Sentinel Network Of General Practitioners Research Articles

Nationwide monitoring of end-of-life care via the Sentinel Network of General Practitioners in Belgium: the research protocol of the SENTI-MELC study

BackgroundEnd-of-life care has become an issue of great clinical and public health concern. From analyses of official death certificates, we have societal knowledge on how many people die, at what age, where and from what causes. However, we know little about how people are dying. There is a lack of population-based and nationwide data that evaluate and monitor the circumstances of death and the care received in the final months of life. The present study was designed to describe the places of end-of-life care and care transitions, the caregivers involved in patient care and the actual treatments and care provided to dying patients in Belgium. The patient, residence and healthcare characteristics associated with these aspects of end-of-life care provision will also be studied. In this report, the protocol of the study is outlined.Methods/DesignWe designed a nationwide mortality follow-back study with data collection in 2005 and 2006, via the nationwide Belgian Sentinel Network of General Practitioners (GPs) i.e. an existing epidemiological surveillance system representative of all GPs in Belgium, covering 1.75% of the total Belgian population. All GPs were asked to report weekly, on a standardized registration form, every patient (>1 year) in their practice who had died, and to identify patients who had died "non-suddenly." The last three months of these patients' lives were surveyed retrospectively. Several quality control measures were used to ensure data of high scientific quality.DiscussionIn 2005 and 2006, respectively 1385 and 1305 deaths were identified of which 66% and 63% died non-suddenly. The first results are expected in 2007. Via this study, we will build a descriptive epidemiological database on end-of-life care provision in Belgium, which might serve as baseline measurement to monitor end-of-life care over time. The study will inform medical practice as well as healthcare authorities in setting up an end-of-life care policy. We publish the protocol here to inform others, in particular countries with analogue GP surveillance networks, on the possibilities of performing end-of-life care research. A preliminary analysis of the possible strengths, weaknesses and opportunities of our research is outlined.

Epidemiology of suicide and suicide attempts in Belgium: results from the sentinel network of general practitioners

To estimate the evolution of incidence of (attempted) suicide between 1993 and 2001 in Belgium and to examine trends in methods, first caretaker and aspects of seasonality. In 1993-1995 and 2000-2001, the national sentinel network of general practitioners registered, for each case of (attempted) suicide, age, sex, date, place of the event, first caretaker, method, and survival. Between 1993-1995 and 2000-2001, the incidence of suicide increased among men from 29/ 100,000 to 35/ 100,000, and decreased among women from 14/ 100,000 to 11/ 100,000. The incidence of attempted suicide increased among men (from 67/ 100,000 to 71/ 100,000) and women (from 131/ 100,000 to 141/ 100,000). None of the above mentioned changes were statistically significant however. The use of violent methods as opposed to non-violent methods remained unchanged in women (OR: 0.95 [0.63-1.41]). No statistically significant trends were observed in the incidence of suicide, the fraction of cases with fatal outcome and the use of violent methods.

Hospitalisations at the end of life: using a sentinel surveillance network to study hospital use and associated patient, disease and healthcare factors

BackgroundHospital deaths following several hospital admissions or long hospital stays may be indicative of a low quality of dying. Although place of death has been extensively investigated at population level, hospital use in the last months of life and its determinants have been studied less often, especially in Europe and with a general end-of-life patient population. In this study we aim to describe hospital use in the last three months of life in Belgium and identify associated patient, disease and healthcare factors.MethodsWe conducted a retrospective registration study (13 weeks in 2004) with the Belgian Sentinel Network of General Practitioners, an epidemiological surveillance system representative of all GPs in Belgium, covering 1.75% of the total Belgian patient population. All registered non-sudden or expected deaths of patients (aged one year or older) at the GPs' practices were included. Bivariate and regression analyses were performed.ResultsThe response rate was 87%. The GPs registered 319 deaths that met inclusion criteria. Sixty percent had been hospitalised at least once in the last three months of life, for a median of 19 days. The percentage of patients hospitalised increased exponentially in the last weeks before death; one fifth was admitted in the final week of life. Seventy-two percent of patients hospitalised at least once in the final three months died in hospital. A palliative treatment goal, death from cardiovascular diseases, the expression of a wish to die in an elderly home and palliative care delivery by the GP were associated with lower hospitalisation odds.ConclusionHospital care plays a large role in the end of patients' lives in Belgium, especially in the final weeks of life. The result is a high rate of hospital deaths, showing the institutionalised nature of dying. Patients' clinical conditions, the expression of preferences and also healthcare characteristics such as being treated as a palliative care patient, seem to be associated with hospital transfers. It is recommended that hospitalisation decisions are only made after careful consideration. Short admissions in the final days of life should be prevented in order to make dying at home more feasible.

