, Schuling J, Meyboom-de Jong B. Adherence to the guidelines of a regional formulary. Family Practice 2000; 17:254-260. Kempen GIJM, Sanderman R, Miedema I, Meyboom-de Jong B, Ormel J. Functional decline after congestive heart failure and acute myocardial infarction and the impact of psychological attributes. A prospective study. Quality of Life Research 2000; 9:439-450. Lagerløv P, Veninga CCM, Muskova M, HummersPradier E, Haaijer-Ruskamp FM, Andrew M, DEP-group. Asthma management in five European countries: doctor’s knowledge, attitudes and prescribing behaviour. European Respiratory Journal 2000; 15:25-29. Noyce P, Huttin C, Atella V, Brenner G, Haaijer-Ruskamp FM, Hedvall MB, Mechtler R. The cost of prescription medicines to patients. Health Policy 2000; 52:129-145. Schuit KW, Otter R, Stewart R, Sleijfer DT, Meijler WJ, Meyboom-de Jong B. The effects of a postgraduate course on opiod-prescribing patterns of general practitioners. Journal of Cancer Education 2000; 15:214-217. Siero FW, Broer J, Bemelmans WJE, Meyboom-de Jong BM. Impact of group nutrition education and surplus value of Prochaska-based stage-matched information on healthrelated cognitions and on Mediterranean nutrition behavior. Health Education Research 2000; 15:635-647. van den Heuvel ETP, de Witte LP, Nooyen-Haazen I, Sanderman R, Meyboom-de Jong B. Short-term effects of a group support program and an individual support program for caregivers of stroke patients. Patient Education and Counseling 2000; 40:109-120. van der Kam WJ, Meyboom-de Jong B, Moorman PW, van der Lei J, Duitgenius J, van der Wouden JC. Communication among physicians when treating patients with suspected breast cancer. Cancer Strategy 2000; 2: 31-34. Veehof LJG, Stewart RE, Haaijer-Ruskamp FM, Meyboomde Jong BM. The development of polypharmacy. A longitudinal study. Family Practice 2000; 17:261-267. Veninga CCM, Denig P, Zwaagstra R, Haaijer-Ruskamp FM. Improving drug treatment in general practice. Journal of Clinical Epidemiology 2000; 53:762-772. Veninga CCM, Lundborg CS, Lagerløv P, HummersPradier E, Denig P, Haaijer-Ruskamp FM. Treatment of uncomplicated urinary tract infections: exploring differences in adherence to guidelines between three European countries. Annals of Pharmacotherapy 2000; 34: 19-26. Verhoeven AAH, Boerma EJ, Meyboom-de Jong BM. Which literature retrieval method is most effective for GPs? Family Practice 2000; 17:30-35. Wachters-Kaufmann CS. Personal accounts of stroke experiences. Patient Education and Counseling 2000; 41: 295-303. Wieringa NF, Vos R, van der Werf GT, van der Veen WJ, de Graeff PA. Co-morbidity of ‘clinical trial’ versus ‘real-world’ patients using cardiovascular drugs. Pharmacoepidemiol Drug Saf 2000; 9:569-579. Wymenga LFA, Duisterwinkel FJ, Groenier K, Visser-van Brummen P, Marrink J, Mensink HJA. Clinical implications of free-to-total immunoreactive prostate-specific antigen ratios. Scandinavian Journal of Urology and Nephrology 2000; 34:181-187. Wymenga LFA, Duisterwinkel FJ, Groenier K, Mensink HJA. Ultrasound-guided seminal vesicle biopsies in prostate cancer. Prostate Cancer and Prostatic Diseases 2000; 3:100-106. Academic publications in other journals Beltman FW, van der Meer K, Fennema MA. De diagnostiek van wittejashypertensie door middel van thuisbloeddrukmeting. Huisarts en Wetenschap 2000; 43: 155-158. Bilo HJG, Ubink-Veltmaat LJ. Wegblijven diabeten 3. Huisarts en Wetenschap 2000; 43 . 