The Continuous Morbidity Registration Nijmegen: Background and history of a Dutch general practice database

Introduction

The Continuous Morbidity Registration (CMR) Nijmegen was founded in 1967 by the founding father of Dutch general practice, Frans Huygen. In a practice-based setting, data were collected concerning health problems patients presented to their general practitioner (GP)—information that was at that time virtually unknown. Huygen was involved in the recording of four practices: in inner-city Nijmegen, in the agricultural villages of Lent and Oosterhout, and in the market town of Doesburg. What started in 1967, never stopped: GPs changed, patients were born, moved into or out of the practice, or died, but the meticulous recording of the health problems presented went on and on. The recording took place in the context of the Dutch healthcare system [1], where patients are listed with a GP for many years and receive all the professional healthcare they need through this GP. As patients commonly join a practice list as a whole family or household, the GP not only serves as a personal doctor but also as a family physician. Data on individual health problems can therefore be related to individual, family, and population demographic characteristics [2], [3].

This issue commemorates the 40-year anniversary of the CMR and presents the core of the experience gained: an overview of health problems and morbidity encountered in general practice over this period. Emphasis, in this overview, is on the dynamics of this experience, on the health problems that have made their mark or disappeared during that period, and on the insights gained by observations over time of the development of individual morbidity. Family patterns and health risks of vulnerable groups have always been of interest, as have psychosocial problems, and this interest will also be apparent. In 1986, a new function of the database was developed: the recording of the process and outcome of care (the Nijmegen Monitoring Project; NMP) [4]. This strengthened the relation between data collection and the care of patients—research and practice—as these data made it possible to monitor and audit care, and provide feedback. This started with the care of patients with diabetes mellitus [4] and has been extended, step by step, to other common chronic diseases. Five other practices joined for this part of the data collection, and, since 1986, the CMR/NMP functions more like a practice-based research network (PBRN) in the North American and UK sense [1]. Summary findings of this experience are also presented in this issue.

History and methodology of the recording and coding of data

An anecdote connected to the founding of the CMR is worth recounting here. At about the same time, Frans Huygen was to be appointed as the inaugural chair of general practice at the medical faculty of the university, now the Radboud University Nijmegen Medical Centre. As one of his first lectures for medical students, he had chosen “German measles”—in that pre-vaccination era, a disease with profound impact on the childhood practice population. No sooner had he set off from his department to the lecture hall—so the anecdote goes—when an official complaint had been tabled by the head of paediatrics, to the dean, against general practice: “measles, as was general knowledge, was a disease of children, and there could be no discussion that childhood morbidity was his—paediatrics—domain”. Such was the lack of empirical information from general practice that even a condition such as measles, hardly ever referred by GPs to paediatricians, could take centre stage in a turf battle at the medical school. If not the trigger to start the CMR, this experience made Frans Huygen even more determined to collect core data concerning the day-to-day experience of GPs.

The challenges of the four GPs in the early years in shaping the CMR must have substantial. There was no classification system available that genuinely covered the health problems presented in general practice. The practices had a combined list of about 12 000 patients, but there was no experience in handling such a large database. Theirs was a fundamental learning-by-doing experience. And, of the decisions they took, a surprising number have become state-of-the-art and characterize current, 2008, practice.

First, they decided to build the database on a population basis—the practice population—and establish the socio-demographic characteristics of that population. Each patient and each family that joined the practice was recorded, irrespective of whether they consulted the GP (Figure 1). For each individual, sex, age, marital status (single, married/living together, widowhood), and social class were established. Social class allocation has been assigned according to the indicators of CBS Statistics Netherlands [5]: a composite score of education and occupation level, grouped as “low”, “middle”, or “high”. Family composition has been defined as any household acting as a societal unity, regardless of the traditional bonds of marriage. Within each family/household, an individual's position has been marked (partners, children ranked according to their birth order). This has been a trademark of the CMR and has allowed the study of morbidity patterns within families and between generations [6], [7].

Figure 1.  Current socio-demographic characteristics of practice population (CMR) compared to Dutch population (CBS).