Epidemiologic surveillance system implemented in the Hautes-Alpes District, France, during the Winter Olympic Games, Torino 2006.

Some of the competitions of the Olympic Winter Games in Torino, 10 to 26 February 2006, were organised in France near the city of Briançon, in the department of Hautes-Alpes. An epidemiologic surveillance system was set up by the local health authorities. The goals were to detect in a timely fashion any phenomenon which could justify prevention or sanitary control action, and to guide interventions in the case of outbreak or environmental pollution. Surveillance was implemented from 30 January to15 March 2006 in the Briançon area. Mortality was tracked using by analysing the number and cause of deaths. A sentinel network of general practitioners was set up and reported the frequency of acute gastroenteritis, influenza-like illness and measles. Medical laboratories provided data about the analyses they undertook. Hospital emergency department and emergency ambulance service activities were followed up. Statutory notification diseases and toxic effects of carbon monoxide surveillances were reinforced. Analysed data were transmitted daily to the health authorities. A French/English report was sent weekly to all participants. The participation rate was close to 100%, and data transmission deadlines were respected. No adverse health event was identified. The strong acceptability of this surveillance system comes from its good understanding by the participants. This surveillance, structured around routine and ad-hoc systems, allowed the establishment of the foundations of a network to be used in case of outbreak or environmental pollution.

A medical locum service as a site for sentinel influenza surveillance

Surveillance of influenza in the countries of the European Union includes a sentinel network of general practitioners reporting cases of influenza-like illness (ILI), the collection of specimens for virological testing, and laboratory reporting of influenza diagnoses. In Victoria, Australia we have a similar sentinel surveillance system, with ILI defined by fever, cough and fatigue, and influenza seasons described by thresholds. The coordination of sentinel general practices can, however, be time consuming and expensive. For the last two influenza seasons we have used a deputising medical locum service as a sentinel site for influenza surveillance. We are not aware of such a service being used as a sentinel site elsewhere in the world. In both retrospective and prospective comparisons, we have shown that ILI surveillance patterns from sentinel general practices are very similar to those from the locum service. Because of its timeliness, flexibility, patient mix and geographic spread, locum service surveillance is able to supplement sentinel ILI surveillance and may also have a role in the recognition of emerging disease patterns. This is likely to be true not only in Australia but also in countries of the European Union.

De morbiditeit en mortaliteit van cerebrovasculaire incidenten in België

Morbidity and mortality of cerebrovascular events in Belgium Stroke is one of the leading causes of death and disability. The objective of this study was to estimate its incidence and mortality in Belgium. The data were recorded in 1998 and ’99 by the Belgian sentinel network of general practitioners (GP). All events, including those for which medical care was immediately obtained in a clinic, were included. Stroke as well as transient ischemic attacks (TIA) were recorded. Not only the firstever events but also recurrent ones were recorded. After a month the GPs received a follow-up questionnaire for all included patients and after 6 and 12 months for those included with a stroke. In total 511 strokes and 257 TIAs were recorded. The yearly incidence per 100,000 inhabitants was estimated at 185 for stroke and at 93 for TIA. During the 12-months follow-up, 47,5% of the patients died. Applying a forward stepwise logistic regression especially coma, diabetes and hemorrhagic stroke but also stroke history, swallow deficit and urinary incontinence exerted a negative influence on stroke survival. Motoric deficit was recorded for 81% of the patients and still remained in 55% of the cases after 12 months. Stroke causes a high morbidity and mortality. Since 1984 the age-and-gender-adjusted incidence decreased significantly.

