Use of a Functional Status Instrument in the Danish Health Study

FRONTIERS OF PRIMARY CARE Series Editor: Mack lipkin, Jr. Frontiers of Primary Care Series Editor: Mack Lipkin, Jr. Editorial Board Charles Bridges-Webb Burton Singer Sydney, Australia New Haven, Connecticut, USA Thomas Delbanco Robert Taylor Boston, Massachusetts, USA Portland, Oregon, USA Sheldon Greenfield Kerr L. White Boston, Massachusetts, USA Standardsville, Virginia, USA Henk Lamberts Maurice Wood Amsterdam, The Netherlands Richmond, Virginia, USA Robert Pantell San Francisco, California, USA Published Volumes Barnes, Aronson, and Delbanco (eds.) Alcoholism: A Guide for the Primary Care Physician Schmidt, Lipkin, Jr., de Vries, and Greep (eds.) New Directions for Medical Education: Problem-Based Learning and Community-Oriented Medical Education Goldbloom and Lawrence (eds.) Preventing Disease: Beyond the Rhetoric WONCA Classification Committee Functional Status Measurement in Primary Care Forthcoming Volumes Lipkin, Jr., Putnam, and Lazare (eds.) The Medical Interview WONCA Classification Committee Functional Status Measurement in Primary Care Foreword by Sheldon Greenfield With Contributions by M. Baker, J. Barrand, B.G. Bentsen, N. Bentzen, W.J.H.M. van den Bosch, C. Bridges-Webb, T. Christiansen, RT. Connis, J. Craenen, M-B. De Munter, L. Dessers, RW. Elford, J. Froom, M.J. Gordon, K. Haepers, RD. Hays, J. Heyrman, A. Keller, J.W. Kirk, H. Lamberts, J.M. Landgraf, J.E. Liljenquist, RS. Mecklenberg, B. Meyboom-de Jong, M.H. Mirza, E.c. Nelson, K.M. Pedersen, T.B. Rogers, H. Shigemoto, R.J.A. Smith, A.J.A. Smits, J.W. Stephens, A.L. Stewart, T.R Taylor, C. van Weel, lH. Wasson, S.R West, RC. Westbury, M. Zubkoff Springer-Verlag New York Berlin Heidelberg London Paris Tokyo HongKong Series Editor Mack Lipkin, Jr., M.D. Director, Primary Care; Associate Professor of Medicine, New York University Medical Center, School of Medicine, New York, NY 10016, USA With 63 Figures Library of Congress Cataloging-in-Publication Data Functional status measurement in primary care: report of the Classification Committee of WONCA (World Organization of National Colleges, Academies, and Academic Associations of General Practice/Family Physicians) p. cm.--(Frontiers of primary care) Papers delivered at a meeting in Calgary Canada, Oct. 24-28, 1988, sponsored by WONCA, College of Family Physicians of Canada, and the Dept. of Family Medicine, University of Calgary. Includes bibliographical references. ISBN -13 :978-0-387-97198-8 1. Health status indicators--Congresses. I. World Organization of National Colleges, Academies, and Academic Associations of General Practitioners/Family Physicians Classification Committee. II. College of Family Physicians of Canada. III. University of Calgary. Dept. of Family Medicine. IV. Series. [DNLM: 1. Activities of Daily Living--co_ngresses. 2. Health Surveys--congresses. 3. Primary Health Care--congresses. W 84.6 F979 1988] RA407.A2F861990 362.l--dc20 DNLM/DLC for Library of Congress 89-26345 Printed on acid-free paper. ©1990 Springer-Verlag New York Inc. All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer-Verlag New York, Inc., 175 Fifth Avenue, New York, NY 10010, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use of general descriptive names, trade names, trademarks, etc., in this publication, even if the former are not especially identified, is not to be taken as a sign that such names, as understood by the Trade Marks and Merchandise Marks Act, may accordingly be used freely by anyone. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Typeset by Thomson Press (India) Limited, New Delhi, India. 987654321 ISBN-13:978-0-387-97198-8 DOl: 10.1007/978-1-4613-8977-4 e-ISBN-13:978-1-4613-8977-4 These papers were delivered at a meeting in Calgary, Canada October 24-28, 1988. Meeting sponsored by the World Organization of National Colleges, Academies, and Academic Associations of General Practice/Family Physicians (WONCA); The College of Family Physicians of Canada; and The Department of Family Medicine of the University of Calgary, Canada. The Classification Committee of WONCA gratefully acknowledges financial assistance for this workshop from The Alberta Heritage Foundation for Medical Research, Smith Kline and French Canada, Ltd., and The Department of Family Medicine of the University of Calgary, Canada. Series Preface Primary care medicine is a new frontier of medicine. Physicians and scholars in primary care are pioneering new ways to improve health, lessen illness, and make care available and affordable for all. Every nation in the world has recognized the necessity to deliver personal and primary care to its people. Primary care has come to mean first contact care based on a positive caring relationship between an individual patient and a single provider who manages the majority of a patient's problems, coordination and advocacy for all the patient's care, and the provision of preventive and psychosocial care as well as care for episodes of acute and chronic illness. These facets of care work most