LIST OF TERMS & ABBREVIATIONS

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LIST OF TERMS & ABBREVIATIONS

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LIST OF TERMS & ABBREVIATIONS

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Absolute market potential An estimate of maximum potential demand, usually based on two factors: the number of potential users and the rate of purchase, in the case of the research this would mean rate of prescriptions

Activated partial thromboplastin time (APTT) A laboratory measure of the blood's ability to clot.

A sensitive measure of the factors involved in the propagation pathway and common pathway. Used to monitor heparin therapy.

Activated clotting time (ACT) A laboratory measure of the blood's ability to clot. A measure of the factors involved in the propagation pathway and common pathway. Used to monitor heparin therapy.

Adjusted-dose heparin A method of administering high doses of standard heparin for prevention of VTE in which administration begins 2 days before surgery and is subcutaneous in dose-adjusted steps. See low-dose heparin.

Antiphospholipid antibodies Antibodies directed against phosphorylated polysaccharide esters of fatty acids. They are associated with immune-mediated illness and stroke and they are thought to be from a hypercoagulable disorder.

Antiphospholipid syndrome A clinical disorder with recurrent arterial and venous thrombotic events, pregnancy wastage and/or thrombocytopenia in the presence of the lupus anticoagulant and/or moderate to high positive anticardiolipin test.

Antithrombin III deficiency A lack of substances that inhibit or prevent the effects of thrombin in such a manner that blood does not coagulate.

Anticoagulant Any substance that prevents blood clotting.

Antihemophilic factor See factor VIII.

Antiplasmin A substance in the blood that inhibits plasmin.

Antithrombin III A protein (an _-globulin, molecular weight 64,000) of normal plasma and extravascular sites that inactivates thrombin in a time-dependent irreversible reaction and serves as a cofactor of heparin in its anticoagulant activities. Antithrombin III also inhibits certain coagulation factors.

Aorta The largest artery in the body originating from the heart, it gives off branches to the extremities, neck and major organs for the purpose of supplying oxygenated blood.

Arixtra An antithrombotic agent containing fondaparinux – a unique, novel, synthetic pentasaccharide. Arixtra is a potent antithrombotic that will first be licensed for the prevention of VTE. Arixtra prevents thrombus formation by interrupting the coagulation cascade at its key step – that involving the conversion of prothrombin to thrombin by factor Xa.

Arteries The vessels in the body that supply oxygenated blood to the tissues, but includes the pulmonary artery, which carries deoxygenated blood.

Arterioles The smallest divisions of the arteries located between the muscular arteries and the capillaries.

Aspirin An antiplatelet drug with antithrombotic properties.

Asymptomatic DVT Also known as sub-clinical DVT. The formation of blood clots in the veins in the inner thigh or the legs. These can form without the patient experiencing any clinical symptoms and could further develop in DVT with symptoms or PE, a long-term consequence of DVT being PTS.

Autopsy examination to find cause of death.

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Atherosclerosis The formation of fatty deposits on the interior surface of arteries.

Atrium Used in anatomical nomenclature to designate a chamber affording entrance to another structure or organ. Usually used alone to designate an atrium of the heart.

Anaphylaxis Extreme sensitivity.

Barriers in the health care sector Laws and rules which determine the nature and extent of the provision of care and which unintentionally hamper coordination between different provisions.

Basic insurance See general insurance

Baumol effect Named after the American economist William Baumol, who observed that wages in the public sector usually rise in line with wages in the free market sector whereas productivity improvements in the public sector lag behind those in the free market sector. In consequence, the products of the public sector become increasingly expensive relative to the products of the free Benchmarking The comparison of the performance of organizations with the (best) performance in the sector.

Blood pressure The pressure of blood on the walls of the arteries, dependent on the energy of the heart action, the elasticity of the walls of the arteries, and the volume and viscosity of the blood. The maximum pressure occurs near the end of the stroke output of the left ventricle of the heart and is termed maximum or systolic pressure. The minimum pressure occurs late in ventricular diastole and is termed minimum or diastolic pressure.

Blood viscosity Thickness of the blood

Bone marrow The soft, spongy tissue found in the centre of most large bones that produces (hemopoiesis) the cellular components of blood: white cells, red cells and platelets.

market sector.

Branded pharmaceuticals With no or marginal innovative added (therapeutic) value compared to existing products (so called ‘me too’ medicine).

Calcium The most abundant mineral in the body and found in nearly all organised tissues. Plays a role in multiple phases of blood coagulation (in which it is called coagulation factor IV) and in many enzymatic processes. See factor IV.

Capillaries The vessels that connect the arterioles and venules, forming a network in nearly all parts of the body. Their walls act as semipermeable membranes for the interchange of various substances, including fluids, between the blood and tissue fluid.

Cardiac cycle The cardiac cycle consists of two major phases: diastole, during which the ventricles are relaxed and fill with blood and systole, during which the ventricles contract.

Care Care given to people who are in need of long-term care or assistance (cf. cure).

Care provider (or health care provider) Institutions and health care professionals that provide (health) care.

Circulatory collapse A significant potentially catastrophic drop in blood pressure.

Circulatory system The circulatory system is composed of the heart, arteries, capillaries and veins.

It serves to transport deoxygenated blood from the body to the lungs and heart (veins) and oxygenated blood from the lungs and heart throughout the body (arteries).

Clinical outcome Events that occur as a result of disease or treatment. For example, clinical cure or improvement or adverse events.

Clinically ‘silent’ not causing any noticeable symptoms

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Current market potential An estimate of the maximum possible sales of a product or a group of products for an entire industry at the present time.

Coagulation (secondary hemostasis) The process of clot formation.

Coagulation factors A group of plasma protein substances (factors I–XIII) contained in the plasma, which act together to bring about clotting of the blood.

Cofactor Small molecule or element required for an enzyme to function.

Cohort A well-defined group of patients who have a common experience or exposure. They are then followed up for the incidence of new diseases or events, as in a cohort or prospective study.

Cohort studies A cohort study is a prospective study in which patients who presently have a certain condition and/or receive a particular treatment are followed over time and compared with another group who are not affected by the condition under investigation.

Collagen The protein substance of white fibers (collagenous fibers) as skin, tendon, bone, cartilage, and all other connective tissue.

Common femoral vein The main vein that runs from the upper part of the thigh towards the pelvis.

Compression stockings Elasticated stockings that apply graduated pressure to the leg, greatest at the ankle. They reduce the crosssectional area of veins and sinuses in the calf, which increases venous flow and reduces stasis. They are used to prevent DVT.

Compartment Since the coalition government agreement of 1994, the government has made a distinction between three compartments in the health care sector. The first compartment includes long-term care (care) and what are known as uninsurable medical risks. The provision and financing of this care are largely regulated by the government through the AWBZ and some grant schemes.

The second compartment includes short-term essential medical care that has to be accessible to everyone. The government, the health insurance funds and the private insurers all have a role in the provision and funding of the health care in this compartment. The third compartment includes the care that is not covered in the first and second compartments and for which everyone can insure themselves voluntarily. Examples include dental care for adults and alternative therapies.

