BACKGROUND:This study examines the association between socioeconomic status (SES) and inflammatory markers in well-functioning older adults and seeks to determine whether any association remains after adjusting for biomedical and behavioral factors typically related to elevated serum levels of inflammatory markers.METHODS:Data were obtained from 3044 men and women, aged 70-79 from Pittsburgh, Pennsylvania and Memphis, Tennessee participating in the Health, Aging and Body Composition study. Three indicators of SES were used: education, income, and ownership of financial assets. Serum levels of interleukin-6, C-reactive protein, and tumor necrosis factor-alpha were measured.RESULTS:Low SES was associated with significantly elevated levels of interleukin-6, C-reactive protein, and tumor necrosis factor-alpha compared to high SES. Behavioral factors (including smoking, drinking, obesity) explained a substantial part of the inverse association between SES and inflammatory markers. Adjustment for prevalent diseases (including heart diseases, lung disease, and diabetes) associated with inflammation explained less of the association.CONCLUSIONS:This study suggests that interventions to improve health behaviors, even in old age and especially in low SES groups, may be useful in reducing risks associated with inflammation.

More social exclusion of chronically ill patients with lower incomesObjective. To determine whether income is connected with the variation in the social exclusion of chronically ill patients.Design. Descriptive.Method. In 223 chronically ill patients that had been detected via patients' associations, general practitioners and outpatient clinics, a structured interview was administered during a home visit 4 times during a period Of 7 months (October 2003-April 2004). Due to dropouts, the actual number of patients interviewed at each of the 4 times was 223, 176, 143 and 105, respectively. Social exclusion was measured with the aid of the Autonomy outside the home' subscale of the 'Impact on participation and autonomy' questionnaire. The possible total score varied from 5 (little social exclusion) to 25 (much social exclusion). In order to explain a possible effect of income, various other patient characteristics were added to the analysis model: type of primary disease (rheumatism, multiple sclerosis, pulmonary emphysema, other), duration of the primary disease, comorbidity, educational level, whether or not the patient was employed or engaged in volunteer work, whether or not the patient lived together with a partner, the self-rated health, physical functioning, social functioning, mental functioning, and the subjective pain. The data were analysed by means of multilevel repeated regression analysis.Results. A low income was associated with social exclusion at all 4 times of measurement. The regression coefficient of income was -1.47 (95% CI: -2.28- -0.65), indicating that the score on the scale for social exclusion decreased by 1.47 for every 544 euro,- (= I x SD) increase in net monthly income. This relationship could not be explained by the other patient characteristics, not even by a low educational level. Conclusion. The supportive care intended for the prevention of social exclusion of chronically ill patients should be concentrated sufficiently on those who have too little income to organise such care for themselves.

BACKGROUND:The association between low socioeconomic status and poor physical functioning has been well described; biomedical factors may play an important role in explaining these differences. This study examines the association between socioeconomic status and incident mobility limitation in well-functioning older adults, and seeks to determine whether this link could be explained by biomedical factors.METHODS:Data were obtained from 3066 men and women, aged 70--79 years from Pittsburgh, Pennsylvania and Memphis, Tennessee participating in the Health, Aging and Body Composition (Health ABC) study. Three indicators of socioeconomic status were used: education, income, and ownership of financial assets. Mobility limitation was defined as reporting difficulty walking 1/4 mile or climbing 10 steps during two consecutive semiannual assessments over 4.5 years. Biomedical factors included a wide range of diseases (e.g., heart and cerebrovascular disease) and biological risk factors (e.g. hypertension, poor pulmonary function, and high serum levels of inflammatory markers).RESULTS:Adjusted hazard ratios of incident mobility limitation were significantly higher in those persons with low education, low income, and few assets. Hazard ratios ranged from 1.66 to 2.80 in the lowest socioeconomic groups. Additional adjustment for biomedical factors reduced the hazard ratios by an average of 41% for education, 17% for income, and 29% for assets.CONCLUSION:Biomedical factors can account for some of the association between socioeconomic status and incident mobility limitation. However, to reduce physical disabilities and, in particular, the socioeconomic differences therein, it may not be sufficient to solely intervene upon biological risk factors and risks of diseases.