effectively when they are embedded in a coherent, integrated approach. The impetus for support of primary care derived from several trends. First, the costs of care based in new technologies rocketed beyond ability to pay and no clear rational approach to prioritization of expenditures emerged. This was exacerbated by expanding populations and diminished real resources in many regions. Simultaneously, the primary care disciplines have grown into mature disciplines with new intellectual and clinical tools to offer in place of more costly and often dehumanized approaches. The intellectual tools include clinical epidemiology that examines the efficacy, effectiveness, and efficiency of every day real world care; clinical decision making, which is finding new ways to enhance the rational basis of every day clinical choice; the medical interview, the major medium of care which is now undergoing scientific scrutiny and refinement; problem based learning and community based medical education, which are enabling efficient learning of the greatest relevance for practice and providing heightened satisfaction for both student and teacher; and the philosophic and empiric study of ethical aspects of care. The emergence of these new disciplines within primary care has prompted a series of ongoing questions. Who is to do primary care and with what preparation? What are the knowledge, skills, and attitudes needed in practitioners and teachers of primary care? What research or teaching and clinical methods are available and what are their strengths and weaknesses? Vll VIII Series Preface Frontiers of Primary Care plans to help meet the needs of primary care professionals and their students by reporting about fundamental and applied research findings in clinically relevant, readable ways. It will provide teachers and clinicians with necessary information about such areas as alcoholism, the medical interview, prevention, and functional assessment of the patient. This volume will serve the needs of both researchers interested in clinical assessment of the function of patients and clinicians who need ways to monitor how their patients are doing with respect to goals of treatment (in addition to the biologic markers of disease). It exemplifies how the community of generalists are working together to develop needed clinical tools. It points to both present applications of the functional assessment approach and to ongoing research needed to further validate and refine these methods. Mack Lipkin, lr. Series Editor Foreword This book represents two extraordinary initiatives. First, it brings together the nations of the world to focus on a critical but heretofore uncharted territory: the standardization of measurement of clinical health, as contrasted to public health on one hand and biological science on the other. It is a far from new occurrence to have a group of oncologists get together at an international meeting to decide on a classification scheme for lymphomas. On the other hand, who has fostered statistics and international comparisons with respect to crude public health measures such as infant mortality? This volume heralds a movement to bring together the physicians of the world on a care level, not a biological, public health, or even epidemiological level. The proposed mechanism to fill that gap is called functional status, which WONCA (World Organization of National Colleges, Academies, and Academic Associations of General Practioners/Family Physicians) has put forward as a standardizable universal that physicians and patients can recognize as part of what they do every day. Standardization through these functional status measures, a goal that this book advances, will allow comparisons and transfer of advances in quality of care, medical education, and cost/resources control that will improve care and unite family and other general physicians. Not only is the choice of functional status good because it represents the goal of family physicians and generalists everywhere, but in addition, this summary measure also potentially reflects the aim of generalists to create the most appropriate and least expensive balance between technical care and interpersonal care. To the degree that functional status measures, which are reported by the patient, represent both technical care and interpersonal care, they document the true role of the generalist in this very complex specialist oriented society. This set of goals is expressed in the WONCA classification, but the inclusion of functional status measurements allows this classification to come alive and to measure and test whether the elements of this classification make sense in daily practice and whether they are being carried out at an optimal level. The second virtue of this volume and the Calgary conference from which it has evolved is the bringing together of pure researchers in psychometrics and ix x Foreword measurement on one hand, with physicians who practice or head up units and use their own practices as testing grounds for reality on the other. The inclusion in this