Confidence interval A range of values for a given variable, constructed so that it has a specified probability of including the true value of the variable. The specified probability is called the confidence level, and the endpoints of the confidence interval are called the confidence limits. As the amount of data increases the CI becomes narrower, reflecting ‘greater confidence’ in the data.

Congestive heartfailure abnormal accumulation of blood in the veins.

Coronary artery The arteries that supply the heart's muscle fibers with nutrients and oxygen.

Cost-benefit analysis (CBA) This method compares the costs and benefits of treatment purely in monetary terms, where benefits are usually defined as costs avoided by the use of the intervention (eg drug therapy). This may include such measures as length of hospitalization, days of disability or lost productivity due to premature death. The aim of CBA is to establish if the cost-saving realized by using the intervention outweighs the costs incurred by obtaining the intervention. By using monetary terms, CBA is a useful measure for comparing the value of treatments with different therapeutic outcomes (eg antihypertensive treatment versus immunization). However, ethical objections to placing monetary value on patient health outcomes tend to limit its use.

Cumbersome Complicated or problematic.

Cure / Curative care Medical care (cf. care).

Cusps Components of the one-way valves in the veins. They open by flattening against the vessel

wall when blood flows in the correct direction (towards the heart), but become filled with blood and

fold back to close the valve should the blood begin to flow in the wrong direction.

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Deep femoral vein It lies deep inside the thigh and returns blood from the upper leg towards the pelvis.

Deep vein thrombosis (DVT) A blood clot (thrombus) usually in the deep veins of the calf in the lower limb. It can be more proximal (nearer the heart ie in the thigh or even the pelvis). It causes full or partial obstruction of the deep vein and a piece of the thrombus may or may not break away (embolize) as a pulmonary embolus.

Diastole The period of dilation of the heart, especially of the ventricles; it coincides with the interval between the second and the first heart sound.

Direct thrombin inhibitor Hirudin, derived from the salivary glands of leeches, is a direct thrombin inhibitor used to prevent VTE. It is therefore an antithrombotic agent.

Distal Away from the center of the body.

Distal DVT DVT occurring in the lower limb.

Distal veins Veins located below the knee (remote from the heart), as opposed to proximal veins which are located above the knee (nearer to the heart).

Dose response The change in activity that is seen with changing dose of active agent.

Dual insurance system A system of health care insurance in which social insurance and private insurance exist alongside each other.

Duty of acceptance Statutory duty of insurers to accept every person who applies for insurance (in so far as the person satisfies the statutory requirements) for a statutory package of entitlements or reimbursements.

Duty of care The statutory duty of health care insurers to purchase sufficient health care of sufficient quality in order to be able to meet the demand for health care of the people they insure in good time. The health care insurer signs contracts to this end with health care providers.

Dyspnea Shortness of breath.

Economy or coach class syndrome Terms coined by the media to describe the occurrence of DVT following long airplane flights or coach journeys because movement of the legs is often very restricted in cramped economy class and coach seating.

Edema Accumulation of fluid in the tissues causing swelling.

Embolism The sudden blocking of an artery by a clot or foreign body which has been brought to its site of lodgement by the blood current.

Embolization The breaking off of an embolus from a thrombus and its movement to another site in the circulation.

Embolus (pl. emboli) A piece of thrombus that breaks off from the original fixed thrombus and is carried by the blood to somewhere else in the body.

Endothelial injury Describes an injury to the venous tunica intima – damage to the inner lining of the blood vessel wall. Such venous injury occurs in patients undergoing surgical procedures risk factors are transient.

Endothelium The layer of epithelial cells that line the cavities of the heart, the blood and lymph vessels and the serous cavities of the body.

Epidemiology Study of disease origin and spread, pattern of disease development.

Epidural Anaesthetic injection into spine.

Erythema Redness of the skin due to dilation of the capillaries in the dermis.

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Erythrocytes One of the elements found in peripheral blood; also called red blood cells or corpuscles. In humans the mature form is normally a non-nucleated, hemoglobin-containing biconcave disk, adapted to transport oxygen.

Estrogen One of the major female sex hormones. High levels occur naturally during pregnancy.

Many oral contraceptives are estrogen based. High levels are a risk factor for VTE.

Extramural Outside the hospital.

Factor III (tissue thromboplastin) A coagulation factor (cellular) tissue factor.

Factor IV The name given to calcium when it is involved in blood coagulation.

Factor V (proaccelerin) Heat- and storage-labile plasma glycoprotein which accelerates the conversion of prothrombin to thrombin in blood coagulation. Factor V accomplishes this by forming a complex with factor Xa (phospholipid) and calcium (prothrombinase complex). Deficiency of factor V leads to Owren's disease. Mutation in factor V within the region implicated in the binding of protein C results in resistance to activated protein C.

Factor VII (proconvertin) Heat- and storage-stable plasma protein that is activated by tissue thromboplastin to form factor VIIa in the extrinsic pathway of blood coagulation. The activated form then catalyses the activation of X to factor Xa.

Factor VIII A coagulation (clotting) factor. Classic hemophilia (hemophilia A) is due to a congenital deficiency in the amount (or activity) of factor VIII. Factor VIII is also known as antihemophiliac factor (AHF) or antihemophiliac globulin (AHG). The gene for factor VIII (that for classic hemophilia) is on the X chromosome so females can be silent carriers without symptoms and males can be hemophiliacs.

Factor Xa Activated form of factor X, a storage-stable glycoprotein blood coagulation factor that can be activated to factor Xa by both the intrinsic and extrinsic pathways. A deficiency of factor X, sometimes called Stuart-Prower factor deficiency, may lead to a systemic coagulation disorder.

Factor XI Stable blood coagulation factor involved in the intrinsic pathway. The activated form XIa activates factor IX to IXa. Deficiency of factor XI is often called hemophilia C.

Factor XII (Hageman) Stable blood coagulation factor activated by contact with the subendothelial surface of an injured vessel. Along with prekallikrein, it serves as the contact factor that

initiates the intrinsic pathway of blood coagulation. Kallikrein activates factor XII to XIIa.

Deficiency of factor XII, also called the hageman trait, leads to increased incidence of thromboembolic disease.

Fibrin The insoluble protein formed from fibrinogen by the proteolytic action of thrombin during normal clotting of blood. Fibrin forms the essential portion of the blood clot.

Fibrinogen (coagulation factor I) A fraction of normal human plasma, which in solution, can be converted into insoluble fibrin when thrombin is added.

Future market potential An estimate that can be achieved during some future period of time

General insurance Compulsory insurance for the whole population with a package of entitlements or reimbursements that is the same for everyone.

Generic pharmaceuticals Products modelled after brand drugs of which the patent has expired.

They do not carry the brand name but the name of the active ingredient.

Glycoprotein Any of a class of conjugated proteins consisting of a compound of protein with a

carbohydrate group. In decomposition they give a product frequently capable of reducing alkaline

solutions of cupric oxide. The glycoproteins include the mucins, the mucoids, and the

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chondroproteins. Glycoproteins have a very high content of polysaccharides are called proteoglycans.

Good quality health care Health care that is provided effectively and with a client focus.

Haemodilution Low(ering) level of erythrocytes, sometimes performed previous to surgery.