The second critical decision was to relate presented morbidity to each individual patient. Each patient on the practice list receives a unique identification number to relate presented morbidity to individual characteristics, including previous morbidity recorded. This makes it possible to relate morbidity data to a population and stresses the fact that general practice, in its community orientation, presents the link between public health and individual primary care. The unique patient number makes it possible to deal with the issue of confidentiality: all morbidity data are recorded in relation to this unique patient number and are sent from the practice to the central database. Only in the practice is it possible to identify and relate data to the individual. All patients on the practice lists have been informed of the practices’ involvement in the CMR and the consequent implications of their morbidity data being recorded and entered into the database and used for research, and all patients have been asked to consent to this. The same principle was alluded to when the recording of the process and outcome of chronic diseases (NMP) was initiated. With very few exceptions, all patients consented to this. In case research of database material requires the collection of additional information from the patient, informed consent has to be collected from the patient through the practice.

The third and most contentious issue in 1967 was how to record morbidity data in general practice. At the time, only the E-book existed [8], and this had been translated for the first Dutch national study [9]. Based on this experience, the CMR recorded morbidity according to this classification framework, and, in order to preserve continuity over time, adhered to this classification.

The first morbidity recordings in general practice triggered a more in-depth classification of health problems in primary care, and, in that respect, development by the World Organization of Family Doctors (Wonca) of the International Classification of Health Problems in Primary care (ICHPPC [10]) followed as a result of the CMR and other databases. The ICHPPC diagnostic definitions have been adopted into the CMR and the NMP, but not the classification as such. Nor was this the case when Wonca developed in 1987 the International Classification of Primary Care (ICPC [11]). Staying with the same classification over time has allowed for longitudinal research into the development of primary care morbidity and individuals’ and families’ medical life histories [7], [12–14].

The NMP monitoring of chronic diseases required the development of additional methodology and structure. Criteria for the process and pursued outcome of care had to be defined. These were derived from the prevailing Dutch College of General Practitioners guidelines [15] that serve as the national reference. For the network, these processes and outcomes are the minimum criteria, and additional criteria have been used for evaluation. In a number of cases, these additions have been included in later reviews of the Dutch College guidelines. In patients’ medical records, a “monitoring file” was structured in which all relevant data were placed. Initially, this was done manually [16], but is now included in electronic medical records [4].

The process and outcome data of each patient are brought together in a central database at the Department of General Practice and structured according to patient and practice. From this database, feedback reports are made that compare actual performance with the guideline criteria as an external reference. This way, practices are compared in terms of their performance, and performance over time is monitored.

In response to the challenges of recording and coding morbidity, the GPs decided to meet regularly to review and compare their classification. From this followed an increasing number of definitions and rules the group had agreed upon. This process is still followed today and has been extended to the monitoring of process and outcome of chronic diseases: the GPs meet monthly, and new GPs who join the practice are trained in recording techniques. The effects are clearly visible in terms of the quality of care and the quality of recorded data: compared to external diagnostic criteria, the validity of the recorded diagnoses has been proven to be well above 80% in a number of studies on a variety of conditions [17], [18]. In an increasing number of patients, their care resembles guideline criteria [4].

This principle of meeting regularly has now been extended to practice assistants. Their contribution to the database is vital—from their check of whether the coding of episodes presented to the practice is complete, to listing new patients in the practices, establishing their demographic characteristics (in particular, coding social class), and seeking informed consent for data recording.

Research in the practice population: Landmark research

Implicitly and explicitly, the CMR/NMP database gets its scientific context from previous and parallel research of the same population. This more or less continuous engagement in research on the practice population attests to the value of the database. With hindsight, five landmark studies stand out. The first brings us back to the founding father, Frans Huygen. In his early years in practice, around the end of the Second World War (1945–1947), epidemics of pneumonia struck the practice population. Malnutrition and other social effects related to the war had increased the risk status of the population, and infectious diseases flourished. Yet, at that time, lobar pneumonia as an infectious disease was poorly understood. Based on his observations in Lent and Oosterhout, Frans Huygen observed their spread through his practice population, analyzing and presenting these observations in his MD/PhD, “Lobar pneumonia as an infectious disease”, which he defended in 1948 [19]. The second study that shaped the CMR was Frans Huygen's observations of morbidity patterns in families, his magnum opus and legacy to family medicine, “Family medicine, the medical life histories of Dutch families” [6].