OBJECTIVE To determine whether high exercise adherence improved physical function among older adults with knee osteoarthritis (OA) who were overweight or obese. METHODS Associations between exercise adherence, changes in 6-minute walking distance in meters, and self-reported disability (Western Ontario and McMaster Universities Osteoarthritis Index function subscale) after 6 and 18 months were examined among an Arthritis, Diet, and Activity Promotion Trial subsample (n = 134) using multiple linear regression models. RESULTS Higher exercise adherence was associated with greater improvements in 6-minute walking distance after 6 and 18 months and in disability after 6 months. Pain and body mass index (BMI) contributed, to some extent, to explaining the link between exercise adherence and changes in physical performance and self-reported disability. CONCLUSION Higher exercise adherence is associated with improved physical function in overweight and obese older adults with knee OA. This indicates that promoting adherence is clinically relevant when prescribing exercise regimens that also focus on decreasing pain and BMI.

OBJECTIVE To assess differences in diabetes care and patient outcomes by comparing two multifaceted quality improvement programs in two different countries, and to increase knowledge of effective elements of such programs. STUDY SETTING Primary care in the ExtraMural Clinic (EMC) of the Department of General Practice of the Vrije Universiteit in Amsterdam, the Netherlands, and the Group Health Cooperative (GHC), a group-model health maintenance organization (HMO) in western Washington State in the United States. Data were collected from 1992 to 1997. STUDY DESIGN In this observational study two diabetes cohorts in which a quality improvement program was implemented were compared. Both programs included a medical record system, clinical practice guidelines, physician educational meetings, audit, and feedback. Only the Dutch program (EMC) included guidelines on the structure of diabetes care and a recall system. Only the GHC program included educational outreach visits, formation of multidisciplinary teams, and patient self-management support. DATA COLLECTION Included were 379 EMC patients, and 2,119 GHC patients with type 2 diabetes mellitus. Main process outcomes were: annual number of diabetes visits, and number of HbA1c and blood lipid measurements. Main patient outcomes were HbA1c and blood lipid levels. Multilevel analysis was used to adjust for dependency between repeated observations within one patient and for clustering of patients within general practices. PRINCIPAL FINDINGS In the EMC process outcomes and glycemic control improved more than at GHC, however, GHC had better baseline measures. There were no differences between programs on blood lipid control. During follow-up, intensification of pharmacotherapy was noted at both sites. Differences noted between programs were in line with differences in diabetes guidelines. CONCLUSIONS Following implementation of guidelines and organizational improvement efforts, change occurred primarily in the process outcomes, rather than in the patient outcomes. Although much effort was put into improving process and patient outcomes, both complex programs still showed only moderate effects.

The main pathway of the disablement process consists of four consecutive phases: Pathology (presence of disease/injury), Impairments (dysfunctions/structural abnormalities), Functional Limitations (restrictions in basic physical/mental actions), and Disability (difficulty doing activities of daily life, ADL). This study determines the presence of the main pathway of disablement in a cohort aged 55 years and older and examines whether progression of the main pathway of disablement is accelerated in the presence of depression. Based on baseline (T1) and two three-year follow-up interviews (T2 and T3) from the Longitudinal Aging Study Amsterdam (LASA) in a population-based cohort of 1110 Dutch persons, we first analysed the intermediate effect of the different consecutive phases of the disablement process by means of multiple regression, adjusted for covariates. Then, depression was used as interaction term in multiple regression analyses linking the consecutive phases of the disablement process. We found that Impairments mediated the association between Pathology and Functional Limitations, and that Functional Limitations mediated the association between Impairments and Disability. Depression significantly modified the associations between Pathology and subsequent Impairments, and between Functional Limitations and subsequent Disability. In sum, the main pathway of the disablement process was identified in our sample. In addition, we found an accelerating effect of depression, particularly in the early and late stages of the model. Reduction of depression may help slow down the process of disablement for persons who find themselves in those stages of the model.

Research on anxiety and depression after fall-related injuries to the extremities and its pre-fall determinants is scarce. The present study sought to examine change between pre-fall and post-fall anxiety and depression and its (pre-fall) predictors. Data were obtained from 181 Dutch persons, aged 57 and older, who sustained fall-related injuries between 1993 and 1997. Demographic (e.g. socio-economic status), health-related (e.g. number of chronic conditions), and psychosocial (e.g. social support, neuroticism) factors were determined in 1993 (prior to the fall). Depressive symptoms and anxiety were determined prior to the fall, and two, five and twelve months after the fall. Taking into account pre-fall anxiety and depression, pre-fall neuroticism was the most consistent, independent predictor of adverse changes in anxiety and depression. Other factors, including severity of the fall and age were not related to changes in anxiety and depression. Our prospective findings may be interpreted as support for the importance of personality for mental health outcomes in persons who have sustained fall-related injuries.

