Citizens' perspectives on relocating care: a scoping review.

BACKGROUND: Healthcare systems around the world are facing large challenges. There are increasing demands and costs while at the same time a diminishing health workforce. Without reform, healthcare systems are unsustainable. Relocating care, for example, from hospitals to sites closer to patients' homes, is expected to make a key contribution to keeping healthcare sustainable. Given the significant impact of this initiative on citizens, we conducted a scoping review to provide insight into the factors that influence citizens' attitudes towards relocating care. METHOD: A scoping review was conducted. The search was performed in the following databases: Pubmed, Embase, Cinahl, and Scopus. Articles had to include relocating healthcare and citizens' perspectives on this topic and the articles had to be about a European country with a strong primary care system. After applying the inclusion and exclusion criteria, 70 articles remained. RESULTS: Factors positively influencing citizens' attitudes towards relocating care included: convenience, familiarity, accessibility, patients having more control over their disease, and privacy. Factors influencing negative attitudes included: concerns about the quality of care, familiarity, the lack of physical examination, contact with others, convenience, and privacy. Furthermore, in general, most citizens preferred to relocate care in the studies we found, especially from the hospital to care provided at home. CONCLUSION: Several factors influencing the attitude of citizens towards relocating care were found. These factors are very important when determining citizens' preferences for the location of their healthcare. The majority of studies in this review reported that citizens are in favour of relocating care. In general citizens' perspectives on relocating care are very often missing in articles. It was significant that very few studies on relocation from the hospital to the general practitioner were identified.

Personalized surveillance and aftercare for non-metastasized breast cancer: the NABOR study protocol of a multiple interrupted time series design.

BACKGROUND: Follow-up of curatively treated primary breast cancer patients consists of surveillance and aftercare and is currently mostly the same for all patients. A more personalized approach, based on patients' individual risk of recurrence and personal needs and preferences, may reduce patient burden and reduce (healthcare) costs. The NABOR study will examine the (cost-)effectiveness of personalized surveillance (PSP) and personalized aftercare plans (PAP) on patient-reported cancer worry, self-rated and overall quality of life and (cost-)effectiveness. METHODS: A prospective multicenter multiple interrupted time series (MITs) design is being used. In this design, 10 participating hospitals will be observed for a period of eighteen months, while they -stepwise- will transit from care as usual to PSPs and PAPs. The PSP contains decisions on the surveillance trajectory based on individual risks and needs, assessed with the 'Breast Cancer Surveillance Decision Aid' including the INFLUENCE prediction tool. The PAP contains decisions on the aftercare trajectory based on individual needs and preferences and available care resources, which decision-making is supported by a patient decision aid. Patients are non-metastasized female primary breast cancer patients (N = 1040) who are curatively treated and start follow-up care. Patient reported outcomes will be measured at five points in time during two years of follow-up care (starting about one year after treatment and every six months thereafter). In addition, data on diagnostics and hospital visits from patients' Electronical Health Records (EHR) will be gathered. Primary outcomes are patient-reported cancer worry (Cancer Worry Scale) and overall quality of life (as assessed with EQ-VAS score). Secondary outcomes include health care costs and resource use, health-related quality of life (as measured with EQ5D-5L/SF-12/EORTC-QLQ-C30), risk perception, shared decision-making, patient satisfaction, societal participation, and cost-effectiveness. Next, the uptake and appreciation of personalized plans and patients' experiences of their decision-making process will be evaluated. DISCUSSION: This study will contribute to insight in the (cost-)effectiveness of personalized follow-up care and contributes to development of uniform evidence-based guidelines, stimulating sustainable implementation of personalized surveillance and aftercare plans. TRIAL REGISTRATION: Study sponsor: ZonMw. Retrospectively registered at ClinicalTrials.gov (2023), ID: NCT05975437.

Evaluation of a standardised protocol to measure the disease burden of respiratory syncytial virus infection in young children in primary care.

BACKGROUND: A better understanding of the burden of respiratory syncytial virus (RSV) infections in primary care is needed for policymakers to make informed decisions regarding new preventive measures and treatments. The aim of this study was to develop and evaluate a protocol for the standardised measurement of the disease burden of RSV infection in primary care in children aged < 5 years. METHODS: The standardised protocol was evaluated in Italy and the Netherlands during the 2019/20 winter. Children aged < 5 years who consulted their primary care physician, met the WHO acute respiratory infections (ARI) case definition, and had a laboratory confirmed positive test for RSV (RT-PCR) were included. RSV symptoms were collected at the time of swabbing. Health care use, duration of symptoms and socio-economic impact was measured 14 days after swabbing. Health related Quality of life (HRQoL) was measured using the parent-proxy report of the PedsQL™4.0 generic core scales (2-4 years) and PedsQL™4.0 infant scales (0-2 years) 30 days after swabbing. The standardised protocol was evaluated in terms of the feasibility of patient recruitment, data collection procedures and whether parents understood the questions. RESULTS: Children were recruited via a network of paediatricians in Italy and a sentinel influenza surveillance network of general practitioners in the Netherlands. In Italy and the Netherlands, 293 and 152 children were swabbed respectively, 119 and 32 tested RSV positive; for 119 and 12 children the Day-14 questionnaire was completed and for 116 and 11 the Day-30 questionnaire. In Italy, 33% of the children had persistent symptoms after 14 days and in the Netherlands this figure was 67%. Parents had no problems completing questions concerning health care use, duration of symptoms and socio-economic impact, however, they had some difficulties scoring the HRQoL of their young children. CONCLUSION: RSV symptoms are common after 14 days, and therefore, measuring disease burden outcomes like health care use, duration of symptoms, and socio-economic impact is also recommended at Day-30. The standardised protocol is suitable to measure the clinical and socio-economic disease burden of RSV in young children in primary care.