The third study was the founding study of the monitoring of the outcome of chronic diseases in the database (NMP): the screening of the population of six general practices for cardiovascular risk status, studying the effects of intervention and monitoring long-term outcome [20], [21].

The fourth study was a study of the outcome of diabetes and the effects of its treatment [4], [13]. After establishing the increased premature mortality and (cardiovascular) morbidity in patients with diabetes mellitus in the general practice population, this study was directed at a critical appraisal of the outcome of care. In fact, this study piloted the audit and feedback that subsequently became the model of the NMP.

The fifth study focused on the experienced morbidity in the CMR practice population and related experienced morbidity to what was presented to the GP [22]. From this study, the “Dutch” ecology of medical care [23], [24] can be constructed, confirming that patients only present 10% of the episodes of ill health they experience. Of this, 90% is managed entirely in general practice (Figure 2).

Figure 2.  The ecology of medical care, based on experience of the CMR population.

Summarizing the 1967–2007 experience

This issue presents an overview of health problems and morbidity encountered in general practice over the period 1967–2007, and presents a summary of the methodology applied and the basic data collected. It is to serve as a documentation of primary care morbidity and the a priori health risks of the general practice population. The presented experience is based on 40 years of the recording and coding of health problems that patients have presented to their GP, but also experience of 40 years of research on the data: cross-sectional and longitudinal analyses from an expanding database in a dynamic population. What was true for the methodology of recording and classifying data was also true for the development of the study methodology. Historic cohort analyses and case-control studies were developed in their scientific rigor, while performed. This has resulted over the years in a substantial number of publications. Table I lists all research papers based on the database that have been published in international peer-reviewed journals.

Table I.  International papers based on CMR/NMP data published in peer-reviewed journals.

1992

Gijsbers van Wijk CMT, Kolk AM, van den Bosch WJHM, van den Hoogen HJM. Male and female morbidity in general practice: the nature of sex differences. Soc Sci Med 1992;35:665–78.

van den Bosch WJHM, Huygen FJA, van den Hoogen HJM, van Weel C. Morbidity in early childhood: differences between girls and boys under 10 years old. Br J Gen Pract 1992;42:366–9.

van den Bosch WJHM, van den Hoogen HJM, Huygen FJA, van Weel C. Morbidity from childhood to adulthood. The medical life history of 103 patients. Fam Pract 1992;9:290–4.

van den Bosch WJHM, Huygen FJA, van den Hoogen HJM, van Weel C. Morbidity in early childhood, sex differences, birth order and social class. Scand J Prim Health Care 1992;10:118–23.

Huygen FJA, van den Hoogen HJM, van de Lisdonk EH, Smits AJA. Impact of serious morbidity of individuals on the registered morbidity of their partners: an exploration with negative results. Fam Syst Med 1992;10:59–63.

Lagro-Janssen ALM, Debruyne FMJ, van Weel C. Psychological aspects of female urinary incontinence in general practice. Brit J Urol 1992;70:499–502.

Lagro-Janssen ALM, Debruyne FJM, Smits AJA, van Weel C. The effects of treatment of urinary incontinence in general practice. Fam Pract 1992;9:284–9.

van de Lisdonk EH, Furer JW, Kroonen APM, Marijnissen AGMM. Catarct, functioning and co-morbidity: a cross-sectional study in family practice. Fam Pract 1992;9:279–83.

1993

van den Bosch WJHM, Huygen FJ, van den Hoogen HJM, van Weel C. Morbidity in early childhood: family patterns in relation to sex, birth order, and social class. Fam Med 1993;25:126–30.

van den Bogaard C, van den Hoogen HJM, Huygen FJA, van Weel C. Is the breast best for children with a family history of atopy? The relation between way of feeding and early childhood morbidity. Fam Med 1993;25:471–5.

1994

Kolnaar BG, van Lier A, van den Bosch WJ, Folgering H, van Herwaarden C, van den Hoogen HJ, van Weel C. Asthma in adolescents and young adults: relationship with early childhood respiratory morbidity. Br J Gen Pract 1994;44:73–8.