137 Research in Evidence Based Medicine in Practice (EBM) 2000 Boendermaker PM, Schuling J, Meyboom-de Jong BM, Zwierstra RP, Metz JCM. What are the characteristics of the competent general practitioner trainer? Family Practice 2000; 17:547-553. Veehof LJG, Meyboom-de Jong B, Haaijer-Ruskamp FM. Polypharmacy in the elderly - a literature review. European Journal of General Practice 2000; 6:98-106. Chapter 4 Wesseling H, Haaijer-Ruskamp FM. Het geneesmiddelenonderzoek bij de mens. In: Wesseling H, Neef C, de Graeff PA (eds.). Algemene farmacotherapie; het geneesmiddel in theorie en praktijk. Houten etc., Bohn Stafleu Van Loghum, 1999: pp. 85-96. Bemelmans WJE, Broer J, de Vries JHM, Hulshof KFAM, May JF, Meyboom-de Jong B. Impact of Mediterranean diet education versus posted leaflet on dietary habits and serum cholesterol in a high risk population for cardiovascular disease. Public Health Nutrition 2000;273283. Broer J, Bleeker JK, Bouma J, de Jongste MJL, Erdman RAM, Meyboom-de Jong B. Regionale verschillen in de tijd tot ziekenhuisopname bij patiënten met een acuut myocardinfact. Nederlands Tijdschrift voor Geneeskunde 2000; 144:78-83. 138 Northern Centre for Healthcare Research Bügel PC, Meyboom-de Jong B, Roordink MH, van der Ven NJAM, Groenier K. Geruststellen in de huisartspraktijk. Video-opnamen van spreekuren. Huisarts en Wetenschap 2000; 43:559-562. de Haan J, Hutter AW. Moeilijke beslissingen rond het diagnostisch en therapeutisch handelen van de huisarts bij oudere patiënten. Nederlands Tijdschrift voor Geneeskunde 2000; 144:1857-1860. de Roo J, Schilthuis YJ, Brus HJ, Schreurs TAJ, Bosveld HEP, Boendermaker PM. Water versus olie als druppelvloeistof vóór het verwijderen van een cerumenprop. een vergelijkend gerandomiseerd onderzoek. Huisarts en Wetenschap 2000; 43:258-259. Self evaluation 1997 - 2002 Smith RJA, Hiddema-van der Wal A, van der Werf GT, Meyboom-de Jong B. Versnippering van de morbiditeitsinformatie in het elektronisch medisch dossier. Huisarts en Wetenschap 2000; 43:391-394. Terluin M, Andeweg ME, Boendermaker PM, Pols J. De structuur van een consult - onderwijs en praktijk. Huisarts en Wetenschap 2000; 43:563-565. van der Molen T, Meyboom-de Jong B, Mulder HH, Postma DS. De initiële behandeling van patiënten met asthma in de huisartspraktijk. Huisarts en Wetenschap 2000; 43:5-8. Veehof LJG, Hinlopen RJ. HIV-screening bij zwangeren haken en ogen. Huisarts en Wetenschap 2000; 43:574-575. Book chapters Bos AME, Tent B. Verpleegkundige zorg. In: Bijlsma JWJ, Voorn ThB (eds.). Reumatologie. Houten, Bohn Stafleu Van Loghum, 2000: pp. 303-313. Denig P, Haaijer-Ruskamp FM. Investigating decisionmaking by prescribers. In: McCavock H (ed.). Handbook of drug use research methodology. Newcastle upon Tyne, United Kingdom Drug Utilisation, 2000: pp. 70-87. Books (monographs) Bilo HJG, van Nunen F, Meyboom-de Jong B, van Ballegooie E, Ubink-Veltmaat LJ. Transmurale Zorgvormen van Diabetes Mellitus, een verkenning van de situatie anno 2000. Zwolle, Isala Klinieken Series No. 29, 2000. 2001 PhD theses Bemelmans WJE. Prevention of coronary heart disease by nutritional interventions. Impact of nutritional education in groups and supplementation with alpha-linolenic acid. 2001. Proefschrift Faculteit der Medische Wetenschappen Rijksuniversiteit Groningen Promotor: prof dr B Meyboom-de Jong; Co-promotor: dr JF May; Referenten: dr J Broer, dr EJM Feskens, dr FW Siero, dr AJ Smit. Bijsterveld HJ. Het ouderenperspectief op thuiszorg; wensen en behoeften van ouderen ten aanzien van de thuis(zorg)situatie in Friesland. 