Half-life Plasma half-life is the time taken for the plasma concentration to decrease by 50%.

Health Care Budget Framework (BKZ) Framework for that part of health care spending for which the Minister of Health, Welfare and Sport has budget responsibility. The BKZ is agreed for each parliamentary term of four years. The framework relates to health care in the first and second compartments and to the relevant Health, Welfare and Sport budget expenditure.

Health care insurer Health insurance funds and private medical expenses insurers and the executive agencies of statutory medical expenses schemes for civil servants.

Health care market General description of the triangular economic relationship between the insured person/patient, health care provider and health care insurer. Within the three-way health care market, the relationships between patients and health care providers are described as the provision of care market, the relationships between insured people and health care insurers as the health care insurance market and the relationship between health care insurers and health care providers as the health care purchasing market. The health care market is very heterogeneous and is made up of numerous subsidiary markets (such as general practitioner care and home care), each of which has the three-way structure.

Health care office Executive agency that implements the AWBZ on behalf of all the medical expenses insurers in a particular region on the basis of a voluntary mandate. In fact, this executive agency is the insurer that has a dominant position in the region concerned.

Health care policy paper The health care policy paper is an important financial policy document issued by the Ministry of Health, Welfare and Sport that is sent to the Lower House annually with the budget; it contains the government’s policy intentions for health care in the coming years.

Health care quota The spending according to the health care policy paper of the Ministry of Health, Welfare and Sport, expressed as a percentage of the Gross Domestic Product.

Health care system The totality of laws and rules with which the government influences the health care sector.

Health care user The patient/insured person or his representative (such as insurers). Income- dependent premium/contribution The income-dependent or percentage premium/contribution is a premium or contribution expressed as a percentage of the wages or other source of income. The sum on which a premium or contribution is payable is usually subject to a maximum, for example the wage ceiling for insurance by a health insurance fund.

Hematoma An accumulation of blood within tissues; often at the site of surgery. It carries a high risk of infection. Commonly the result of the excess bleeding that is a side effect of some methods of VTE prophylaxis.

Hemoglobin The four subunit globular oxygen carrying protein of vertebrates and some invertebrates.

Hemophilia A One of the two main forms of the hemorrhagic diathesis hemophilia. Hemophilia A

(classic hemophilia, factor VIII deficiency), an X linked disorder due to deficiency of coagulation

factor VIII. Determined by a mutant gene near the telomere of the long arm of the X chromosome

(Xq), but a different loci and are characterised by subcutaneous and intramuscular hemorrhages,

bleeding from the mouth, gums, lips and tongue, hematuria and hemarthroses.

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Hemophilia B A form of hemophilia in males that results from a deficiency of clotting factor IX, transmitted as a X-linked trait. Symptoms include easy bruising, nosebleeds, bleeding gums and bleeding into muscle tissue (hematoma) or a joint space (hemarthrosis). Treatment includes the infusion of factor IX concentrates to normalize blood coagulation.

Hemostasis The arrest of bleeding, either by the physiological properties of vasoconstriction and coagulation or by surgical means.

Heparin An agent to prevent DVT. Present in many tissues, especially the liver and lungs, and has potent anticoagulant properties. It is believed to act by inhibiting the conversion of prothrombin to thrombin, and thus fibrinogen to fibrin.

Heparin-induced thrombocytopenia A decrease in the number of platelets, caused by heparin.

Hirudins Types of anticoagulant derived from the salivary glands of leeches. They are direct thrombin inhibitors. Recombinant Hirudins are used to prevent VTE.

Homeostasis A tendency to stability in the normal body states (internal environment) of the organism.

Homocysteine Metabolite of the essential amino acid methionine.

Hypercoagulability Abnormally increased tendency for the blood to clot.

Iliac veins The veins in the pelvis leading up to the inferior vena cava, which carries the blood on up to the heart.

Iliofemoral system Circulatory system pertaining to proximal veins of the legs, the ileum (in the pelvis) and femur.

Immune system The protection against infectious disease conferred either by the response generated by immunisation or previous infection or by other non-immunologic factors.

Income solidarity When premiums for health insurance are not set proportionally to the risks, despite the fact that every insured person is deemed to have the same risk, income solidarity exists.

The contribution is fixed in regard to the insured person’s income, so that there is solidarity between insured people with high and low incomes, or in other words contribution according to ability to pay (cf. risk solidarity).

Inflammatory bowel disease Any of a group of inflammatory conditions of the intestine.

Initiation pathway The first step in the development of a clot. The initiation pathway is triggered by an external invasive element, such as a burn or cut, and results in the release of chemical factors from the damaged vessel wall.

Inhibitors Substance slowing a chemical reaction.

Innovative proprietary pharmaceuticals Branded drugs developed by the manufacturer that are or used to be patented.

Intermittent pneumatic compression devices Devices used to prevent VTE. They are comprised of a soft but inflatable bandage or sheath into which air is intermittently pumped. They are applied to the leg, usually the calf, and reduce venous stasis by generating intermittent pressure for about 10 seconds in every minute.

International normalized ratio (INR) A laboratory measure of the blood's ability to clot. The World Health Organization recommended ratio is a standardized method of reporting the prothrombin time (PT or PTT). It is based on comparison of patient's PT with the mean normal PT corrected for the 'sensitivity' of the tissue factor (factor III) used. (See prothrombin time).

Intramural Within the hospital.

Intramuscular Within the muscle.

j Intravenous Within the veins.

Ions Atoms or radicals having a charge of positive (cation) or negative (anion) electricity owing to the loss (positive) or gain (negative) of one or more electrons.

Insurance system The totality of laws and rules relating to the insurance of health care expenses.

The characteristic of an insurance system is that it is funded by means of premiums.

Key success factor A key success factor is an asset or competency that is needed to be successful in a market.

Leukocyte A white blood cell or corpuscle, which may be granular or non-granular.

Linear dose response The relationship between the change in the dose of a drug and the measured change in the patient that the dose change causes (the response) is usually represented graphically. A linear dose response means a straight-line relationship between the two; i.e. a doubling of dose causes a doubling in response etc. For most drugs the dose–response graph is not linear.

Low-dose heparin Standard heparin given in low doses to prevent DVT by inhibiting thrombin and coagulation factors IIa and Xa, as well as factors XIIa, XIa and IXa. See adjusted-dose heparin for its use in higher doses.

Low molecular weight heparins (LMWHs) A group of agents used to prevent VTE, which have the same mechanism of action as unfractioned heparin, but inhibit thrombin to a lesser degree.

Lyse Disintegrate

Macrophage A relatively long-lived phagocytic cells of mammalian tissues, derived from blood monocytes. In response to foreign materials, macrophages may become stimulated or activated.

Macrophages play an important role in the killing of some bacteria, protozoa and tumour cells. They also release substances that stimulate other cells of the immune system and are involved in antigen presentation.

Malignancy Cancerous growth.

Market forces Decisions about producing, buying and upgrading goods and services are taken by individual producers, consumers and owners of means of production. The wishes of the buyers/users, the price and the quality of the supply are important factors.

Megakaryocytes The giant cell of bone marrow, a large cell with a greatly lobulated nucleus;

mature blood platelets are released from its cytoplasm and into the blood.

