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Transcription

113

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
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
problem is the measurement of quality of care
Chapter 4
only available when these strategies are used in
2 Strategy and policy
116
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
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
Foundation for Preventive Medicine (Preventiefonds)
Chapter 4
•
118
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
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
on lacunas in these guidelines, a large multi-
120
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)
started to go more deeply in this area, when
Chapter 4
our results show that greater care should be
121
122
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
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
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
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
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.
Risk and Safety in Medicine. 2002: 15:1-151.
125
Chapter 4
•
5 Internal evaluation
Interview with Betty Meyboom - de Jong
126
Main themes
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.
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).
•
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
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
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%
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
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
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
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)
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.
•
•
•
•
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
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
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.
Promotores: prof dr MGM Hunink, prof dr WPThM Mali,
prof dr L Koopmans.
Dijkers FW. Repeat prescriptions; a study in general practice
in the Netherlands. 1997.
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.
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.
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.
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.
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.
Promotor: prof dr B Meyboom-de Jong;
Co-promotor: dr J Schuling.
Heesen WF. Pathophysiology and effects of treatment. 1998.
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.
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.
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
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.
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)
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.
Luteijn AJ. Primary health care in Dominica. 1999.
Promotores: prof dr B Meyboom-de Jong, prof dr GAC
Grell, prof dr D Picou.
Schuit KW. Palliative care in general practice. 1999.
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.
Promotores: prof dr B Meyboom-de Jong, prof dr FM
Haaijer-Ruskamp.
Verhoeven AAH. Information-seeking bij general
practitioners 1999.
Promotor: prof dr B Meyboom-de Jong.
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.
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.
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
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.
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.
Promotor: prof dr FM Haaijer-Ruskamp.
Visser S. Hypochondriasis. Assessment and treatment.
2000.
Promotores: prof dr PMG Emmelkamp, prof dr B
Meyboom-de Jong;
Co-promotor: dr TK Bouman.
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.
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
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
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.
Smith RJA, Hiddema-van der Wal A, van der Werf
GT, Meyboom-de Jong B. Versnippering van de
morbiditeitsinformatie in het elektronisch medisch dossier.
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.
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.
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.
Promotores: prof dr J de Haan, prof dr B Meyboom-de
Jong.
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.
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.
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.
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.
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.
Promotores: prof dr B Meyboom-de Jong, prof dr R
Sanderman;
Co-promotor: dr LP de Witte.
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
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
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.
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.
Berendsen AJ, Schuling J, Meyboom-de Jong B. Zieken
huisopnamevervangende zorg; een literatuurstudie naar
effecten van een vorm van transmurale zorg. Nederlands
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
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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