An 8 year nationwide prospective registration of non-consented HIV testing in Belgium.

Little information is available on the number of HIV tests that are carried out without the patient's consent. The aim of this study was to find out about the number of HIV tests for which the specific consent of the patient was not obtained and to describe the circumstances in which these tests were carried out. Since 1993 a representative network of sentinel general practitioners (GPs) has recorded data about requests for HIV tests, risk behaviour and the patient's awareness about the test. In total 11,660 HIV tests were recorded and for 3628 tests the question about patient awareness was completed. Although non-consensual HIV testing (NHT) is against European guidelines on informed consent, 453 tests were performed without informed consent. Of the 292 participating GPs, 17.5 per cent never completed the question about the patient's awareness and 35.6 per cent performed at least one non-consensual HIV test. For 28.9 per cent of NHT, no risk behaviour for HIV infection was identified and for 43.4 per cent the risk behaviour was unknown. NHT was recurrent for patients with suggestive symptoms (22.7 per cent), patients consulting for a check-up (21.1 per cent) and women consulting for antenatal care (12.8 per cent). Never before have figures been available about NHT forthcoming from a prospective registration including such a large number of tested subjects. Physicians should be reminded once more about the unacceptability of NHT. Instead of performing a non-consensual HIV test, physicians should invest more time in pre-test counselling, especially in those patients with a higher risk or with suggestive symptoms for HIV.

Non-consented HIV testing by Belgian general practitioners

Diagnostic HIV testing without the patient's consent is unethical and illegal [1,2]. This paper reports on the proportion of non-consented HIV tests (NHT) in Belgian general practice and the circumstances in which these tests are performed. Data were recorded from 1993 to 2000 in the Belgian network of sentinel general practitioners (GPs). The network is representative of Belgian GPs, and has been a reliable surveillance system for more than 20 years [3,4]. Since May 1988, every adult patient who has asked his GP for an HIV test has been recorded on a weekly registration form. Since 1993, questions about patient consent have been included. SPSS-PC 10 (SPSS Inc., Chicago, IL, USA) was used for analysis and statistical processing. In total, 292 GPs recorded 11 660 requests for an HIV test (52% by women). The mean age of the tested individuals was 33.2 years. Information about patient consent was available for 3628 tests. In total, 453 tests were performed without patient consent. This corresponds to 3.9% of all tests performed and 14% of the tests for which information is available about patient consent. The proportion of NHT decreased during the early 1990s from approximately 17% to less than 8%, and has increased since 1996 to approximately 12% in 2000. The proportion of NHT is 30% in the age group below 15 years, 40% in the age group above 64 years, and between 10 and 15% in the other age groups. For 29% of the NHT no risk behaviour was detected, and for 43% the existence of risk behaviour was unknown. In 28% of all NHT the patient declared him or herself to be at risk of HIV. Eighteen per cent of the HIV tests among patients originating from an endemic region were NHT and 15% of the tests in homosexual men were NHT. Twenty-three per cent of the NHT were performed on patients with suggestive symptoms. NHT was also popular as part of a check-up (21%) or during antenatal care (13%). Eleven per cent were carried out for an administrative reason, 8% in prospect of a new relationship and 8% among patients awaiting a surgical intervention. The proportion of NHT performed according to the motivation for the test is displayed in Table 1.Table 1: Proportion of non-consented HIV tests according to the motivation for the test in percentages (N = 3421).In total, 36% of all GPs performed at least one NHT. HIV tests returned positive for 1.5% (n = 7) of the NHT and for 0.5% (n = 23) of the consented tests. The Belgian medical deontology and law state that patients should be informed about the results of an HIV test. In this context, the proportion of NHT is astonishing. So is the proportion of physicians performing HIV tests without informed consent. A national telephone survey among hospital staff members in the USA revealed a similar problem [5]. A registration in Minnesota (USA) confirmed that only 10% of test requests were documented in the medical record [6]. The proportion of NHT in our study is remarkably lower. However, the comparison with the Minnesota study is difficult because it reports data on written notification and our study reports on non-specified oral or written consent. It is likely that most of the patients tested without consent did not receive the necessary pre-test counselling. NHT was popular in the context of preoperative and prenatal care. The argument that HIV testing is necessary to protect healthcare workers is improper. The knowledge of the patient's HIV status provides a false sense of security and there is still a window period during which the virus cannot be identified. Another delicate point in this study is the high proportion of NHT among patients consulting for administrative reasons or for a control in view of a wedding, a new relationship or a general check-up. Patient authorization for a blood test does not imply that physicians have the authorization for an HIV test. The Belgian Medical Council and the Belgian authorities should remind physicians once more about the unacceptability of NHT. Instead of performing HIV tests without consent, physicians should invest more time in pre-test counselling, especpecially in patients with a higher risk or with suggestive symptoms of HIV. In most of these cases valuable opportunities to provide risk-reduction counselling were missed. Acknowledgements The authors would like to thank all participating sentinel practitioners for their daily efforts over many years, Henk Van Renterghem for his contribution to the dataset, and Karolien Vantomme, Marianne van Winden, Neeltje Blommaert and Rinaldo Lauwers for their contribution to the text.