This contribution reports on the acceptability and feasibility to nurses and patients of an intervention to ameliorate minor depression among patients with chronic physical diseases. Elderly patients with chronic obstructive pulmonary disease (COPD) and type II Diabetes Mellitus were recruited from 10 general practices. All eligible patients were screened. Twenty-nine patients with minor depression gave their informed consent to participate in this feasibility study. The nurses spent an average of 70 min per visit. Our intervention appeared feasible and acceptable to patients and nurses. For the nurses, it provided an additional tool for a well-known problem. The majority of the patients regarded the intervention as worthwhile and effective. Patients had difficulties in understanding the link between physical complaints and symptoms of depression. The intervention has been further improved on the basis of our experiences, and is now ready to be tested in an effectiveness study.

Objective: This study examined the association between socioeconomic status and mobility decline and whether this could be explained by disease severity and comorbidity in four different chronic disease groups (asthma/COPD, heart disease, diabetes mellitus, and low back pain). It is not clear, whether the adverse course of physical functioning in persons with a low socioeconomic status can be explained by a higher prevalence of more severe disease or comorbidity in these persons. Design: Dutch GLOBE study: prospective cohort study Setting: Region of Eindhoven (south east of the Netherlands) Participants: 1384 persons suffering from at least one of the four chronic diseases were selected. The number of respondents in each group was: asthma/COPD 465, heart disease 788, diabetes mellitus 137, and low back pain 707. There were 580 respondents who suffered from more than one condition. Main results: Odds ratios of mobility decline between 1991 and 1997, adjusted for age, sex, marital status, and baseline mobility, were significantly higher in low socioeconomic groups in comparison with high socioeconomic groups. Only very little of this association could be explained by the higher disease severity and comorbidity in these patients. Findings were similar in patients with asthma/COPD, heart disease, diabetes mellitus, and chronic low back pain. Conclusion: These findings indicate that to reduce physical disabilities and particularly the socioeconomic differences therein, it may not be sufficient to solely intervene upon the risks of severe disease and comorbidities.

In this study a randomised controlled trial was carried out to investigate the effectiveness of an education programme for patients with asthma or chronic obstructive pulmonary disease (COPD). All asthma and COPD patients using medication and experiencing pulmonary symptoms were randomly assigned to the intervention (n=139) or usual-care group (n=137). The intervention consisted of taylor-made education conducted by a general practice assistant and focussing on a patients’ technical skills and coping with the disease. Measurements took place at baseline, and after 1 and 2 years of follow-up. After 1 and 2 years the inhalation technique was significantly better in the intervention group compared to the usual-care group. No significant differences were observed regarding disease symptoms, health related quality of life, compliance, smoking cessation, self-efficacy, and coping. The results only support the implementation of the intervention regarding the technical skills (inhalation technique). However, given the importance of improvement of patients’ coping and the need for more efficient care, we recommend further exploration of the possibilities of a more structured and intensive education programme.

AIM:To compare two intervention programmes, aimed at improving the quality of care provided for patients with Type 2 diabetes in the longer term.METHODS:A retrospective comparison of data derived from two non-randomized trials with 3.5 years of follow-up. In the first intervention group 401 patients were included, 413 in the second intervention group and 105 in the reference group. The first programme focused on improving the skills and knowledge of general practitioners (GPs) with regard to Type 2 diabetes, and supported them in making organizational changes in their practice (GP care only). Centralized shared diabetes care was implemented in the second programme in which the GPs received therapy advice according to a protocol for each individual patient. The patients were also encouraged in self-management, and received structured diabetes education (Diabetes Service). The main patient outcomes were HbA1c, blood pressure and serum lipid levels. Multilevel analysis was applied to adjust for dependency between repeated observations within one patient and for clustering of patients within general practices.RESULTS:The HbA1c levels of patients of GPs who were supported by the Diabetes Service improved significantly more than the HbA1c levels of patients receiving GP care only (-0.28% [95% confidence interval (CI) -0.45; -0.11]). In contrast, the systolic blood pressure of patients receiving GP care only decreased more than that of patients of GPs supported by the Diabetes Service [4.14 mmHg (95% CI 1.77, 6.51)].CONCLUSION:A Diabetes Service, providing GPs with individual therapy advice and patient education, resulted in better glycaemic control over 3.5 years than an intervention aimed at improving the skills of GPs in combination with organizational changes in the general practice.