volume of case reports which suggest acceptability for these instruments represents a nice juxtaposition of clinical sensibility with the use of psychometric maneuvers such as factor analysis to develop and test the instruments. The introductory chapters by Stuart and Rogers set a solid groundwork for a field about which most clinicians are naive and in fact could benefit from with respect to physiologic measures, which do not often meet good measurement standards. Trials in different countries in different units indicate good supporting data for early acceptance of these instruments by family physicians. Perhaps the most extensive trials have been with the Dartmouth Coop Charts, which show some very promising results toward a goal of international classification. Whether or not this goal is achieved through those charts or other health status measures, consideration of universal standards, even with different instruments, opens the way to the standardizations and comparisons and ultimately training that are necessary. The Health Status Conferences sponsored by the Henry J. Kaiser Family Foundation and the Institute of Medicine called "Advances in Health Status Assessment," have shown remarkable convergence of instruments, despite the fact that the originators of these instruments built them on what initially appeared to be rather disparate, conceptual foundations. Despite some differences, particularly in administration and inclusion or exclusion of various dimensions, this remarkable convergence of Instruments, is indicated in this volume. Is the glass half full or is the glass half empty? Where do we stand and where does this volume tell us we stand with respect to the creation and use of functional status instruments? In many respects we have come quite far as indicated here, but what is left to do? One of the striking needs expressed by members of WONCA and authors in this book is the need for a short easily administered form that can be well integrated into generalists' practices. One ofthe great virtues ofthe Dartmouth Coop Charts, as well as other measures, is that they are short. It is important, however, to address the trade-off between short instruments and those Rogers refers to as a "wider band," i.e., longer, more precise instruments. It may be, for example, that the functional status instruments might be better used every six months with a longer version that supplies more generalizeable and more cotnparative information with shorter forms being used in between. The trade-offs between the short form and longer forms, a topic that Nelson et al. address, needs to be understood better before this issue of the trade-ofT is fully appreciated. A second issue surrounding the relationship of these measures to clinical health states is still to be determined. There is much work in this book relating functional status measures to various diagnoses, but for a doctor, what is as critical is the patient's level of severity of disease within a diagnosis. A diabetic patient with high blood sugar and no complications is much more like a normal person or a person with mild hypertension than they are like a severe Foreword Xl diabetic with heart, eye, and kidney disease in terms of functional status and total disease burden. Parsing out the amount of patient dysfunction due to disease severity vis-a-vis psychosocial causes will guide the physician's attention to either technical or interpersonal care or to some combination of both. Just as we need to relate blood sugar to hemoglobin AI, BUN to creatinine, chest x-ray for heart size to ejection fraction, symptoms of shortness of breath and dyspnea exertion to heart size, so too do we need to relate functional status measures to clinical measures so that the doctor can understand the patient's combined clinical and functional state. A third question, suggested in many of these chapters, is how are doctors going to respond to functional status data? Many ofthe doctors reported that they liked the measures and that they provided new information. However, will that information improve the patient's functional status or the relationship between doctor and patient, or anything that we can measure? Fourth, can we relate these functional status measures to costs of care? If patients achieve similar functional status and some physicians or systems or specialties are spending a lot more money and using a lot more resources, interventions can be designed based upon that information. Fifth, can we make international comparisons or even comparisons within a country of different socioeconomic status groups with measurements that are adjusted for socioeconomic and cultural variables so that we can interpret them more clearly. These are but some of the future questions that could not even be raised or addressed were it not for the kind of information presented in this book and the level of consensus achieved with respect to the importance and need for functional status information. The continued work of those visionary people who brought about the Calgary Conference and