Kolnaar BG, van den Bosch WJ, van den Hoogen HJ, van Weel C. The clustering of respiratory diseases in early childhood. Fam Med 1994;26:106–10.

Kolnaar B, Beissel E, van den Bosch WJ, Folgering H, van den Hoogen HJ, van Weel C. Asthma in adolescents and young adults: screening outcome versus diagnosis in general practice. Fam Pract 1994;11:133–40.

1995

de Grauw WJ, van de Lisdonk EH, van den Hoogen HJ, van Weel C. Cardiovascular morbidity and mortality in type 2 diabetic patients: a 22-year historical cohort study in Dutch general practice. Diabet Med 1995;12:117–22.

van Weel C. Validating long term morbidity recording. J Epidemiol Commun Health 1995;49 Suppl 1:29–32.

de Grauw WJ, van de Lisdonk EH, van de Hoogen HJ, van Gerwen WH, van den Bosch WJ, Willems JL, et al. Screening for microalbuminuria in type 2 diabetic patients: the evaluation of a dipstick test in general practice. Diabet Med 1995;12:657–63.

1996

Stoverinck MJ, Lagro-Janssen AL, Weel CV. Sex differences in health problems, diagnostic testing, and referral in primary care. J Fam Pract 1996;43:567–76.

Kolnaar BGM, van den Hoogen HJM, van Weel C. Long term consistency of an asthma questionnaire. Eur J Gen Pract 1996;2:113–6.

van Weel C. Chronic diseases in general practice: the longitudinal dimension. Eur J Gen Pract 1996;2:17–21.

van de Lisdonk EH, van Weel C. New referrals, a decreasing phenomenon in 1974–94: analysis of registry data in the Netherlands. Br Med J 1996;313:602.

van Weel C, van de Lisdonk EH, van den Bosch WJHM. Seasonal incidence of stroke. Lancet 1996;347:1703.

1997

Kolnaar BGM, Folgering HTM, van den Hoogen HJM, van Weel C. Asymptomatic bronchial hyperresponsiveness in adolescents and young adults. Eur Respir J 1997;10:44–50.

van Weel C. Morbidity in family medicine: the potential for individual nutritional counselling, an analysis from the Nijmegen Continuous Morbidity Registration. Am J Clin Nutr 1997;65 Suppl:1928s–32s.

van Weel C, Michels J. Dying, not old age, to blame for costs of health care. Lancet 1997;350:1159–60.

1998

de Grauw WJ, van den Hoogen HJ, van de Lisdonk EH, van Gerwen WH, van Weel C. Control group characteristics and study outcomes: empirical data from a study on mortality of patients with type 2 diabetes mellitus in Dutch general practice. J Epidemiol Community Health 1998;52 Suppl 1:9S–12S.

van Weel-Baumgarten EM, van den Bosch WJHM, van den Hoogen HJM, Zitman FG. The ten year follow-up of depression in general practice. Br J Gen Pract 1998;48:1643–7.

1999

Doherty S, Lagro-Janssen T, Avery T. Contraception trends in Dutch general practice: differences according to socioeconomic status. Eur J Gen Pract 1999;5:54–8.

de Grauw WJ, van de Lisdonk EH, Behr RR, van Gerwen WH, van den Hoogen HJ, van Weel C. The impact of type 2 diabetes mellitus on daily functioning. Fam Pract 1999;16:133–9.

2000

van Weel-Baumgarten EM, van den Bosch WJHM, Hekster YA, van den Hoogen HJM, Zitman FG. Treatment of depression related to recurrence: 10-year follow-up in general practice. J Clin Pharm Ther 2000;25:61–6.