The objective of the study was to evaluate the prevalence of Chlamydia trachomatis infection and the participation, among partners of asymptomatic cases in general practice. Index cases were requested to invite partners for testing by mailed urine samples. One or more partners of 62% of the index cases participated, and the prevalence of infection among partners was 48%. A steady relationship was a determinant of both participation and prevalence. In conclusion, the mailing strategy is an effective strategy for partner notification. A high prevalence wasfound among partners.

Reattribution has been developed as a cognitive-behavioural treatment model for somatisation in general practice. Our objective is to make reattribution suitable for application on patients with long-standing somatisation, including hypochondria, and to evaluate feasibility. Three modifications were developed: (1) dealing with persistent illness worry, (2) adjustment of the doctor’s speed to that of the patient, and (3) the use of symptom diaries. Performance of ten experienced general practitioners (GPs), after a 20h training programme (six sessions of variable length), was measured by self-registrations and audio-taped consultations. GPs were interviewed on factors interfering with performance. Nine GPs completed the course. Reattribution was applied to 51 out of 75 indicated somatising patients, which required on average three consultations of 10–30min duration. We conclude that the modified reattribution model offers a feasible approach to the broad spectrum of somatisation seen in general practice; only the modification ‘dealing with illness worry’ showed limited feasibility.

BACKGROUNDAdequate treatment and follow-up of patients is essential to the success of a screening programme for Chlamydia trachomatis. There has been a lack of data on follow-up, confirmation of infections, and reinfection rates among asymptomatic patients in general practice.AIM7b study the rates of diagnostic confirmation of C trachomatis infection, successful treatment, and reinfection one year after cases were detected in a screening programme for asymptomatic infections.DESIGN OF STUDYProspective cohort studySETTINGFifteen general practices in Amsterdam, The Netherlands.METHODOne hundred and twenty-four patients with asymptomatic C trachomatis infections were requested to provide a cervical or urethral swab and a urine specimen, for the purpose of diagnostic confirmation before being treated. One year after the first screening, all of the patients were invited for a second screening. All samples were tested using the ligase chain reaction (Abbott Laboratories, Chicago, USA).RESULTSOut of 124 patients, 110 (89%) attended the scheduled appointment for diagnostic confirmation and treatment; 92 (84%) of them were confirmed to be positive and received treatment. At the second screening a year later, none of the 56 patients who had received treatment and who had been screened a second time were reinfected.CONCLUSIONNo asymptomatic patients werefound to have reinfections with C trachomatis one year after diagnostic confirmation and treatment. This underlines the effectiveness of the screening and treatment strategy

Aims To longitudinally assess risk factors for diabetic polyneuropathy (DPN) severity, and to longitudinally assess risk factors for the change of DPN severity during 2-4 years of follow-up.Methods From 1995 to 1999, 486 Type 2 diabetes patients in general practice were examined annually with regard to DPN severity and its possible risk factors. DPN severity was assessed with a clinical neurological examination (CNE) which included pinprick sense, light touch sense, vibration sense and ankle jerk. Longitudinal (multivariate) linear associations of (change of) CNE score and predicting variables were analysed using multilevel analyses.Results In this population, 50% of participants were men and had a mean age of 65.4 years, almost one-third (31.7%) of the participants had a CNE score > 4 at baseline and were classified with DPN. CNE score significantly increased during follow-up. Among participants not graded with DPN at baseline, 21.3% progressed towards a CNE score > 4 after 3 years of follow-up. Longitudinal multivariate analyses showed that age, diabetes duration, HbA(1c), height, body mass index and ankle-arm index together best predicted CNE score during follow-up. Change of CNE score during follow-up was best predicted by age, diabetes duration and HbA(1c), with the latter being the strongest predictor.Conclusions Although several factors are longitudinally associated with DPN, HbA(1c), age and diabetes duration were the best predictors of CNE change during follow-up. Therefore, improving glycaemia remains an important amenable factor in preventing worsening of diabetic polyneuropathy.