who authored chapters for this book will be critical to our future understanding of the relationship of functional status to resource utilization, to medical education, to the doctorpatient relationship, to cultural differences, and to all the understanding and wisdom that we can gain to improve the quality of medical care. Sheldon Greenfield Preface WONCA Committee on International Classification Statement on Functional Status Assessment, Calgary, October 1988 1. The WONCA Classification Committee will focus on functional status rather than health status or quality oflife, although it recognizes that these three concepts are related. The Classification Committee will continue to employ the definition of function, which is "function is the ability of a person to perform and adapt to the individual's given environment, measured both objectively and subjectively over a stated period of time." 2. Functional status measurements must relate directly to current classifications that the committee has produced which include ICHPPC-2-Defined, IC-Process-PC, ICPC, and the International Glossary for Primary Care. 3. Functional status indicators are not identical with objective findings, although objective findings may be used to measure function. 4. Work on functional status assessment is a logical consequence as well as a necessary sequential task which builds on the committee's earlier work to completely define the content of the primary care encounter. 5. A classification of functional status instruments is unlikely to be useful to family physicians. Instead a method of incorporating functional status assessment into clinical practice as well as relating different functional status assessment tools to each other in a hierarchical fashion will be attempted. 6. Several elements must be considered when designing an instrument for use in primary care. These are: assessment of function must be related to the components of the primary care encounter including reason for encounter, diagnosis, process, and others; the time intervals at which functional status is to be assessed must be stated; notation of differences and similarities between assessments by the patient and by the physician is necessary; use of the instruments must be feasible by primary care providers during the routine care of their patients in the ambulatory care setting; the relation- Xlll XIV Preface ship between intervention and a change in function should be understood in clinical terms; instruments employed should be sensitive to the measurement of small changes in function, as well as larger changes expected to occur in more seriously ill patients or rapidly progressing conditions; the use of functional status instruments should facilitate the assessment of outcome; in general several scores derived from the measurement of the several components of function are preferred to aggregate single scores; and validity and reliability assessments of any instruments employed should be as high as possible. 7. Instruments selected should appeal to busy physicians. 8. The committee must keep lines of communication open to social scientists and other disciplines interested in the assessment of patient's function. 9. It is desirable to have some indicators of severity of disease. Functional status may playa role in severity assessment. The committee considered elements offunction which should be measured. These include physical, mental, and social dimensions. Under the physical dimensions are included activities of daily living which are the necessary daily tasks such as bathing, transferring, mobility, eating, dressing, and continence. The committee considered how the Dartmouth COOP charts fulfilled these several requirements in accord with the principles enunciated above and the needs of the international community. Clearly these charts were attractive to the committee for several reasons. These are: the charts have been demonstrated to have a high level of reliability and validity; they have been demonstrated to have been useful and acceptable in the U.S., The Netherlands, Japan, and Canada; they can be self-administered or administered by a health provider; the time of administration is brief; and the accompanying drawings were felt to aid in understanding (particularly cross-cultural), although the drawings were not attractive to all persons who received the tests. The physical function assessment is linked to cardiovascular fitness without adjustment for age. Thus this is an absolute rather than a relative measure. The emotional charts describe feeling but fail to measure cognitive function. The daily work chart relates to one's major role or job. The social activities assessment includes social functions outside of one's self but only as related to limitations caused by impaired physical and emotional health. These first four charts therefore are functional measures. Additional charts do not relate to function. The pain chart simply measures pain rather than functional impairment. The change in condition chart was developed to measure the course of