Meta-analysis Meta-analysis is a set of statistical procedures designed to accumulate experimental and correlation results across independent studies that address a related set of research questions. It is commonly used when studies are individually too small to demonstrate a clinical benefit.

Moral hazard The phenomenon that there is no restraining effect on the use of extra care or extra expensive care because it involves no (extra) cost for the insured person.

Myocardial infarction From myocardium (meaning heart muscle) and infarction (meaning tissue damage due to insufficiency of blood supply). Usually the result of occlusion of a coronary artery.

More informally known as heart attack.

Nanotechnology Application of extremely small particles.

Needlestick injury An injury, usually to a healthcare worker, caused by accidental puncture of the

skin by with a clean (unused) or used hypodermic needle.

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Needlestick prevention syringe or device A syringe and needle designed to prevent needlestick injuries.

Nephrotic syndrome Syndrome characterised by excessive edema, re3sulting from renal failure.

Nidus (pl. nidi) The Latin word for nest. The small place where something starts. In this context the place where a clot first begins to form because of particularly suitable conditions.

Oligopoly Market with a small number of sellers.

Oral anticoagulants Any of a group of substances that is given orally to prevent coagulation of the blood. Warfarin is the best known example.

Pathologist Specialist in study of disease.

Pathophysiology Changes caused by disease.

Pelvis basin shaped cavity or body part

Pentasaccharide A molecule containing five saccharide (sugar) units.

Peripartum Before birth.

Pharmacodynamic study of how pharmaceuticals affect users Pharmacokinetic study of reaction to pharmaceuticals

Pharmacokinetic variability Variability (between individuals and over time in the same individual) in the way the body absorbs, distributes and removes a drug. It leads to variations in plasma concentration and the time the drug remains in the plasma, even though the same standard dose is given. A drug with a low pharmacokinetic variability is more predictable in its actions and will have a lower risk of drug interactions and side-effects.

Phlebitis Inflammation of the wall of a vein.

Plasma The fluid portion of the blood in which the particulate components are suspended. Plasma is to be distinguished from serum, which is the cell-free portion of the blood from which the fibrinogen has been separated in the process of clotting.

Platelet A disk shaped structure, 2 to 4mm in diameter, found in the blood of all mammals and chiefly known for its role in blood coagulation; platelets, which are formed in the megakaryocyte and released from its cytoplasm in clusters, lack a nucleus and DNA but contain active enzymes and mitochondria.

Platelet activation The process that occurs upon adhesion of platelets to an injured vessel wall in which their behaviour changes. After activation platelets assemble glycoproteins, which in turn bind fibrinogen and von Willebrand factor (VWF).

Platelet activating factor Potent activator of many leukocyte functions, not just platelet activation.

Platelet aggregation The attachment of platelets to one another. This clumping together can be induced by a number of agents (e.g. thrombin, collagen) and is part of the mechanism leading to the formation of a thrombus.

Platelet plug The initial seal of platelets that forms at a site of the vessel wall injury.

Popliteal vein A vein that runs up behind the knee, returning blood from the lower extremities of the leg.

Posterior tibial vein Runs within the calf towards the knee.

Postpartum After birth.

Post-phlebitic or post-thrombotic syndrome A condition characterized by edema, pain, stasis

dermatitis, cellulitis and varicose veins and, in later stages, by ulceration of the lower limb, that is

often a sequel to DVT of the lower extremity.

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Post-thrombotic syndrome (PTS) A syndrome that follows vascular thrombosis. The term is used to indicate symptomatic difficulties, such as persistent edema.

Primary hemostasis The activation and subsequent aggregation of blood platelets to form a temporary platelet plug to seal a damaged vessel following endothelial injury. See secondary hemostasis.

Primary prevention Aims at the elimination of determinants (causes) of disease, or a risk factor for disease in the healthy population, so that the disease has no chance to occur. Well know forms of primary prevention are immunization, health education, hygiene, prophylaxis with medication, and health protection.

Procoagulant A precursor of a natural substance necessary for the coagulation of blood.

Prophylaxis Any method undertaken to prevent the development of a disease or condition.

Prostatectomy See transvesical prostatectomy

Protein C A vitamin K-dependent protein in plasma that enters into the cascade of biochemical events leading to the formation of a clot. Activated protein C selectively degrades coagulation factors Va and VIIIa. A mutation in the factor V gene, renders the factor V molecule less sensitive to the action of activated protein C (APC resistance). APC resistance is a major risk factor for venous thrombosis.

Protein S A vitamin-K dependent plasma glycoprotein. It functions as a cofactor to protein C in the inactivation of factors Va and VIIIa.

Prothrombin Clotting factor II.

Prothrombinase Also known as thromboplastin. Traditional name for substance in plasma that converts prothrombin to thrombin. The prothrombinase complex is composed of factor Xa, the cofactor Va, a membrane surface and calcium ions.

Prothrombin time (PT) A laboratory measurement of the blood's ability to clot. It is the time taken for the patient's blood to clot when it is incubated with tissue factor (brain extract) and calcium chloride. It evaluates the extrinsic (initiation pathway) clotting system and the common pathway.

Proximal Towards the centre of the body.

Proximal DVT DVT occurring in proximal veins, i.e. veins above the knee.

Proximal veins Veins located above the knee (close to the heart), as opposed to distal veins, which are found in the lower leg (further from the heart).

Puerperal Relating to childbirth.

Pulmonary arteries The main vessels leading from the heart to the lungs. Deliver deoxygenated blood from the right ventricle to the lungs. They are the only arteries in the human body that carry deoxygenated blood.

Pulmonary circulation The circulation of blood through the lungs.

Pulmonary embolism (PE) A piece of thrombus that has broken away from the original DVT, which is carried by the blood stream via the heart to the blood vessels in the lungs, causing a severe dysfunction in respiratory function. A PE often has its origin in the veins of the lower extremities where clots form in the deep veins in the legs and travel to the lungs through the circulatory system.

Symptoms include rapid onset shortness of breath, chest pain and rapid heart and respiratory rates.

Diagnosis can be made on a ventilation perfusion scan of the lung or on a pulmonary angiogram.

Pulmonary hypertension High blood pressure in the pulmonary circulation that supplies blood to the lungs.

Pulmonary veins The veins that return the oxygenated blood from the lungs to the left atrium of the

heart.

m Red blood cells See erythrocytes.

Renal insufficiency Defective function of the kidneys that results in reduced ability to remove waste products, and many drugs, from the blood.

Regulated market forces Market forces operating within constraints laid down by the government.

Sclerosis Hardening of a part of the body as a result of inflammation. In this context, it is the hardening of the blood vessels.

Scintigraphy Scan.

Secondary hemostasis The formation of a long-lasting thrombosis consisting of aggregated platelets interwoven with fibrin strands. See primary hemostasis.

Secondary prevention The active detection of a disease, or a risk factor for a disease, at an early stage when the ‘patient’ is unaware of it, in order to improve the prognosis. Secondary prevention often comes in the form of screening programs for population groups at risk, such as middle-aged women for breast cancer.

Sepsis The presence of infection, usually due to bacteria.