Verhaak PFM, van de Lisdonk EH, Bor JHJ, Hutschemaekers GJM. GP's referral to mental health during the past 25 years. Brit J Gen Pract 2000;50:307–8.

van Weel-Baumgarten EM, van den Bosch WJHM, van den Hoogen HJM, Zitman FG. The long-term perspective: a study of psychopathology and health status of patients with a history of depression more than 15 years after the first period. Gen Hosp Psych 2000;22:399–404.

van Weel-Baumgarten EM. The validity of the diagnosis of depression in general practice: is using criteria for diagnosis as a routine the answer? Br J Gen Pract 2000;50:284–7.

van Weel-Baumgarten EM, Schers HJ, van den Bosch WJ, van den Hoogen HJ, Zitman FG. Long-term follow-up of depression among patients in the community and in family practice settings. A systematic review. J Fam Pract 2000;49:1113–20.

van Weel C, Smith H, Beasley JW. Family practice research networks. Experience from three countries. J Fam Pract 2000;49:938–43.

2001

de Grauw WJC, van de Lisdonk EH, van Gerwen WHEM, Verstappen M, van den Hoogen HJM, Willems JL, et al. Microalbuminuria in patients with type 2 diabetes mellitus from general practice: course and predictive value. Diabet Med 2001;18:139–43.

de Grauw WJC, van de Lisdonk EH, van Gerwen WHEM, van den Hoogen HJM, van Weel C. Insulin therapy in poorly controlled type 2 diabetic patients: does it affect quality of life? Brit J Gen Pract 2001;51:527–32.

Jacobs JE, van de Lisdonk EH, Smeele I, van Weel C, Grol RPTM. Management of patients with asthma and COPD: monitoring quality of life and the relationship to subsequent GP interventions. Fam Pract 2001;18:574–80.

2002

Bakx JC, van den Hoogen HJM, van den Bosch WJHM, van Weel C. Cardiovascular risk factors and disease in general practice: results of the Nijmegen Cohort Study. Br J Gen Pract 2002;52:135–7.

de Grauw WJC, van Gerwen WHEM, van de Lisdonk EH, van den Hoogen HJM, van den Bosch WJHM, van Weel C. Outcomes of audit-enhanced monitoring of patients with type 2 diabetes. J Fam Pract 2002;51:459–64.

van Weel C. General practice research networks: gateway to primary care evidence. Med J Aust 2002;177:62–3.

Muller IS, de Grauw WJ, van Gerwen WH, Bartelink ML, van den Hoogen HJ, Rutten GE. Foot ulceration and lower limb amputation in type 2 diabetic patients in Dutch primary health care. Diabetes Care 2002;25:570–4.

2003

Janssens HJ, van de Lisdonk EH, Bor H, van den Hoogen HJ, Janssen M. Gout, just a nasty event or a cardiovascular signal? A study from primary care. Fam Pract 2003;20:413–6.

van Weel C, Lagro-Janssen T, van de Lisdonk E, Bakx C, van den Hoogen H, Bor H, et al. Future trends in morbidity in general practice: the limitations of biomedical factors. Zdrav Var 2003;42:51–7.

Janssens HJEM, Pasker de Jong PCM, van de Lisdonk EH, Janssen M. Diuretics do not induce gout. A cross-sectional and case-control study from primary health care. Arthritis Rheum 2003;48 Suppl:S662.

van de Lisdonk EH, Weller DP. Primary care research networks. In: Oxford textbook of primary medical care. Jones R, Briten N, Culpepper L, Gass D, Grol R, Mant D, et al., editors. Oxford: Oxford University Press; 2003. p. 518–22.

2004

Veldhuis HM, Vos AG, Lagro-Janssen AL. Complications of the intrauterine device in nulliparous and parous women. Eur J Gen Pract 2004;20:82–7.

WinklerPrins V, van den Nieuwenhof L, van den Hoogen H, Bor H, van Weel C. The natural history of asthma in a primary care cohort. Ann Fam Med 2004;2:110–5.

Teunissen D, Lagro-Janssen T. Urinary incontinence in community dwelling elderly: are there sex differences in help-seeking behaviour? Scand J Prim Health Care 2004;22:209–16.

Teunissen TA, van den Bosch WJ, van den Hoogen HJ, Lagro-Janssen AL. Prevalence of urinary, fecal and double incontinence in the elderly living at home. Int Urogynecol J Pelvic Floor Dysfunct 2004;15:10–3.