illness over time. The overall condition chart is primarily related to physical and emotional states. The social support chart is a subjective assessment of support but does not relate to patient needs. The quality of life chart is the most general question of all. The committee believes that the relationships between function, health, and quality oflife may be conceived as concentric circles with a core being functional status, a surrounding circle that of health, and it is in turn surrounded by quality oflife. Perhaps an outer circle Preface xv might be labeled 'future." The several charts relate to these concentric circles as follows: physical condition, emotional condition, daily work, and social activities belong under function; pain, overall condition, and social support are part of health, which is the second circle; and quality of life is part of the third circle. Additional elements of quality of life include the availability of food, water, and shelter, as well as others. The committee considered each of the COOP charts in detail and how it may either meet or fail to meet the needs of the committee. For each of the charts suggestions were made for modifications and how these charts may relate to other measures of function. 1. Physical Condition This chart measures function in absolute rather than relative terms. It is really a measure of physical fitness. It relates well to the RAND 10 and 25 item questionnaires which give additional detail on physical functioning. Thus those two instruments could be used in a hierarchical fashion if information from the physical condition chart is insufficient. This chart appears to be a poor measure of small motor skills and insufficient to fully assess the activities of daily living. As mentioned above it correlates well with the RAND scales and in addition to the Duke-UNC Health Profile. The issue of time frame (i.e. During the last 4 weeks) which involved the other charts as well was discussed. Several time frames were suggested which included 4 weeks, 2 weeks, 1 week, 1 day and even 6 months. The time frame issue relates both to frequency of patient visits as well as patient's ability to recall health events. There was much support for using the 1 day or current time frame so that this chart would be introduced by a statement that said, "What is the most strenuous level of physical activity that you can do for at least 2 minutes?" Additional changes recommended were to use a single set of pictures rather than a dual set and to simplify the illustrations, perhaps with stick drawings rather than dough-boy type drawings. It was also noted that both physician and patient ratings may be useful, as well as both patient and health provider administration. It may be useful to have a place on the chart to designate who has done the rating and how the charts were administered. The committee also noted that the five categories were not equi-distant in terms of physical fitness and that these charts were not suitable for children. The committee did recommend retention of a five point scale for this chart as well as for all of the others. Lastly, there was the question of retitling this chart to Physical Fitness rather than Physical Condition. 2. Emotional Condition This chart might very well be retitled "Feelings." It is noted that cognitive ability and issues of control of one's life were missing from this category of function. It was suggested that a group of second level instruments might XVI Preface include a mini-mental assessment for cognitive skills and a depression scale for patients with disturbed feelings. For this chart, too, there was discussion about time frame and also changing the type of drawings. A simple circle with changes of the mouth from a big smile to a big frown was suggested as a possible alternate. 3. Daily Work It was noted that the word work may by difficult to translate into the several languages and may have different meanings within the several countries. It was noted too that this is a relative scale rather than one that is absolute and that there is an expanded instrument to measure this aspect of function produced by the RAND Corporation which interdigitates nicely with this chart. Daily activities or daily tasks might be more accurate titles dlthough semi-literate persons may have more difficulty in understanding those meanings. 4. Social Activities This scale generated considerable discussion. Some felt that social activities were not really a part of function. Others felt that there would be severe problems with translation of this chart and that it may be linked to daily work. The committee finally recommended that this chart be eliminated as a core chart since it correlates quite well with the first three charts and therefore may be superfluous. It may be used at a second level of administration rather than as a core chart. 5. Pain It was noted that this chart is related to severity of disease. In addition there are other pain scales available such as a visual analog scale and the McGill Melzack pain questionnaire. 