2001. Proefschrift Faculteit der Medische Wetenschappen Rijksuniversiteit Groningen Promotores: prof dr D Post, prof dr B Meyboom-de Jong; Referent: dr J Greidanus. de Groot RA. De telefoon als managementinstrument in de huisartspraktijk. 2001. Proefschrift Faculteit der Medische Wetenschappen Rijksuniversiteit Groningen Promotores: prof dr J de Haan, prof dr B Meyboom-de Jong. Academic publications in international refereed journals Ubink-Veltmaat LJ, Kleefstra N, Houweling ST, Groenier KH, Meyboom-de Jong B. Why is the cardiovascular risk profile in type 2 diabetes so hard to improve? Diabetologia 2001; 44:A249. van den Heuvel ETP, de Witte LP, Schure LM, Sanderman R, Meyboom-de Jong B. Risk factors for burn-out in caregivers of stroke patients, and possibilities for intervention. Clinical Rehabilitation 2001; 15:669-677. van der Kam WJ, Meyboom-de Jong B, Tromp TFJ, Moorman PW, van der Lei J. Effects of electronic communication between the GP and the pharmacist. The quality of medication data on admission and after discharge. Family Practice 2001; 18:605-609. Veninga CCM, Denig P, Pont LG, Haaijer-Ruskamp FM. Comparison of indicators assessing the quality of drug prescribing for asthma. Health Services Research 2001; 36: 143-161. Wahlström R, Lagerløv P, Lundborg CS, Veninga CCM, Hummers-Pradier E, Dahlgren LO, Denig P. Variations in general practitioners’ views of asthma management in four European countries. Social Science and Medicine 2001; 53: 507-518. Wieringa NF, Denig P, de Graeff PA, Vos R. Assessment of new cardiovascular drugs. Relationships between considerations, professional characteristics, and prescribing. International Journal of Technology Assessment in Health Care 2001; 17:559-570. Dekker HM, van der Jagt EJ, van Leeuwen JTM, van der Werf GT, Hunink MGM. Role of abdominal sonography in excluding abdominal malignancy in the initial workup of patients with abdominal complaints. AJR (American Journal of Roentgenology) 2001; 177:47-51. Wieringa NF, Vos R, van der Werf GT, de Graeff PA. Inclusion of patients with co-morbidity and co-medication in pre-marketing trials of cardiovascular drugs. Drug Development Research 2001; 51:159-168. Hiddema-van der Wal A, Smith RJA, van der Werf GT, Meyboom-de Jong B. Towards improvement of the accuracy and completeness of medication registration with the use of an electronic medical record (EMR). Family Practice 2001; 18:288-291. Wymenga LF, Groenier K, Schuurman J, Boomsma JH, Elferink RO, Mensink HJ. Pretreatment levels of urinary deoxypyridinoline as a potential marker in patients with prostate cancer with or without bone metastasis. BJU International 2001; 88:231-235. Hof AL, Koerhuis CL, Winters JC. ‘Coupled motions’ in cervical spine rotation can be misleading. Comment on V. Feipel, B. Rondelet, J.-P. Le Pallec and M. Rooze. Normal global motion of the cervical spine: an electrogoniometric study. Clin. Biomechanics 1999; 14: 462-470. Clinical Biomechanics 2001; 16:455-458. Wymenga LF, Boomsma JH, Groenier K, Piers DA, Mensink HJ. Routine bone scans in patients with prostate cancer related to serum prostate-specific antigen and alkaline phosphatase. BJU-international 2001; 88:226-230. Oppewal F, Meyboom-de Jong B. Family members’ experiences of autopsy. Family Practice 2001; 18:304-308. Bemelmans WJE, Siero WF, Broer J, Jonker B, Meyboomde Jong B. Gedragsdeterminanten bij dieetgedrag en bewegen. TSG: Tijdschrift voor