Quality of preventive performance in general practice: the use of routinely collected data (original) (raw)
Chapter 1 services) are outlined by the college (NHG) and the association (LHV) of Dutch GPs [5]. Nearly all Dutch citizens are registered with a general practice. General practices have quite complete EMRs for their patients because most patients are registered with the same practice for long periods of time. Dutch GPs play a key role in health care delivery, and they are the gatekeepers of the health care system. The publicly insured patients require a referral from the GP before going to a consultant/specialist; privately insured patients do not, but GPs usually act as the gatekeeper for most privately insured patients as well. Consultants/specialists usually report back to general practices. Dutch GPs are partly paid by capitation (for about 60% of their patients, the publicly insured ones) and partly by fees for services (for the privately insured patients). In January 2004, there were 2392 residents for each full-time-equivalent GP in the Netherlands (16,254,933 residents and 6795 full-time-equivalent GPs). In total, there were 8209 GPs, of whom 31% were women and 79% were 40 years old or older. The GPs work in 4564 general practices, of which 60.7% were single-handed, 26.4% were shared (two GPs) and 12.9% were group practices (Table 1) [6]. 12 Chapter 1 Box 2. Cervical cancer screening and the Dutch population-based approach Population-based cervical cancer screening 'Cervical cancer" is cancer in the cervix, the lower, narrow part of the uterus (womb) Cancer of the cervix is the second most common cancer in women worldwide, and it is a leading cause of cancer-related death of women in underdeveloped countries. Worldwide, approximately 500,000 cases of cervical cancer are diagnosed each year. Early cervical cancer is often asymptomatic In women who receive regular screening, the first sign of the disease is usually an abnormal Pap test result [24] Cervical cancer is preventable and curable if it is detected early, so screening for precancerous changes in the uterine cervix, or cervical cancer itself, by examination of a cervical smear is widely recognised as instrumental in reducing both morbidity and mortality [25-27]. Appropriate management of precursor lesions detected by cervical screening reduces the risk of developing cervical cancer. The failure of women with abnormal Pap smears to return for follow-up care can increase morbidity, mortality, and the cost of health care [28] Not only is high attendance important; a high follow-up rate of cytological abnormalities is also required for an effective population-based screening programme for cervical cancer [26,27,29-32] Screening programmes were started in some European countries and North America in the 1960s [25]. Cervical cancer screening was introduced around 1970 in the Netherlands, and in 1976, an experimental massscreening programme was started in part of the country. The current Dutch cervical screening programme is nationwide and primary care based; the smears (initial and follow-up) are taken in a general practice setting [33]. The target population includes women between 30 and 60 years of age, and the screening interval is 5 years. Three main systems for inviting and reminding the women are in operation, each with a different invitation and reminder approach, namely, a fully authority-based approach, a general-practicebased approach and a combination approach in which the authonty invites the women and the GP reminds them if necessary [34] Population-based smears are free of charge to the patients, and GPs are paid for taking the smears. Furthermore, to facilitate the necessary organisation, a computer programme is available to search databases for women in the target population, inviting the eligible women, and managing the data pertaining to the smears. To spread the workload in general practices and the laboratories, invitations are spread over the year General introduction 13 facilitate the organisation; it was linked to the EMRs. This software made the organisation of both the influenza immunisation campaign and the populationbased screening easier. The software makes it easier for GPs to make lists of the target population and create personal letters to invite and remind the target group. Computers in general practice: routine data Thus, the attention to programmed prevention in general practice has accompanied further computerisation of Dutch general practices in recent years. Computers are used more and more for registration purposes, and information communication and technology, or ICT, has also become a normal part of Dutch general practice. The Dutch College of General Practitioners (NHG) and the Dutch National Association of General Practitioners (LHV) started the Working Group for Coordination, Automation, and Computerization (WCIA). The WCIA formulated reference models, which describe the minimum requirements for a General Practice Information System (GPIS) [36]. In 1994, 22% of the GPs did not have a computer at all, and only 37% made use of EMRs. In 1997, 93% of the practices were computerised and 80% used EMRs [37]. Now, almost all Dutch general practices (97%) are computerised [38]. Most GPs have replaced the paper-based patient records with EMRs in daily practice, and they are using more and more functions of the EMR systems. Patient data are entered into the computer directly during the patient encounters. Computerised EMRs can be used for many purposes, including individual patient care, management, health services research, and research on the quality of care provided to patients. General practices possess a wealth of information about the health of their patients. The central role of Dutch GPs in the delivery of health care and the stable relationship between GPs and their patients suggest that general practice records could be a very useful information source for research, education, or management [39]. General-practice-based health information has proved to be helpful for solving epidemiological and health policy questions in various studies [40], and primary care research networks are very important in building research capacity and output in primary care [41]. Therefore, we were interested to see whether such information could be used to monitor the results of the programmatic prevention activities. The Dutch National Information Network of General Practice (LINH) is available to gather data on this issue routinely. We investigated whether this network is able to 14 Chapter 1 monitor the results of the programmatic prevention activities, and whether it can be used to detect points for improvement.