Objective - To identify medical and psychosocial indicators of childhood adversity in somatising patients in primary care. Design - Retrospective questionnaires and interviews. Setting - Primary health care in The Netherlands. Subjects - Three-hundred-and-seventy-four somatising frequent attenders in 27 general practices between 20 and 45 years of age. Main outcome measures - Major problems in childhood. Results - The questionnaire on childhood problems reflected acceptable validity against a structured interview in 77 patients (correlation 0.69); however, the item ''abuse'' was underreported in the questionnaire. Four out of five patients reported one or more major childhood problems. Childhood adversity was indicated independently by chronic difficulties in present relations and by genital-sexual symptoms of patients. Conclusion - When GPs want to take a more active approach towards somatisers they may show interest in the childhood and life story of patients, especially when patients are known with chronic difficulties in relations and genital-sexual symptoms.

BACKGROUND Depression may be a potential risk factor for subsequent cardiac death. The impact of depression on cardiac mortality has been suggested to depend on cardiac disease status, and to be stronger among cardiac patients. This study examined and compared the effect of depression on cardiac mortality in community-dwelling persons with and without cardiac disease. METHODS A cohort of 2847 men and women aged 55 to 85 years was evaluated for 4 years. Major depression was defined according to psychiatric DSM-III criteria. Minor depression was defined by Center for Epidemiologic Studies-Depression Scale scores of 16 or higher. Effects of minor and major depression on cardiac mortality were examined separately in 450 subjects with a diagnosis of cardiac disease and in 2397 subjects without cardiac disease after adjusting for demographics, smoking, alcohol use, blood pressure, body mass index, and comorbidity. RESULTS Compared with nondepressed cardiac patients, the relative risk of subsequent cardiac mortality was 1.6 (95% confidence interval [CI], 1.0-2.7) for cardiac patients with minor depression and 3.0 (95% CI, 1.1-7.8) for cardiac patients with major depression, after adjustment for confounding variables. Among subjects without cardiac disease at baseline, similar increased cardiac mortality risks were found for minor depression (1.5 [95% CI, 0.9-2.6]) and major depression (3.9 [95% CI, 1.4-10.9]). CONCLUSION Depression increases the risk for cardiac mortality in subjects with and without cardiac disease at baseline. The excess cardiac mortality risk was more than twice as high for major depression as for minor depression.

OBJECTIVE To assess, in an older population, the prevalence of diagnosed and undiagnosed diabetes, the number needed to screen (NNTS) to identify one individual with undiagnosed diabetes, and factors associated with undiagnosed diabetes. RESEARCH DESIGN AND METHODS Socioeconomic and health-related factors were assessed at the baseline examination of the Health, Aging, and Body Composition (Health ABC) Study, a cohort of 3,075 well-functioning people aged 70-79 years living in Memphis, Tennessee and Pittsburgh, Pennsylvania (42% blacks and 48% men). Diabetes was defined according to the 1985 World Health Organization criteria (fasting glucose > or =7.8 mmol/l or 2-h glucose > or =11.1 mmol/l) and the 1997 American Diabetes Association criteria (fasting glucose > or =7.0 mmol/l). RESULTS The prevalence of diagnosed and undiagnosed diabetes was 15.6 and 8.0%, respectively, among all participants (NNTS 10.6), 13.9 and 9.1% among white men (NNTS 9.5), 7.8 and 7.4% among white women (NNTS 12.4), 22.7 and 9.1% among black men (NNTS 8.5), and 21.6 and 6.2% among black women (NNTS 12.6). In multivariate analyses, compared with individuals without diabetes, individuals with undiagnosed diabetes were more likely to be men and were more likely to have a history of hypertension, higher BMI, and larger waist circumference. NNTS was lowest in men (9.1), individuals with hypertension (8.7), individuals in the highest BMI quartile (6.9), and individuals in the largest waist circumference quartile (6.8). CONCLUSIONS In approximately one-third of all older people with diabetes, the condition remains undiagnosed. Screening for diabetes may be more efficient among men and individuals with hypertension, high BMI, and large waist circumference.