Gezondheidswetenschappen 2001; 79:293-300. Academic publications in other journals Books (monographs) Bügel PC. Het geluk wenkt. Amsterdam, Contact, 2001. Bügel PC, Groenier KH, Roordink M. Placebowerking van doktersgedrag. Waardering van gesimuleerde videoconsulten door huisartsopleiders en huisartsen in opleiding. Gedrag & Gezondheid 2001; 29:228-240. Houweling ST, Beenakker EAC, Levi MM, Stehouwer CDA, Gans ROB. Probleemgeoriënteerd denken binnen de interne geneeskunde: een praktijkboek voor de opleiding en de kliniek. Leusden, De Tijdstroom, 2001. de Groot RA, Schot SM, Kors JW, Bosveld HEP, de Haan J. De spoedlijn: een garantie voor bereikbaarheid? Huisarts en Wetenschap 2001; 44:314-344. Kamps GB, Schuling J, Meyboom-de Jong B. Farmacotherapeutische adviezen vergeleken. Groningen, Universiteitsdrukkerij, 2001. de Groot RA, de Haan J, Bosveld HEP, Meyboom-de Jong B. Het terugbelspreekuur van de huisarts: de gevolgen voor de praktijkassistente. Huisarts en Wetenschap 2001; 44: 624-625. de Visser CL, Bilo HJG, Feskens EJM, de Visser W, Groenier KH, Meyboom-de Jong B. Oversterfte aan harten vaatziekten bij mannen op Urk. TSG: Tijdschrift voor Gezondheidswetenschappen 2001; 79:226-232. Gerritsen M, Berg I, Deelman B. De Snijders-Oomen nietverbale intelligentietest: bruikbaar bij ouderen? Tijdschrift voor Gerontologie en Geriatrie 2001; 32:24-28. Lagerwey HJG, van der Werf GT. Onderzoek in de huisartspraktijk getoetst; evaluatie van de Commissie Wetenschappelijke Aangelegenheden Noord-Nederland. Huisarts en Wetenschap 2001; 44:98-100. Post J, de Haan J, Groenier K. De vraag naar huisartsenzorg buiten kantooruren: een rekenmodel. Huisarts en Wetenschap 2001; 44:418-422. Ubink-Veltmaat LJ, Houweling ST, Rischen RO, Bilo HJG. Wegblijven diabeten 4. Huisarts en Wetenschap 2001; 44: 31. van den Berg MP, Oldehinkel AJ, Haaijer-Ruskamp FM, Ormel J. Medicijngebruik door ouderen met depressieve klachten. Nederlands Tijdschrift voor Geneeskunde 2001; 145:958-961. Veehof LJG, Haaijer-Ruskamp FM, Meyboom-de Jong B. Polyfarmacie bij ouderen, een probleem? Huisarts en Wetenschap 2001; 44:446-449. 2002 PhD theses Pols J. De beroepsvoorbereiding van studenten geneeskunde: verkenningen op het gebied van chronisch zieken. 2002. Proefschrift Faculteit der Medische Wetenschappen Rijksuniversiteit Groningen Promotores: prof dr R Zwierstra, prof dr B Meyboom-de Jong, prof dr MH van Rijswijk; Co-promotor: dr J Cohen-Schotanus. Pont LG. Assessing the quality of prescribing in general practice. 2002. Proefschrift Faculteit der Medische Wetenschappen Rijksuniversiteit Groningen Promotores: prof dr FM Haaijer-Ruskamp, prof dr WH van Gilst, prof dr T van der Molen. van den Heuvel ETP. Supporting caregivers of stroke patients; an intervention study. 2002. Proefschrift Faculteit der Medische Wetenschappen Rijksuniversiteit Groningen Promotores: prof dr B Meyboom-de Jong, prof dr R Sanderman; Co-promotor: dr LP de Witte. Academic publications in international refereed journals Bemelmans WJ, Lefrandt JD, Feskens EJ, Broer J, Tervaert JW, May JF, Smit AJ. Change in saturated fat intake is associated with progression of carotid and femoral intimamedia thickness, and with levels of soluble intercellular adhesion molecule-1. Atherosclerosis 2002; 163:113-120. Bemelmans WJ, Broer J, Feskens EJ, Smit AJ, Muskiet FA, Lefrandt JD, Bom VJ, May JF, Meyboom-de Jong B. Effect of an increased intake of alpha-linolenic acid and group nutritional education on cardiovascular risk factors: the Mediterranean Alpha-linolenic Enriched Groningen Dietary Intervention (MARGARIN) study. American Journal of Clinical Nutrition 2002; 75:221-227. Boendermaker PM, Ket P, Dusman H, Schuling J, van der Vleuten CP, Tan LH. What influences the quality of educational encounters between trainer and trainee in vocational training for general practice? Medical Teacher 2002; 24:540-543. de Groot RA, de Haan J, Bosveld HEP, Nijland A, Meyboom-de Jong B. The implementation of a call-back system reduces the doctor’s workload, and improves accessibility by telephone in general practice. Family Practice 2002; 19:516-519. de Visser CL, Bilo HJG, Groenier KH, de Visser W, Meyboom-de Jong B. The influence of cardiovascular disease on quality of life in type 2 diabetics. Quality of Life Research 2002; 11:249-261. Denig P, Wahlström R, Chaput de Saintonge M, HaaijerRuskamp FM. Improving the quality of prescribing decisions: the place of clinical judgement analysis. Medical Education 2002; 36:770-779. Denig P, Witteman CLM, Schouten HW. Scope and nature of prescribing decisions made by general practitioners. Quality & Safety in Health Care 2002; 11:137-143. Denig P, Wahlström R, de Saintonge MC, Haaijer-Ruskamp F. The value of clinical judgement analysis for improving the quality of doctors’ prescribing decisions. Medical Education 2002; 36:770-780. Deschepper R, van der Stichele RH, Haaijer-Ruskamp FM. Cross-cultural differences in lay attitudes and utilisation of antibiotics in a Belgian and a Dutch city. Patient Education and Counseling 2002; 48:161-169. Haaijer-Ruskamp FM. Experiences with patient charges. International Journal of Risk and Safety in Medicine 2002; 15:93-96. Houweling ST, Ubink-Veltmaat LJ, Kleefstra N, Meyboomde Jong B. Referral from primary to secondary health care of patients with type 2 diabetes mellitus: are guidelines properly implemented? Diabetologia 2002; 45:A307. 139 Research in Evidence Based Medicine in Practice (EBM) de Groot RA, de Haan J, Bosveld HEP, Meyboom-de Jong B. De telefoon: wat gaat er fout? Huisarts en Wetenschap 2001; 44:16-17. Bergman GJ, Winters JC, van der Heijden GJ, Postema K, Meyboom-de Jong B. Groningen Manipulation Study; the effect of manipulation of the structures of the shoulder girdle as additional treatment for symptom relief and for prevention of chronicity or recurrence of shoulder symptoms. Design of a randomized controlled trial within a comprehensive prognostic cohort study. Journal of Manipulative and Physiological Therapeutics 2002; 25:543549. Chapter 4 Boendermaker PM, Schuling J. Toetsing van huisartsopleiders. De toetsinstrumenten getoetst. Huisarts en Wetenschap 2001; 44:248-250. Kasje WN, Timmer JW, Boendermaker PM, HaaijerRuskamp FM. Dutch GP’s perceptions: the influence of out-of-pocket costs on prescribing. Social Science and Medicine 2002; 55:1571-1578. 140 Northern Centre for Healthcare Research Kasje WN, Denig P, Haaijer-Ruskamp FM. Specialists’ expectations regarding joint treatment guidelines for primary and secondary care. International Journal for Quality in Health Care 2002; 14:509-518. Klein R, Sturm H. Viagra: a success story for rationing? Health Affairs 2002; 21:177-187. Pont LG, van der Werf GTh, Denig P, Haaijer-Ruskamp FM. Identifying general practice patients diagnosed with asthma and their exacerbation episodes from prescribing data. European Journal of Clinical Pharmacology 2002; 57: 819-825. Rietveld AH, Haaijer-Ruskamp FM. Policy options for cost