Septum A dividing wall or partition; a general term for such a structure, eg the partition between the two halves of the heart, dividing the atria and ventricles longitudinally.

Sequela (pl. sequelae) A medical condition that is the consequence of (or a sequel to) a preceding disease or accident.

Serotonin A vasoconstrictor found in animals, bacteria, and in many plants.

Sickle cell disease A hereditary blood disease, mainly affecting Afro-Caribbean individuals, in which abnormal hemoglobin is produced. The abnormal hemoglobin precipitates in the red blood cells when the blood is deprived of oxygen, distorting the cells into a sickle shape.

Sinuses In this context, wide channels containing venous blood, eg calf sinuses in lower limbs.

Solidarity (see also: income solidarity and risk solidarity) Financial transfers between (groups of) insured people, as a result of which insured people actually bear one another’s costs (see also: risk solidarity and income solidarity).

Spinal Relating to spine.

Stasis Stagnation or stoppage of the blood flow.

Stroke See myocardial infarction

Subcutaneous Beneath the skin. With reference to injections, a subcutaneous injection (sc) is injected beneath the skin but not into the underlying muscle (which would be intramuscular; im).

Systemic circulation Circulation pertaining to or affecting the body as a whole.

Synthetic Obtained by chemical synthesis.

Systole The period of contraction of the heart, especially that of the ventricles. The closure of the atrioventricular valves causes the first heart sound and the rebounding blood closing the pulmonary and aortic valves with a snap is the second heart sound.

Tachycardia An increase in the heart rate above normal.

Tachypnea A rapid breathing rate.

Tertiary prevention A form of care that aims at overcoming, reducing or compensating shortages in a particular health condition. Making ill patients less dependent of external help and preventing deterioration of disease are part of this type of care.

Thrombin The enzyme derived from prothrombin which converts fibrinogen to fibrin.

n Thrombocytes Blood platelets.

Thrombocytopenia A condition in which there are abnormally low concentrations of platelets in the blood and hence an increased risk of bleeding.

Thrombus A blood clot which forms inside a blood vessel. Tissue factor Integral membrane glycoprotein of around 250 residues that initiates blood clotting after binding factors VII or VIIa.

Transient risk factors

Transvesical prostatectomy Removal of the prostate gland via an incision in the lower abdomen followed by incision in bladder; a major procedure with poor control of bleeding and inevitable pressure on, and trauma to, the veins that run behind the bladder from the lower limbs.

Trauma Bodily injury.

Tunica adventitia The outer coat of the blood vessels, made up of connective tissue and elastic fibers.

Tunica intima The inner coat of the blood vessels, made up of endothelial cells surrounded by longitudinal elastic fibers and connective tissue.

Tunica media The middle coat of the blood vessels, made up of transverse elastic and muscle fibers.

Ulcer A break in skin or mucous membrane that fails to heal and is often accompanied by inflammation.

Unfractionated heparin An anticoagulant used in the prophylaxis of venous thromboembolism. It consists of standard heparin, but is termed unfractionated heparin to differentiate it from the newer low molecular weight heparins, which have a longer duration of action.

Valves Devices that control the flow of a fluid through a pipe. Vasoconstriction The diminution of the calibre of vessels, especially constriction of arterioles leading to decreased blood flow to a part.

Varices Swollen or knotted vein.

Veins The vessels carrying blood toward the heart.

Venesection Cut into vein, exsanguinate / tap blood from the vein.

Venography x-ray examination of the veins Venous Relating to the veins.

Venous lumen Space within veins.

Venous pump Contraction of the calf muscles

Venous stasis Describes slow blood flow and may develop as a result of periods of immobility and inflammatory conditions.

Venous thromboembolism The disease encompassing deep venous thrombosis and pulmonary embolism.

Ventricles The two chambers of the heart that expel blood into the systemic or pulmonary circulations.

Venules Any of the small vessels that collect blood from the capillary plexuses and join to form veins; called also venula (pl. venulae).

Virchow’s triad The three factors described by the pathologist Rudolph Virchow as causing thrombosis – stasis, hypercoagulability and endothelial injury.

Vitamin K antagonist Any agent that prevents vitamin K from producing blood clotting factors and

thus reduces the concentrations of factors IIa, VIIa, IXa and Xa in the blood. See Warfarin.

o

Vitamin K deficiency A nutritional condition produced by a deficiency of vitamin K in the diet, characterised by an increased tendency to hemorrhage (hemorrhagic diathesis). Such bleeding episodes may be particularly severe in newborn infants.

Von Willebrand factor Plasma factor involved in platelet adhesion through an interaction with factor VIII.

Waiting room drugs Pharmaceutical that are registered for use but that are not reimbursed.

Warfarin A vitamin K antagonist. An oral anticoagulant routinely used in the treatment of established DVT and sometimes used in the prevention of VTE in surgical patients.

White blood cells White corpuscles that are spherical, colourless and nucleated masses involved with host defenses. Normal white blood cell counts are variable with age and sex. Normal adult range is 4,500 to 11,000 cells per cubic millimeter of blood. Slightly higher counts are seen in children. Elevated counts can be seen in cases of inflammation and infection.

2. A BBREVIATIONS

ACCP American College of Chest Physicians

AOW Old Age Pensions Act (Algemene ouderdomswet)

AWBZ Exceptional Medical Expenses Act (Algemene Wet Bijzondere Ziektekosten)

BOGIN Bond van de generieke geneesmiddelenindustrie Nederland (Association of the Dutch Generic Pharmaceutical Industry)

CBB Business Community Appeals Committee (College van beroep vo o r het bedrijfsleven) CBG College ter Beoordeling van Geneesmiddelen (Medical Evaluations Board)

CBO Kwaliteitsinstituut voor de Gezondheidszorg

CBS Centraal Bureau voor de Statistiek (Central Statistics Office)

CBZ Hospitals Construction Committee (College bouw z ie ke nhuisvoor z ie ninge n) CCMO Central Committee for Medical Research

CEA Comité Européen des Assurances

CHMP Committee for Medicinal Products for Human Use COPD

CPB Centraal Plan Bureau (Netherlands Bureau for Economic Policy Analysis) CTG National Health Tariffs Authority (College tarieven gezondheidszorg) CT-scan Computed Tomography-scan

CTZ Supervisory Board for Health Care Insurance (College van toezicht op de zorgverzekeringen) CVZ College voor zorgverzekeringen (Health Care Insurance Board)

DBC European Union

DTC diagnosis treatment combination DTC direct-to-consumer (advertising) DVT Deep Vein Thrombosis

EBM evidence-based medicine

p

EFPIA European Federation of Pharmaceutical Industries and Associations EMEA European Agency for the Evaluation of Medicinal Products ENW Evening Weekend Night

EU European Union

EVS elektronisch voorschrijfsysteem (electronic prescription system)

FTO Farmaco-Therapeutisch Overleg (pharmacist-GP consultation meeting)

FTTO Farmaco Therapeutisch Transmuraal Overleg (public pharmacist- hospital pharmacist- GP consultation meeting)

GFB Gedragscode voor de Farmaceutische Branche (Code of Behaviour for the Pharmacutical Industry)