6. Change in Condition This chart differs from the other in that a score of three indicates no change and for both improvement and getting worse there are only two levels available. Thus, it may be useful to add additional ranks. The committee felt that this scale required validation using both Dutch and United States data, and that the issue of appropriate time for reassessment was uncertain. There may be a lack of sensitivity in the use of this scale. In addition the illustrations might be improved. 7. Overall Condition For this chart an alternate way of phrasing the question might be, "Overall how would you rate your health?" since it was noted that this chart is more a measure of health rather than of function. Preface XVll 8. Social Support The committee felt that this chart, too, may be a secondary scale to be used if daily work is impaired. It was believed that the chart asks hypothetical questions and to some extent covers dependency, resources, and patients' fragility. It was noted that a dependency scale might be a very useful addition to the charts. Most of the committee members felt that this chart should be eliminated and that there was a need for another chart containing one item that would clearly define the essential components of social function. It was felt that the two charts on social issues, that is social support and social activities, did not measure social function. 9. Quality of Life There was agreement that this chart should be eliminated from the core charts but it could be used for special purposes. There are other aspects of function for which assessment is desirable. These are: 1. Communication (i.e. vision, speech, and hearing). 2. Coping ability. Can patients complete tasks? What is their level of optimism? What strategies have they adopted for coping? Are they able to relax? 3. Basic health needs. These encompass availability of water, food, and shelter, especially in underdeveloped countries. 4. Measurement of dependency. An international version of the COOP charts are planned and in preparation. An international field test will follow. Jack Froom Chairman Contents Series Preface. Foreword .. Preface . . . . Contributors Vll IX Xlll xxiii Part I Psychometric Issues Chapter 1 Psychometric Considerations in Functional Status Instruments A.L. Stewart. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 2 The Development of a New Measuring Instrument T.B. Rogers . . . . . . . . . . . . . . . . . . . . . . . . 3 27 Part II Primary Care Considerations Chapter 3 The Use of Functional Status Assessment Within the Framework of the International Classification of Primary Care H. Lamberts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Chapter 4 The History of Health Status Assessment from the Point of View of the General Practitioner B.G. Bentsen.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Chapter 5 Disease-Specific Functional Status Assessment J. Froom . . . . . . . . . . . . . . . . . . . . . . . 66 Chapter 6 Functional Status Assessment in Relation to Health Promotion and Preventive Medicine C. Bridges- Webb and J. Barrand. . . . . . . . . . . . . . . . . . . . . . 72 xix xx Contents Chapter 7 A Clinical Measure for Evaluating Patient Functioning in Diabetics K W. Elford, K T. Connis, T.K Taylor, M.J. Gordon, J.E. Liljenquist, KS. Meeklenberg, J.w. Stephens, and M. Baker .. . . . . . . . . . .. 79 Part III Dartmouth COOP Charts Chapter 8 The COOP Function Charts: A System to Measure Patient Function in Physicians' Offices E.C. Nelson, J.M. Landgraf, KD. Hays, J.w. Kirk, J.H. Wasson, A. Keller, and M. ZubkofJ . . . . . . . . . . . . . . . . . . . . . . . . .. 97 Chapter 9 Studies with the Dartmouth COOP Charts in General Practice: Comparison with the Nottingham Health Profile and the General Health Questionnaire B. Meyboom-de Jong and R.J.A. Smith .................. 132 Chapter 10 Assessing Function: Does It Really Make a Difference? A Preliminary Evaluation of the Acceptability and Utility of the COOP Function Charts J.M. Landgraf, E.C. Nelson, KD. Hays, J.H. Wasson, and J.w. Kirk 150 Chapter 11 Use of the Dartmouth COOP Charts in a Calgary Practice KC. Westbury . . . . . . . . . . . . . . . . . . . . . . 166 Chapter 12 A Trial of the Dartmouth COOP Charts in Japan H. Shigemoto . . . . . . . . . . . . . . . . . . . . . . . 181 Part IV Other Functional Assessment Instruments Chapter 13 Results of Studies of the Auckland Health Status Survey S.R. West . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191 Chapter 14 Functional Status Assessment in the Elderly J. Heyrman, L. Dessers, M-B. De Munter, K. Haepers, and J. Craenen 213 Chapter 15 Studies Using the Nottingham Health Profile in General Practice C. van Weel, A.J.A. Smits, and W.J.H.M. van den Boseh. . . . . . . 