The impact of health symptoms on health-related quality of life in early-stage breast cancer survivors.

PURPOSE: In breast cancer patients, treatment-related health symptoms can occur that may affect their health-related quality of life (HRQoL). This study aimed to determine the impact of health symptoms on HRQoL in breast cancer patients up to 5 years after diagnosis. METHODS: Females surgically treated for early-stage breast cancer diagnosed between 2012 and 2016 (n = 876) were selected from the Netherlands Cancer Registry and invited for a survey about current health symptoms ('Symptoms and Perceptions questionnaire', SaP) and HRQoL ('EORTC-QLQ-C30'). From the latter, functioning and global health were included. Mean scores were compared to norm population scores (T test). Multivariable linear regression analyses were performed to determine the association between health symptoms and global health and functioning. RESULTS: 404 patients (46%) responded. The median age was 62.2 ± 10.9 years. Respondents had significantly lower mean scores for role, cognitive, emotional, and social functioning than the general population. The most frequently reported health symptoms were musculoskeletal (including pain/complaints in lower/upper extremities/back/neck; 71%) and central nervous system symptoms (including concentration impairment, dizziness, neuralgia; 66%), and fatigue (63%). While most symptoms affected functioning, irrespective of time since diagnosis, especially fatigue, musculoskeletal, central nervous system, and gastrointestinal symptoms were significantly associated (p < 0.05) with lower functioning. CONCLUSIONS: The majority of health symptoms that occur after breast cancer treatment were associated with lower functioning of patients in daily life. This paper urges healthcare providers to support breast cancer patients in alleviating or coping with health symptoms, even years after end of treatment, to improve their functioning.

Prescription patterns of lipid lowering agents among older patients in general practice: an analysis from a national database in the Netherlands.

BACKGROUND: Dutch cardiovascular risk management guidelines state almost every older adult (≥70 years) is eligible for a lipid lowering drug (LLD). However, life expectancy, frailty or comorbidities may influence this treatment decision. OBJECTIVE: investigate how many older adults, according to age, frailty (Drubbel-frailty index) and comorbidities were prescribed LLDs. METHODS: data of 244,328 adults ≥70 years from electronic health records of 415 Dutch general practices from 2011-15 were used. Number of LLD prescriptions in patients with (n = 55,309) and without (n = 189,019) cardiovascular disease (CVD) was evaluated according to age, frailty and comorbidities. RESULTS: about 69% of adults ≥70 years with CVD and 36% without CVD were prescribed a LLD. LLD prescriptions decreased with age; with CVD: 78% aged 70-74 years and 29% aged ≥90 years were prescribed a LLD, without CVD: 37% aged 70-74 years and 12% aged ≥90 years. In patients with CVD and within each age group, percentage of LLD prescriptions was 20% point(pp) higher in frail compared with non-frail. In patients without CVD, percentage of LLD prescriptions in frail patients was 11pp higher in adults aged 70-74 years and 40pp higher in adults aged ≥90 years compared to non-frail. Similar trends were seen in the analyses with number of comorbidities. CONCLUSION: in an older population, LLD prescriptions decreased with age but-contrary to our expectations-LLD prescriptions increased with higher frailty levels.

What are essential elements of high-quality palliative care at home? An interview study among patients and relatives faced with advanced cancer.

BACKGROUND: In the Netherlands, general practitioners (GPs) and community nurses play a central role in the palliative care for home-dwelling patients with advanced cancer and their relatives. To optimize the palliative care provision at home, it is important to have insight in the elements that patients and relatives consider essential for high-quality palliative care, and whether these essentials are present in the actual care they receive. METHODS: Qualitative semi-structured interviews were conducted with 13 patients with advanced cancer and 14 relatives. The participants discussed their experiences with the care and support they received from the GP and community nurses, and their views on met and unmet needs. Interview data were analysed according to the principles of thematic analysis. RESULTS: Patients as well as relatives considered it important that their GP and community nursing staff are medically proficient, available, person-focused and proactive. Also, proper information transfer between care professionals and clear procedures when asking for certain resources or services were considered essential for good palliative care at home. Most interviewees indicated that these essential elements were generally present in the care they received. However, the requirements of 'proper information transfer between professionals' and 'clear and rapid procedures' were mentioned as more difficult to meet in actual practice. Patients and relatives also emphasized that an alert and assertive attitude on their own part was vital in ensuring they received the care they need. They expressed worries about other people who are less vigilant regarding the care they receive, or who have no family to support them in this. CONCLUSIONS: Medical proficiency, availability, a focus on the person, proper information transfer between professionals, clear procedures and proactivity on the part of GPs and community nursing staff are considered essential for good palliative care at home. Improvements are particularly warranted with regard to collaboration and information transfer between professionals, and current bureaucratic procedures. It is important for care professionals to ensure that the identified essential elements for high-quality palliative care at home are met, particularly for patients and relatives who are not so alert and assertive.