GECS Graduated Elastic Compression Stockings GDP Gross Domestic Product

GP general practitioner

GVS geneesmiddelenvergoedingensysteem (pharmaceuticals reimbursement system)

HBO Hoger Beroepsonderwijs (University of professional education) HIDHA Huisarts in dienst van een andere huisarts

HOED Huisartsen Onder Één Dak (all GP’s under one roof) HRT Hormon Replacement Therapy

ICER Interdepartementale Commissie Europees Recht (Interdepartmental Committee on European Law)

ICT Information and communication technology

IGZ Inspectie voor de Gezondheidszorg (Health Care Inspectorate) IMS IMS-Health Nederland (data supplier)

INR International Normalised Ratio of the Prothrombin time IPC Intermitted Compression Pump

IU International Units

IZA Instituut Zorgverzekeringen voor Ambtenaren Nederland (Netherlands Institute for Civil Servants Health Care Insurance)

IZR Instituut Ziektekostenregeling (Medical Expenses Schemes Institute)

KOL Key Opinion Leader

KNMG Koninklijke Nederlandsche Maatschappij ter bevordering der Geneeskunst (Royal Dutch Association for the Advancement of Medicine)

KNMP Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie (Royal Dutch Association for the Advancement of Pharmacy)

LHV Landelijke Huisartsen Vereniging (National Association of General Practitioners) LMWH Low Molecular Weight Heparin

LVT Landelijke Vereniging voor Thuiszorg (National Home Care Association)

MEB Medicine Evaluation Board

q MI Myocardial Infarction

MOOZ Medefinanciering Oververtegenwoordiging Oudere Ziekenfondsverzekerden (Shared Funding of Overrepresentation of Older People Insured by Health Insurance Funds Act)

MRI Magnetic Resonance Imaging (= magneetscan)

Nefarma Nederlandse Vereniging van de Research-georiënteerde Farmaceutische Industrie

Nefemed Nederlandse Federatie van producenten, importeurs en handelaren van medische producten

Neprofarm Nederlandse Vereniging van de Farmaceutische Industrie van Zelfzorggeneesmiddelen en Gezondheidsproducten

NHG Nederlands Huisartsen Genootschap (Dutch College of General Practitioners)

NICTIZ Nationaal ICT Instituut voor de Zorgsector (National ICT Institute for the care sector) NIVEL Nederlands instituut voor onderzoek van de gezondheidszorg

NMa Nederlandse Mededingingsautoriteit (Dutch Competition Authority)

NPCF Nederlandse Patiënten/Consumenten Federatie (Dutch Patients/Consumers Federation) NP Nurse Practitioner

OAC Oral Anti-Coagulant

OECD Organization for Economic Cooperation and Development OTC over-the-counter (pharmaceuticals)

PA Physician Assistant PE Pulmonary Embolism PLC Product Life Cycle

PLS Post-Thrombotic Leg Syndrome

RIVM Rijksinstituut voor Volksgezondheid en Milieu (National Institute of Public Health and the Environment)

RVZ Raad voor de Volksgezondheid en Zorg (National Advisory Council for Public Health)

SCP Sociaal Cultureel Planbureau (Social and Cultural Planning Office) SER Sociaal Economische Raad (Social and Economic Council)

SFK Stichting Farmaceutische Kengetallen (The Foundation for Pharmaceutical Statistics) SPC (expiry)

SPSS

TNO Nederlandse organisatie voor Toegepast Natuurwetenschappelijk Onderzoek

UFH Unfractionated Heparin

VTE Venous Thromboembolism

VTV Volksgezondheid Toekomstverkenning

VWS Ministry of Health, Welfare and Sport (Volksgezondheid, Welzijn en Sport)

WAO Wet op de Arbeidsongeschiktheidsverzekering (Occupational Disability Act)

r

WBMV Wet op de bijzondere medische verrichtingen (Special Medical Treatments Act) WCPV Wet collectieve preventie volksgezondheid (Collective Preventive Public Health Act) WGBO Wet op de geneeskundige behandelingsovereenkomst (Act on Medical Treatment Covenant) WGP Wet geneesmiddelenprijzen (Pharmaceutical Prices Act)

WHO World Health Organisation

WRR Wetenschappelijke Raad voor het Regeringsbeleid (Scientific Council for Government Policy)

WTG Wet tarieven gezondheidszorg (Health Care Tariffs Act)

WTZ Wet op de toegang tot ziektekostenverzekeringen (Access to Health Care Insurance Act) WTZ 1998 Wet op de toegang tot ziektekostenverzekeringen 1998 (Healthcare Insurance Access Act 1998)

ZFW ZiekenFondsWet (Compulsary Health Insurance Act)

ZN Zorgverzekeraars Nederland (Association of Dutch Health Insurers)

s

APPENDIXES

t

APPENDIXES

1. I

GP'

...

Algemene karakteristieken respondent ... v

Bekendheid met VTE... v

Risico op VTE ... v

Epidemiologie... v Standpunt tav VTE profylaxe ... w Voorschrijfgedrag ... w Standpunt ten aanzien van VTE profylaxe in de extramurale “medical patient”...z 2. I

KOL'

...

3. F

D

2005 ...

u 1. I NTERVIEW QUESTIONS AND TABLE GP' S

INTRODUCTIE (1-2 minuten)

Geachte heer mijn naam is Angelo Siligato, alvorens te beginnen met het interview wil ik u graag de hele bedoeling van het interview kort uiteenzetten.

In het kader van mijn afstudeerproject van mijn studie bedrijfskunde aan de rijksuniversiteit Groningen doe ik onderzoek naar de wenselijkheid van extramurale VTE profylaxe door de huisarts.

Het interview dat ik met u wil afnemen heeft tot doel de huidige situatie ten aanzien van VTE profylaxe bij de huisarts in de praktijk in kaart te brengen.

Het interview is opgebouwd uit een viertal onderwerpen, 1) uw bekendheid met VTE problematiek in het algemeen en de incidentie van VTE in uw praktijk, 2) uw beleid ten aanzien van VTE, 3) uw standpunt ten aanzien van VTE profylaxe en als laatste een aantal algemene vragen gericht op uw voorschrijfgedrag.

Het interview zal ongeveer een half uur in beslag nemen. Ondanks het feit dat het vast omlijnde vragenlijst is die ik u af ga nemen, is het de bedoeling dat u vrijelijk antwoord geeft op de vragen en stellingen die ik u voor leg en u mij vertelt wat u denkt, vindt en ervaart in uw praktijk.

Omdat het letterlijk noteren van het gehele gesprek te veel tijd zou vragen en de aandacht van het gesprekonderwerp af kan leiden, wil ik graag het gesprek op band vast te leggen. Het vastleggen van het interview komt tevens de validatie en verwerking van het interview ten goede.

De opnames die gemaakt worden zullen na verwerking van de gegevens worden vernietigd.