Surveillance of influenza in the North-West Region of England 2001-02.

A local sentinel network of general practitioners has been established in the north west of England for the surveillance of influenza. In the 2001-02 winter, consultation rates for influenza-like-illness (ILI) were low but the surveillance network was able to demonstrate sub-regional variations in the timing of peak influenza activity, and the infection of different age groups. This suggests the network can contribute to better planning to winter pressures on the North West health service.

Tratamiento hormonal sustitutivo en España. Un estudio de utilización

The consumption of hormonal replacement therapy (HRT) in Spain is not known. Therefore, we have conducted a study to know the mean features of that consumption and to find out the prevalence of use among women older than 40. To know the consumption, we have used the information contained in ECOM database from the Ministry of Health regarding medicines sold to the Spanish Health System. Also, data gathered by the General Practitioner Sentinel Network of Castilla y León had been used. The data of consumption are presented in daily defined dose per 1000 women more than 40 years (DHD); prevalence of use per year and for ages was also estimated. The HRT consumption in Spain throughout the National Health System was 6,94 DHD in 1989 and 39.92 DHD in 1999. The percentage of women using this therapy was 0.7% in 1989 and 3,4 in 1999; the group 50-54 years had the highest prevalence of use, 10,84% (IC 95%, 10.66-11.01). The release into the market of those transdermal forms of HRT facilitated an increase in the consumption. Nonetheless, the proportion of postmenopausal women on HRT in Spain is lower than that of the other countries from the European Union. The proportion of women treated with estrogens and progestins is also small compared with current recommendations.

Diarrhoea-related morbidity and rotavirus infection in France.

To assess the importance of diarrhoea in France and, specifically, rotavirus-related diarrhoea among children, we reviewed data obtained from three complementary sources: (1) general practitioner (GP) sentinel surveillance; (2) hospital discharge data from paediatric hospitals; and (3) laboratory based surveillance. The GP sentinel network is based on 500 physicians who electronically notify new cases of eight illnesses, including diarrhoea, each week. It was estimated that about 3.3 million patients seek medical attention for diarrhoea from their GP each year, with a winter outbreak associated with an increased rate of isolation of rotavirus. A national system of hospital discharge diagnosis was used to estimate the burden of diarrhoeal morbidity in two paediatric wards in Tours, France. Between 1994 and 1996, 1164 patients under 15 y of age (9.7% of all admissions) were admitted for diarrhoea, of whom 83% were reported as having viral gastroenteritis; 14.3% were dehydrated and 52% were under 1y old. Hospital admissions had a seasonal pattern similar to notifications from sentinel GP for children under 5 y old. A centralized laboratory surveillance network representing 17 of the 22 French regions describes a rotavirus outbreak each winter that is concomitant of outbreaks detected by the GP sentinel network and seen in hospitals. Most of the isolates (98%) identified through this surveillance system are among children under 5y of age. All the data reviewed in this study indicate that the epidemiology of rotavirus diarrhoea in France fits well with what has been reported in other developed countries.

Italian influenza surveillance network: results of the first year of activity. The Collaborative Group for influenza surveillance.