222 Contents xxi Chapter 16 Position Paper on the Assessment of Functional Status in Primary Care in a Developing Country-Pakistan MoHo Mirza 232 Chapter 17 Use of a Functional Status Instrument in the Danish Health Study No Bentzen, KoMo Pedersen, and To Christiansen 236 0 Index 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 263 Contributors M. Baker, M.D. Family Practice Group, Pocatello, ID, USA John Barrand, L.M.S.S.A., D.A., F.R.A.C.G.P., M.H.P.E.D. Department of Community Medicine, University of Sydney, Sydney, Australia Bent Guttorm Bentsen, M.D. Department of Community Medicine and General Practice, University of Trondheim, Trondheim, Norway Niels Bentzen, M.D. Department of General Practice, Institute of Community Health, Odense University, Odense, Denmark W.J.H.M. van den Bosch, M.D. Department of General Practice/Family Medicine, University of Nijmegen, Nijmegen, The Netherlands Charles Bridges-Webb, M.D. Division of Family Medicine, University of Sydney, Sydney, Australia Terkel Christiansen, M.Sc. Department of Economics, Odense University, Odense, Denmark Richard T. Connis, Ph.D. Department of Health Services, School of Public Health and Community Medicine, University of Washington, Seattle, WA, USA Jan Craenen, M.D. Department of General Practice, Catholic University of Leuven, Leuven, Belgium Maria-Bernadette De Munter, M.D. Department of General Practice, Catholic University of Leuven, Leuven, Belgium xxiii XXIV Contributors Luc Dessers, M.D. Department of General Practice, Catholic University of Leuven, Leuven, Belgium R. Wayne Elford, M.D. Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada Jack Froom, M.D. Department of Family Medicine, State University of New York at Stony Brook, Health Sciences Center, Stony Brook, NY, USA Michael J. Gordon, Ph.D. Department of Family Medicine, School of Medicine, University of Washington, Seattle, W A, USA Kristien Haepers, M.D. Department of General Practice, Catholic University of Leuven, Leuven, Belgium Ron D. Hays, Ph.D. Behavioral Sciences Department, The RAND Corporation, Santa Monica, CA,USA Jan Heyrman, M.D. Department of General Practice, Catholic University of Leuven, Leuven, Belgium Adam Keller, M.P.H. Dartmouth COOP Project, Department of Community and Family Medicine, Dartmouth Medical School, Hanover, NH, USA John W. Kirk, M.D. The Dartmouth COOP Project, Department of Community and Family Medicine, Dartmouth Medical School, Hanover, NH, USA Henk Lamberts, M.D., Ph.D. Department of Family Medicine, University of Amsterdam, Amsterdam, The Netherlands Jeanne M. Landgraf, M.A. The Dartmouth COOP Project, Department of Community and Family Medicine, Dartmouth Medical School, Hanover, NH, USA J.E. Liljenquist, M.D. Private Practice, Idaho Falls, ID, USA R.S. Mecklenberg, M.D. Section of Endocrinology and Metabolism, Mason Clinic, Seattle, WA, USA Betty Meyboom-de Jong, M.D., Ph.D. Department of Family Medicine, University of Groningen, Groningen, The Netherlands Contributors xxv Mohib H. Mirza M.B.B.S., B.Sc., D.M.R.E., E.C.H. College of Family Medicine, Punjab, Lahore, Pakistan Eugene C. Nelson, Ph.D. Director, Quality of Care Research, Hospital Corporation of America, Nashville, TN, USA Kjeld M~ler Pedersen, M.Sc. Health Department, Vejle County Hospital, Vejle, Denmark Tim B. Rogers, Ph.D. Department of Psychology, University of Calgary, Calgary, Alberta, Canada Hirosada Shigemoto, M.D. Shigemoto Medical Clinic, Okayama, Japan R.J.A. Smith, M.Sc. Department of Family Medicine, State University of Groningen, Groningen, The Netherlands A.J.A. Smits, M.D. Department of General Practice/Family Medicine, University of Nijmegen, Nijmegen, The Netherlands lW. Stephens, M.D. Portland Diabetes Center, Portland, OR, USA Anita L. Stewart, Ph.D. Institute of Health and Aging, University of California San Francisco, San Francisco, CA, USA Tom R. Taylor, M.D., Ph.D. Department of Family Medicine, School of Medicine, University of Washington, Seattle, WA, USA Chris van Weel, M.D., Ph.D., Prof. Department of General Practice/Family Medicine, University of Nijmegen, Nijmegen, The Netherlands John H. Wasson, M.D. The Dartmouth COOP Project, Department of Community and Family Medicine, Dartmouth Medical School, Hanover, NH, USA S. Rae West, M.B.Ch.B. Division of General Practice, School of Medicine, University of Auckland, Auckland, New Zealand Robert C. Westbury, M.D. (Cantab.) Family Physician, Calgary, Alberta, Canada Michael Zubkoff, Ph.D. Dartmouth COOP Project, Department of Community and Family Medicine, Dartmouth Medical School, Hanover, NH, USA The WONCA Classification Committee Dr. Jack Froom, Chairman Dr. Charles Bridges-Webb Prof. Dr. Jan Heyrman Dr. Robert C. Westbury Dr. Niels Bentzen Dr. A.K. Coates Dr. Erik Hagman Dr. Irene F. Osmund Dr. Bijon Chakraborty Dr. Philip Sive Dr. Hirosada Shigemoto Dr. Bang Bu Yo un Dr. Kumar Rajakumar Dr. Henk Lamberts Dr. S. Rae West Dr. S.E. Mbanefo Dr. Bent Guttorm Bentsen Dr. Mohib H. Mirza Dr. Primitivo D. Chua Dr. Eduardo Mendes Dr. Bill Dodd Dr. W.M. Patterson Dr. Paul Chan Dr. Dennis Aloysius Dr. Britt-Gerd Malmberg Dr. Gisela Fischer Dr. Maurice Wood USA Australia Belgium Canada Denmark England Finland Hong Kong India Israel Japan Korea Malaysia The Netherlands New Zealand Nigeria Norway Pakistan Philipines Portugal Saudi Arabia Scotland Singapore Sri Lanka Sweden West Germany USA xxvii