Heeft u naar aanleiding van het voorgaande nog vragen. Zo niet dan zou ik graag willen beginnen

met het feitelijke interview.

v

EERSTE SET Vragen (5-10 minuten)

Algemene karakteristieken respondent (VRAGEN ASSISTENT)

− Leeftijd:

− Praktijk type / aantal HA in praktijk:

− Hoe lang is de respondent praktiserend huisarts:

− Praktijkgrootte:

− Leeftijdsopbouw patiënten praktijk <40: 40-60: >60:

− Geslacht (zelf invullen) m / v

− Locatie (zelf invullen):

−

Bekendheid met VTE

1. Kunt u een korte omschrijving geven van het ziektebeeld van Veneuze Trombose?

Topics

Maakt de huisarts hierbij u onderscheid naar DVT PE en PTS?

2. Wat zijn de acute complicaties van een Veneuze Trombose en welke complicaties onderscheidt u op lange termijn?

Risico op VTE

Het belang van Veneuze Tromboseprofylaxe neemt toe met het tromboserisico.

3. Welke risicofactoren kent u?

4. Welke van deze risicofactoren ziet u vaak bij de patiënten uit uw praktijk?

5. Welke groep patiënten binnen u huisartsen praktijk loopt volgens u het grootse risico op het krijgen van een Veneuze Trombose?

Epidemiologie

6. Hoe vaak kwam u in het afgelopen jaar in uw in praktijk in aanraking met patiënten met een Veneuze Trombose; DVT en / of PE?

7. Wat waren de vermoedelijke en / of objectief vastgestelde oorzaken voor de Veneuze Trombose

in deze patiënten?

w Standpunt tav VTE profylaxe

8. Wat is uw standpunt ten aanzien van primaire preventie van Veneuze Trombose in uw praktijk

− Waarom?

Voorschrijfgedrag

9. Schrijft u wel eens tromboseprofylaxe voor ter voorkoming van Veneuze Trombose bij patiënten in uw praktijk?

− Zo ja, Bij wie?

Waarom juist die?

Welke medicatie en / of mechanische hulpmiddelen?

Waarom juist die therapie?

Hoe lang?

Waarom?

− Zo nee, waarom niet? (Ga verder met vraag 11)

10. Welke personen, instanties en / of partijen spelen een rol in de profylaxe van VTE in uw praktijk? (Ga naar vraag 14)

− Waarom?

− Hoe?

11. Wanneer zou u wel overgaan tot het preventief behandelen van patiënten binnen uw praktijk met een verhoogd risico op een Veneuze Trombose?

− Waarom?

12. Welke medicatie en / of therapie komt volgens u in aanmerking voor de profylaxe van Veneuze Trombose bij patiënten in uw praktijk?

− Bij wie, waarom en hoe lang?

13. Welke personen, instanties en of partijen dienen volgens u direct betrokken te zijn in het profylaxe beleid van VTE?

− Waarom?

− Hoe?

x

TWEEDE SET VRAGEN (MEDICAL PATIENT; 10-20 minuten)

Veneuze Tromboseprofylaxe is aangewezen bij gehospitaliseerde patiënten die worden opgenomen met een acute aandoening, reeds bedlegerig zijn of een aantal dagen bedrust krijgen, in aanwezigheid van ten minste één andere risicofactor met name hartfalen, een ernstige luchtweginfectie of eerdere veneuze trombo-embolie. (Kwaliteitsinstituut voor de gezondheidszorg CBO)

De volgende tabel geeft een overzicht van de risicofactoren waarvoor profylaxe bij deze wordt aanbevolen op basis van de door de CBO en ACCP opgestelde richtlijnen (American CollegeofChestPhysicians).

LEEFTIJD > 40 +

IMMOBILITEIT ( > 3 dagen )

Plus tenminste één van de volgende risico’s

Klasse III-IV Hartfalen − Ischemic Cardiomyopathy

− Non-ischemic Cardiomyopathy

− CHF Secondary to Valvular Disease

− Chronic Idiopathic Cardiomyopathy

− CHF Secondary to arrythmia

Acute / chronische ademhaling insufficentie

− Acute Exacebrations of Chronic Obstructive Pulmonary Disease (AE/COPD)

− Adult Respiratory Distress Syndrome

− Community-Acquired Pneumonia

− Non cardiogenic pulmonary edema

− Pulmonary malignancy

− Interstitial Lung Disease

Acute / ernstige infecties

− Pneumonia

− Urinary Tract Infection

− Abdominal Infection

Maligniteit

Eerdere Veneuze Trombose

Toestand van verhoogde stolbaarheid / Hypercoagulabiliteit

Reumatische aandoening

y

14. Welke van deze risicofactoren herkent u vaak bij de patiënten uit uw praktijk?

15. Hoe groot schat u het jaarlijks aantal patiënten in uw praktijk die binnen het in de tabel genoemde risicoprofiel vallen?

De kans op Veneuze Trombose bij patiënten, die binnen het risicoprofiel vallen, bij afwezigheid van profylaxe is 10% - 26%, in patiënten met hartfalen zelfs 20% - 40%.

16. Neemt u op dit moment maatregelen ter voorkoming van Veneuze Trombose bij patiënten die binnen het in de tabel genoemde risicoprofiel vallen?

− Zo ja: Bij wie?

Waarom juist die?

Welke medicatie en / of mechanische hulpmiddelen?

Waarom juist die maatregelen?

Hoe lang?

Waarom?

(Ga naar vraag 19)

− Zo nee, waarom niet? (Ga verder met vraag 17)

17. Wanneer zou u wel overgaan tot het preventief behandelen van patiënten die binnen het in de tabel genoemde risicoprofiel vallen?

− Niet: Waarom? (Ga naar vraag 19)

− Wel: Waarom?

18. Welke medicatie en / of therapie komt volgens u in aanmerking voor de profylaxe van Veneuze Trombose bij patiënten die binnen het in de tabel genoemde risicoprofiel vallen?

− Waarom en hoe lang?

Het is aangetoond dat de kans op trombose in patiënten die binnen het eerder geschetste risicoprofiel vallen, kan worden gereduceerd met medicamenteuze profylaxe.

Met name de toepassing van LMW-heparines en nieuwe anticoagulantia (Fondaparinux, Hydraparinux 1 x weeks sub-cutaan, Ximelagatran oraal) heeft aangetoond dat het risico op Veneuze Trombose VTE significant gereduceerd wordt in deze patiënt.

19. Hoe staat u naar aanleiding van gegevens tegenover het gebruik van LMWH en nieuwere

vormen van anticoagulantia in de preventie van Veneuze Trombose in patiënten in uw praktijk?

z

Standpunt ten aanzien van VTE profylaxe in de extramurale “medical patient”

We zijn nu bijna aangekomen bij het einde van dit interview. Naar aanleiding van het interview heb ik echter nog een specifiek aantal vragen alvorens dit interview af te sluiten.

20. Zou u, nu u weet dat Veneuze Trombose profylaxe is aanbevolen bij patiënten met de risicofactoren uit de eerder genoemde tabel en het feit dat de toepassing van LMW-heparines de kans op VTE in die patiënten significant reduceert, uw huidige beleid ten aanzien van de risicopatiënten in uw eigen praktijk, willen, kunnen of moeten veranderen?

− Zo ja, hoe en waarom?

− Zo nee, waarom niet en wanneer wel?

21. In hoeverre vindt u het hanteren van een lijst met risicofactoren relevant in huisartsenpraktijk/

setting?