Vos AA, Veldhuis HM, Lagro-Janssen TL. Intrauterine contraception: the role of general practitioners in four Dutch general practices. Contraception 2004;69:283–7.

Olde Hartman TC, Lucassen PLBJ, van de Lisdonk EH, Bor HJ, van Weel C. Chronic functional somatic symptoms: a single syndrome? Br J Gen Pract 2004;54:922–7.

Naushahi MJ, de Grauw WJC, Avery AJ, van Gerwen WHEM, van de Lisdonk EH, van Weel C. Risk factors for development of impaired renal function in type 2 diabetes mellitus patients in primary care. Diab Med 2004;21:1096–101.

2005

Bakx C, Schwarte J, van den Hoogen H, Bor H, van Weel C. First myocardial infarction in a Dutch practice population. Trends in incidence from 1975–2003. Br J Gen Pract 2005;55:860–3.

Teunissen D, van Weel C, Lagro-Janssen T. Urinary incontinence in older people living in the community: examining help-seeking behaviour. Br J Gen Pract 2005;55:776–82.

van Weel C. Longitudinal research and data collection in primary care. Ann Fam Med 2005;3:S46–51.

Mol GD, van de Lisdonk EH, Smits JPJM, van den Hoogen JMP, Bor JHJ, Westert GP. A widening health gap in general practice? Socio-economic differences in morbidity between 1975 and 2000 in the Netherlands. Public Health 2005;119:616–25.

van Wayenburg CAM, van de Laar FA, de Waal MW, Okkes IM, van den Akker M, van der Veen WJ, et al. Nutritional deficiency in Dutch primary care: data from general practice research and registration networks. Eur J Clin Nutr 2005;59 Suppl 1:S187–94.

Bakx JC, van der Wel MC, van Weel C. Self monitoring of high blood pressure. Br Med J 2005;331:466–7.

2006

de Lusignan S, van Weel C. The use of routinely collected computer data for research in primary care: opportunities and challenges. Fam Pract 2006;23:253–63.

van Weel C, de Grauw WJC. Family practices registration networks contributed to primary care research. J Clin Epidemiol 2006;59:779–83.

Janssens JEM, van de Lisdonk EH, Janssen M, van den Hoogen HJM, Verbeek ALM. Gout, not induced by diuretics? A case-control study from primary care. Ann Rheum Dis 2006;65:1080–3.

van Weel C, Bakx JC, van den Hoogen HJM, Thien T, van den Bosch WJHM. Long-term outcome of cardiovascular prevention: a Nijmegen academic family practices network study. J Am Board Fam Med 2006;19:62–8.

van Weel C, van Weel-Baumgarten EM, Mold J. The importance of longitudinal studies in family medicine: experiences of two practice-based research networks. J Am Board Fam Med 2006;19:69–74.

2007

Uijen AA, Bakx JC, Mokkink HG, van Weel C. Hypertension patients participating in trials differ in many aspects from patients treated in general practices. J Clin Epidemiol 2007:60;330–5.

van der Wel MC, Jansen RW, Bakx JC, Bor HH, Olderikkert MG, van Weel C. Non-cardiovascular co-morbidity in elderly patients with heart failure outnumbers cardiovascular co-morbidity. Eur J Heart Fail 2007;9:709–15.

Klein Woolthuis EP, de Grauw WJ, van Gerwen WH, van den Hoogen HJ, van de Lisdonk EH, Metsemakers JF, et al. Identifying people at risk for undiagnosed type 2 diabetes using the GP's electronic medical record. Fam Pract 2007;24:230–6.

Klein Woolthuis EP, de Grauw WJ, van Gerwen WH, van den Hoogen HJ, van de Lisdonk EH, Metsemakers JF, et al. Screening for type 2 diabetes in primary care using a stepwise protocol: the Diabscreen study. Prim Care Diabetes 2007;1:199–202. Epub 2007 Oct 30.

2008

Meerman L, van de Lisdonk EH, Koopmans RT, Zielhuis GA, Olde Rikkert MG. Prognosis and vascular co-morbidity in dementia. A historical cohort study in general practice. J Nutr Health Aging 2008;12:145–50.