The spread of influenza is of major public health concern. Community based clinical morbidity data constitute an excellent predictor of when the peak of influenza virus activity will be reached. Surveillance programmes exist in many countries [1, 2]. A voluntary system for the surveillance of acute respiratory infection (ARI) and influenza was established in Italy in 1996. The surveillance is based on a sentinel network of general practitioners (GPs) and pediatricians (Ps) for the collection of clinical data and a network of virological laboratories. The physicians report to the Istituto di Virologia on a weekly basis.

Is early adulthood a critical developmental stage for psychosis proneness? A survey of delusional ideation in normal subjects

It has been hypothesized that late adolescence and early adulthood might be a brain developmental stage favoring the clinical expression of psychotic symptoms in psychiatric or neurological diseases. The aim of the present survey was to examine the relationship between age and delusional ideation in a sample of subjects with no psychiatric disorder. The survey was carried out with the Aquitaine Sentinel Network of general practitioners. Consecutive practice attenders were invited to complete the PDI-21 (Peters Delusional Inventory 21 items), a self-report questionnaire designed to measure delusional ideation in the normal population. The study concerned 444 patients who had no lifetime history of psychiatric disorder and who completed the PDI-21. A principal component analysis of the PDI-21 items was performed in order to identify delusional dimensions. An age-related decrease in the likelihood to report delusional ideas was found, younger subjects scoring higher on most dimensions of delusional ideation, such as ‘persecution’, ‘thought disturbance’, ‘grandiosity’ and ‘paranormal beliefs’. ‘Religiosity’ was the only dimension positively associated with age. The results suggest that there may be a physiological neurodevelopmental stage favouring the expression of psychosis proneness in normal subjects, and support the hypothesis that the association between age and positive psychotic symptoms in functional and organic psychoses may be linked to the interaction between normal brain maturational processes and cerebral abnormalities involved in the aetiology of functional and organic psychoses.

A survey of delusional ideation in primary-care patients.

To assess the prevalence of delusional ideas in primary-care patients. A survey was carried out with the Aquitaine Sentinel Network of general practitioners (GPs). Consecutive practice attenders were invited to complete the Peters et al. Delusional Inventory (PDI-21) self-report questionnaire, designed to measure delusional ideation in the normal population. GPs, blind to the questionnaire results, provided information on patients' psychiatric history. Of the 1053 attenders included in the survey, 348 (35%) had a lifetime history of psychiatric disorder, of whom 20 (2%) had a history of broadly defined psychotic disorder. The self-report questionnaire was completed by 790 patients. The range of individual PDI-21 item endorsement in subjects with no psychiatric history varied between 5 and 70%, suggesting that delusional ideation is a dimensional phenomenon lying on a continuum with normality. The main discriminative items between psychotic and non-psychotic patients were those exploring persecutory (OR = 15.2, 95% CI 4.3-53.7), mystic (OR = 6.4, 95% CI 1.9-22.4) and guilt (OR = 5.8, 95% CI 1.5-23.2) ideas. This survey demonstrates that questions that explore delusions and hallucinations are well-accepted by most primary-care patients. More research is needed on psychotic disorders in primary-care settings to improving early identification of these disorders.

Changing patterns in acute clinical viral hepatitis encountered by Belgian general practitioners.

The sentinel network of general practitioners in Belgium was set up in 1979 and monitors a wide range of infectious and non-infectious diseases. Such surveillance systems have been tested and found to be effective and are currently applied in several coun

The incidence of rubella virus infections in Switzerland after the introduction of the MMR mass vaccination programme.

We have collected data on the incidence of rubella in Switzerland from 1987 to 1992 to help evaluating the impact of the measles, mumps and rubella (MMR) mass vaccination programme which started in 1985 in this country. We used detailed informations on samples submitted for diagnostic testing in conjunction with anonymous laboratory notifications to the Swiss Federal Office for Public Health, and data from the Swiss sentinel network of general practitioners to find trends in the incidence of rubella after the introduction of mass vaccination. We observed an unabated seasonal oscillation without decreasing trend during the observation period and were unable to detect a shift in the age distribution of cases. An important proportion of laboratory-confirmed rubella occurred in women of childbearing age. Immigrants from regions with low endemicity of rubella were at increased risk of contracting rubella and transmitting it to their offspring. We conclude, that MMR mass vaccination has not interrupted the circulation of rubella virus in Switzerland, and that improvements in the implementation and surveillance of the MMR vaccination campaign are necessary in order to avoid untoward effects of it.