containment of pharmaceuticals. International Journal of Risk and Safety in Medicine 2002; 15:29-54. Self evaluation 1997 - 2002 Sanderson P, Finnegan YE, Williams CM, Calder PC, Burdge GC, Wootton SA, Griffin BA, Joe-Millward D, Pegge NC, Bemelmans WJ. UK Food Standards Agency alpha-linolenic acid workshop report. British Journal of Nutrition 2002; 88: 573-579. Stienstra Y, Muller S, van der Werf TS, Abdo-Rabbo A, Haaijer-Ruskamp FM. Availability of drugs to admitted patients in Yemeni public hospitals. European Journal of Clinical Pharmacology 2002; 58:79-80. van den Heuvel ETP, de Witte LP, Stewart RE, Schure LM, Sanderman R, Meyboom-de Jong B. Long-term effects of a group support program and an individual support program for informal caregivers of stroke patients: which caregivers benefit the most? Patient Education and Counseling 2002; 47:291-299. Visser G, Rake JP, Labrune P, Leonard JV, Moses S, Ullrich K, Wendel U, Groenier KH, Smit GP. Granulocyte colonystimulating factor in glycogen storage disease type 1b. Results of the European Study on Glycogen Storage Disease Type 1. European Journal of Pediatrics 2002; 161: S83-S87. Wahlström R, Hummers-Pradier E, Lundborg CS, Muskova M, Lagerløv P, Denig P, Oke T, de Saintonge MC. Variations in asthma treatment in five European countries - judgement analysis of case simulations. Family Practice 2002; 19:452460. Wieringa NF, Denig P, de Graeff R, Vos R. Clinical relevance of the gap between pre-marketing and medical practice: the case of the cardiovascular drugs. Netherlands Heart Journal 2002; 10:441-448. Academic publications in other journals Berendsen AJ, Schuling J, Meyboom-de Jong B. Zieken huisopnamevervangende zorg; een literatuurstudie naar effecten van een vorm van transmurale zorg. Nederlands Tijdschrift voor Geneeskunde 2002; 146:2302-2308. Cohen-Schotanus J, Reinders JJ, Agsteribbe J, Meyboomde Jong B. Tien jaar arts: een longitudinaal onderzoek naar de loopbaan van artsen die hun studie begonnen in Groningen. Nederlands Tijdschrift voor Geneeskunde 2002; 146:2474-2478. de Haan J, de Groot RA, Groenier KH. De intakefunctie van de praktijkassistente: “Ik verbind u even door?”. Huisarts en Wetenschap 2002; 45:438-439. Haaijer-Ruskamp FM. Kennis beter delen bij de optimalisering van geneesmiddelengebruik. TSG: Tijdschrift voor Gezondheidswetenschappen 2002; 80:7. Houweling ST, Timmerman GJ, Hoogstraten MFM, UbinkVeltmaat LJ, Verhoeven S, Bilo HJG. Aanbevelingen voor het instellen en aanpassen van insulinetherapie bij diabetes mellitus type 2. Nederlands Tijdschrift voor Geneeskunde 2002; 146:1823-1827. Meyboom-de Jong B, Beaufort ID. Oudere patiënten: lastig, eigenwijs of autonoom. Huisarts en Wetenschap 2002; 45: 181-184. Oud MJT, Schuling J. Patiënten met een chronische psychose in de huisartspraktijk: actief volgen. Nederlands Tijdschrift voor Geneeskunde 2002; 146:697-700. Book chapters Haaijer-Ruskamp FM, Denig P. Voorschrijven van geneesmiddelen. In: Buurma H, de Jong-van den Berg LTW, Leufkens HGM (eds.). Het geneesmiddel. Maarssen, Elsevier Gezondheidszorg, 2002: pp. 124-149. Books (monographs) Houweling ST, Kleefstra N, Ubink-Veltmaat LJ, Meyboomde Jong B, Bilo HJG. Protocollaire diabeteszorg; mogelijkheden voor taakdelegatie. Zwolle, Isala Klinieken, 2002. Meyboom-de Jong B, Schmitt-Jongbloed G, Willemsen MC, (eds). De arts van straks: een nieuw medisch opleidingscontinuüm. Wijk bij Duurstede, Hentenaar, 2002.
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