The data collection, the audit and feedback, and the studies that used the recorded data would not have been possible without the ongoing commitment of the practices and all their team members—GPs, practice assistants, practice managers and supervisors, and others (Table II lists their names). This issue is a tribute to their invaluable contribution. In particular, the issue is an acknowledgement of the vital contribution of the statistician who developed and supervised this for the better part of the 1967–2007 period: Henk van den Hoogen has been at the scientific helm of the database since 1975, until his retirement in December 2007, and has made a unique contribution to general practice and primary care. This issue is written by Nijmegen staff members who had the privilege of receiving Henk's friendly supervision, wise council, and sound advice over all these years, to pay their tribute to an unsung hero of international general practice research. Henk, thank you for all of this!

Table II.  Current team members of the practices that made data collection possible.

GPs, n=37; practice assistants/nurse practitioners, n = 68

Lent

GPs: Bosch, Wil van den; Laar, Floris van de; Schers, Henk; Serrarens, Ton

Practice assistants/nurse practitioners: Jansen, Marieke; Keijser, Carleen; Leusink, Aniek; Marks, Antoinette; Rossum, Marloes van; Sas, Agnes van; Toonen, Bernadette

Nijmegen 1

GPs: Lagro, Bert; Lagro-Janssen, Toine; Spanninga, Renske; Muijsenbergh, Maria van den

Practice assistants/nurse practitioners: Gijsbers-Peperzak, Sandra; Nooijen, Masja; Dieten, Melissa van

Oosterhout

GPs: Ewijk, Erna van; Verhoeff, Charles; Olde Hartman, Tim; Nobacht, Inge; Beekwilder, Han

Practice assistants/nurse practitioners: Baak, Annegien van; Brok, Trudy den; Cornelissen, Moniek; Jansen, Rian; Kropman, Marij; Melchers, Dian; van der Velde, Karin

Doesburg

GPs: Bakx, Carel; Gelpke, Erik

Practice assistants/nurse practitioners: Bonnes, Ellen; Eefting, Bianca; Hetterscheid, Miranda; Kemperman, Trees; Koolwijk, Dorothé van; Riewald, Femy; Samson, Patricia; Vermeulen, Siny

Wijchen

GPs: Drenth, Bernard van; Hoogen, Jos van den

Practice assistants/nurse practitioners: Schluter, Marieke; Albers, Tamara; Arents, Monique

Nijmegen 2

GPs: Kemper, Merijn; Levelink, Herman; Metz, Marie Jose; Meijer, Miriam; Mooren, Juliet; Ouwendijk, Olaf; Vleugel, Ysbrand van de; Wel, Mark van der

Practice assistants/nurse practitioners: Aalbers, Nora; Breuker, Wendy; van Dorp, Tamara; Christ-Willemse, Stephanie; Dijk, Margaret van; Mil-Gaal, Mascha van; Gaakeer, Mariken; Jans, Heidi; Kuijpers, Cristel; Peer, Mandy

Schaijk

GPs: Bavel, Ies van; Kollenburg, René van; Schulte, Henk; Vrancken, Amber

Practice assistants/nurse practitioners: Boxtel, Fion van; Grootendorst, Binnie; Heijden, Ronnie van der; Jans, Elly; Kouwenberg, Jolanda; Rutten, Ria; Sanders, Clasien; Aarts, Danielle

Berghem

GPs: Boersema, Patrijs; Brink, Wyb; Grauw, Wim de; Hameleers, Stefan; Krogt, Jaap van de; Plönes-van der Krogt, Liselot

Practice assistants/nurse practitioners: Bosch, Sabrina in den; Boxtel, José van; Hoof, Marijke van; Koopmans, Diana; Oort, Marion van; Ven, Gerry van de; Vissers, Jannie

Weurt/Beuningen

GPs: Haverkort, Andre; Rooyackers-Lemmens, Noor; Rutten, Guy; Broek Adriënne van de

Practice assistants/nurse practitioners: Arts, Thea; Derks-Thijssen, Marja; Franken, Helma; Giesen, Ingrid; Hesling, Elly; Liefrink, Angelien; Vastbinder, Hanneke; Westen, Vanessa van der