Constitution and monitoring of an epidemiological surveillance network with sentinel general practitioners

The Réseau National Télé-informatique de surveillance et d'information sur les Maladies Transmissibles (RNTMT) (French communicable diseases computerised surveillance network) comprises a network of sentinel general practitioners (SGP). These benevolent volunteers are responsible for the weekly epidemiological surveillance. Since its creation, 1,700 SGPs have participated in the RNTMT, representing a total of more than 120,000 connections to the RNTMT telematic service center. The principal motivation of these benevolent SGPs was to 'actively participate in public health', although only a minority of them (17.6%) had any training in this field. Such a system, based on the benevolent and voluntary activity of SGPs, requires a good understanding of SGPs' attitudes towards epidemiological surveillance in general and the tool used, in order to quantitatively and qualitatively follow their participation and to provide regular and useful feedback to the surveillance actors.

Respiratory syncytial virus or influenza?

We compared data from clinical surveillance of acute respiratory infections in elderly people reported by a network of sentinel general practitioners, virus isolate data for respiratory syncytial virus (RSV) and influenza A and B viruses, and registered deaths, during the past four winters. Cases of acute respiratory disease (ARD) and deaths (3-week moving averages) showed strong similarity in timing. Periods of high incidence of ARD and numbers of deaths were followed within 2-3 weeks by reports of high numbers of RSV or influenza virus isolates. The epidemic period in December, 1989, was followed by high numbers of both virus isolates, but in all other epidemic periods one virus predominated. The lethality of epidemics due to RSV or influenza A or B varied both within and between years. These analyses suggest that RSV is as important as influenza viruses in causing morbidity and excess deaths among elderly people. RSV was prevalent at the end of each of the past four years in the UK; its importance as a cause of excess deaths would therefore be concealed in any analysis based on several years' experience. By contrast, the inconsistency of epidemics due to influenza viruses makes excess deaths due to these viruses easily recognisable. Integrated clinical and viriological surveillance is essential if epidemics due to RSV, influenza virus, or any other virus are to be correctly interpreted.

Suicide and attempted suicide reported by general practitioners in Belgium, 1990-1991.

In 1990-1991 the Belgian sentinel network of general practitioners recorded suicide and suicide attempts within their practices. The annual attempted suicide rate is estimated at 13.0 cases per 10,000 inhabitants. The highest incidence rates are found among women and young people. The annual suicide rate is estimated at 2.3 cases per 10,000 inhabitants, with the highest rates in men and in elderly people. The highest incidence rates of suicide attempts as well as of suicide are found among divorced people. About 30% of the attempters and committers made at least one earlier attempt. Drug overdose and hanging are the most frequently used methods, respectively when attempting and committing suicide. About 60% of both committers and attempters contacted their general practitioner within a period of 1 month preceding the attempt. Nearly half of the attempters and of the committers were treated for a mental disorder in the year preceding the attempt.

Five years of sentinel surveillance of acute respiratory infections (1985–1990): The benefits of an influenza early warning system

For the last five years, the Brussels Institute of Hygiene and Epidemiology has been involved in the surveillance of acute respiratory infections (ARI). The four indicators used (number of encounters of ARI by GP's/100 encounters, virus isolations, absenteeism and mortality) are discussed. A regression procedure is applied to the data collected by a sentinel network of general practitioners (GP's). This procedure permits the baseline to be visualized and an epidemic threshold to be determined in order to recognize early an influenza outbreak. The traditional use of flu-like illnesses as an indicator might be improved by the addition of non-specific ARI which are more precocious, especially in children. The criteria for an accurate definition of an influenza epidemic are discussed. The same mathematical model can be used for the analysis of mortality linked with an outbreak. It shows that the last epidemic in the winter 1989-1990 was responsible for about 4900 deaths directly or indirectly related to influenza.