22. Beschikt u op dit moment over een goede methode om patiënten met risico op VTE in kaart te brengen en te beoordelen?

− Zo ja welke en maakt u hiervan gebruik?

− Zo nee, zou u daar behoefte aan hebben?

− Zo ja hoe zou deze methode eruit moeten zien?

23. Welke ontwikkelingen op het gebied van de gezondheidszorg hebben een belangrijke en / of directe invloed op de uitoefening van uw praktijk?

Dit was het interview, ik dank u hartelijk en wil u vragen of er van u kant nog vragen en

opmerkingen zijn naar aanleiding van het interview? Zo ja…zo nee…

aa 2. I NTERVIEW QUESTIONS AND TABLE KOL' S

INTRODUCTIE (1-2 minuten)

Geachte heer mijn naam is Angelo Siligato, alvorens te beginnen met het interview wil ik u graag de hele bedoeling van het interview kort uit eenzetten.

In het kader van mijn afstudeerproject van mijn studie bedrijfskunde aan de rijksuniversiteit Groningen doe ik onderzoek naar de wenselijkheid van extramurale VTE profylaxe door de huisarts.

Het interview dat ik met u wil afnemen heeft tot doel uw standpunt ten aanzien van extramurale VTE profylaxe in de medical patient via de huisarts in kaart te brengen.

Voorafgaand aan dit interview heb ik interviews gehouden bij huisartsen gedaan naar de wenselijkheid van extramurale VTE profylaxe in de huisartsenpraktijk. De voorlopige resultaten van deze interviews wil ik graag meenemen in het interview met uw en bespreken daar waar van toepassing.

Omdat het letterlijk noteren van het gehele gesprek te veel tijd zou vragen en de aandacht van het gesprekonderwerp af kan leiden, wil ik graag het gesprek op band vast te leggen. Het vastleggen van het interview komt tevens de validatie en verwerking van het interview ten goede.

De opnames die gemaakt worden zullen na verwerking van de gegevens worden vernietigd.

Heeft u naar aanleiding van het voorgaande nog vragen. Zo niet dan zou ik graag willen beginnen met het feitelijke interview.

EERSTE SET Vragen

1. Welke groep patiënten binnen de huisartsen praktijk loopt volgens u het grootse risico op het krijgen van een Veneuze Trombose?

Uit het onderzoek ik heb gehouden onder huisartsen komt naar voren dat huisartsen bekend zijn met het ziektebeeld van vte.

De incidentie van VTE in de huisartsenpraktijk is op basis van een schatting van de huisartsen zelf gemiddeld 2-4 gevallen per 1000 patiënten. Deze cijfers komen overeen met het aantal gevallen binnen de ziekenhuis omgeving.

De meest genoemde risicofactoren op VTE op basis van 'on-geholpen bekendheid' in de huisartsenpraktijk zijn: immobiliteit, leeftijd, stollingstoornissen, zwangerschap / kraambed hormoongebruik, maligniteit, post-operatief en langdurig reizen.

Daarnaast komt uit het onderzoek naar voren dat de vermoedelijke dan wel objectief vastgestelde oorzaken van veneuze trombose in de ha praktijk, vaak te herleiden zijn tot immobiliteit in combinatie met leeftijd. Tevens komen regelmatig gevallen terug die vermoedelijk zijn te herleiden tot stollingstoornissen, hormoongebruik, post-operatief, kraambed en langdurige immobiliteit als gevolg van reizen, al dan niet in combinatie met elkaar. Voor het overige zijn de meeste gevallen niet te herleiden tot een duidelijke oorzaak.

Dit zij ook die patiënten die volgens de meeste huisartsen het grootste risico lopen op een

veneuze trombose in hun eigen praktijk.

bb 2. Wat is uw reactie hierop?

3. Heeft uw andere of aanvullende gegevens die inzicht kunnen geven in de incidentie van VTE in de huisartsen praktijk?

− Zo ja, wat is de meest vastgestelde oorzaak voor de Veneuze Trombose in deze patiënten?

4. Wat is uw standpunt ten aanzien van primaire preventie van Veneuze Trombose in de huisartsenpraktijk?

De standpunten van huisartsen ten aanzien VTE profylaxe in hun eigen praktijk zijn meestal positief. Bijna alle huisartsen geven echter aan dat ze geen medicamenteuze profylaxe voorschrijven omdat ze er niet aan denken, daar geen aanleiding toe hebben op basis van de aard van de ziekte en de lage incidentie in hun praktijk.

De belangrijkste voorwaarde om dit wel te doen is voor de huisartsen medisch wetenschappelijk onderzoek en inzicht in de kosten en baten analyse in termen van risico's op VTE en bijwerkingen van eventuele medicatie.

5. Wat is uw reactie hierop?

6. Welke medicatie en / of therapie komt volgens u in aanmerking voor de primaire preventie van Veneuze Trombose bij patiënten in de huisartsen praktijk?

− Welke medicatie en / of mechanische hulpmiddelen?

− Waarom juist die therapie en / of maatregelen?

− Bij wie?

− Waarom en hoe lang?

7. Welke personen, instanties en of partijen dienen volgens u direct betrokken te zijn in primaire preventie van VTE in de huisartsenpraktijk?

− Waarom en hoe?

TWEEDE SET VRAGEN

Veneuze Tromboseprofylaxe is aangewezen bij gehospitaliseerde (zgn. medical) patiënten die worden opgenomen met een acute aandoening, reeds bedlegerig zijn of een aantal dagen bedrust krijgen, in aanwezigheid van ten minste één andere risicofactor met name hartfalen, een ernstige luchtweginfectie of eerdere veneuze trombo-embolie. (CBO)

De volgende tabel geeft een overzicht van de risicofactoren waarvoor profylaxe bij deze wordt aanbevolen op basis van de door de CBO en ACCP opgestelde richtlijnen (AmericanCollegeofChestPhysicians). Daarnaast bevat de tabel de inclusiecriteria van de patiënt populatie uit de ARTEMIS en MEDENOX studies naar de wenselijkheid van profylaxe van

“medical patients”.

cc LEEFTIJD > 40

+

IMMOBILITEIT ( > 3 dagen )

Plus tenminste één van de volgende risico’s

Klasse III-IV Hartfalen − Ischemic Cardiomyopathy

− Non-ischemic Cardiomyopathy

− CHF Secondary to Valvular Disease

− Chronic Idiopathic Cardiomyopathy

− CHF Secondary to arrythmia

Acute / chronische ademhaling insufficentie

− Acute Exacebrations of Chronic Obstructive Pulmonary Disease (AE/COPD)

− Adult Respiratory Distress Syndrome

− Community-Acquired Pneumonia

− Non cardiogenic pulmonary edema

− Pulmonary malignancy

− Interstitial Lung Disease

Acute / ernstige infecties

− Pneumonia

− Urinary Tract Infection

− Abdominal Infection

Maligniteit

Eerdere Veneuze Trombose

Toestand van verhoogde stolbaarheid / Hypercoagulabiliteit

Reumatische aandoening

8. Kan dit risicoprofiel en de bijbehorende aanbevelingen voor de primaire preventie van deze

categorie risico patiënten worden vertaald naar huisartsenpraktijk?