Effect of the partner's health and support on cancer patients' use of general practitioner care.

OBJECTIVE: Cancer and its treatment often have a profound impact on patients, leading to increased health care use in the years after diagnosis. Social support is an important determinant of health care use. Partners of cancer patients may not always be able to provide all support patients need and patients may then revert to professional health care. We examined whether partners' health and the support they provide affect the use of general practitioner (GP) care in cancer patients. METHODS: Cancer patients aged ≥18, diagnosed <20 years ago with a cancer type with a 5-year survival rate >20% and no distant metastases were sent a questionnaire, along with their partners. Patients' self-reported recent use of GP care, i.e. whether they had discussed health problems with the GP in the past year, was assessed. Partner support as perceived by the patient was measured on three scales: Active engagement, protective buffering and overprotection. RESULTS: We included 219 patients and partners. Many patients discussed physical and emotional problems with their GP (60% and 28% of patients, respectively). Patients were less likely to discuss physical problems when they experienced active engagement and protective buffering, the latter only for females. CONCLUSION: Partner support affects use of GP care in cancer patients. GPs should therefore pay attention to the support style of the partner. GPs could ask about the support provided by the partner and inform both patients and partners about support groups where they can share experiences.

A methodological comparison of two European primary care databases and replication in a US claims database: inhaled long-acting beta-2-agonists and the risk of acute myocardial infarction.

PURPOSE: Results from observational studies on inhaled long-acting beta-2-agonists (LABA) and acute myocardial infarction (AMI) risk are conflicting, presumably due to variation in methodology. We aimed to evaluate the impact of applying a common study protocol on consistency of results in three databases. METHODS: In the primary analysis, we included patients from two GP databases (Dutch-Mondriaan, UK-CPRD GOLD) with a diagnosis of asthma and/or COPD and at least one inhaled LABA or a "non-LABA inhaled bronchodilator medication" (short-acting beta-2-agonist or short-/long-acting muscarinic antagonist) prescription between 2002 and 2009. A claims database (USA-Clinformatics) was used for replication. LABA use was divided into current, recent (first 91 days following the end of a treatment episode), and past use (after more than 91 days following the end of a treatment episode). Adjusted hazard ratios (AMI-aHR) and 95 % confidence intervals (95 % CI) were estimated using time-dependent multivariable Cox regression models stratified by recorded diagnoses (asthma, COPD, or both asthma and COPD). RESULTS: For asthma or COPD patients, no statistically significant AMI-aHRs (age- and sex-adjusted) were found in the primary analysis. For patients with both diagnoses, a decreased AMI-aHR was found for current vs. recent LABA use in the CPRD GOLD (0.78; 95 % CI 0.68-0.90) and in Mondriaan (0.55; 95 % CI 0.28-1.08), too. The replication study yielded similar results. Adjusting for concomitant medication use and comorbidities, in addition to age and sex, had little impact on the results. CONCLUSIONS: By using a common protocol, we observed similar results in the primary analysis performed in two GP databases and in the replication study in a claims database. Regarding differences between databases, a common protocol facilitates interpreting results due to minimized methodological variations. However, results of multinational comparative observational studies might be affected by bias not fully addressed by a common protocol.

Predictors of influenza in the adult population during seasonal and A(H1N1)pdm09 pandemic influenza periods.

We aimed to assess whether the characteristics of influenza-like illness (ILI) cases in the general population were similar during the seasonal and pandemic A(H1N1)pdm09 influenza periods. We conducted a study using a general population database, which included demographic (sex, age) and clinical (underlying medical conditions, influenza vaccination status) information on more than 80 000 subjects. We assessed the most important predictors of ILI during each season by using multiple logistic regression. We descriptively compared whether they were similar during different seasons. The model, including all demographic and clinical characteristics, showed that age ⩾60 years decreased the odds for ILI by 52% and 81% during the seasonal and A(H1N1)pdm09 pandemic periods, respectively. Being vaccinated decreased the odds of ILI for seasonal influenza by 32%, while suffering from the comorbidities other than lung or cardiovascular diseases doubled the odds of ILI during the A(H1N1)pdm09 pandemic.

Citizens' perspectives on relocating healthcare.

BACKGROUND: Healthcare systems around the globe are facing challenges. There are increasing demands and costs at the same time as a diminishing health workforce. Without change, healthcare will become unsustainable. The Dutch government is searching for solutions, one of which is relocating healthcare. Relocating healthcare from expensive institutions to sites closer to patients' homes is an important part of this. This relocation is expected to reduce costs and lessen shortages of personnel. However, although citizens have an important stake in this, little is known about how they think about this topic. This research aims at investigating citizens' perspectives on relocating care. METHODS: In December 2021, three open-ended questions were sent to 1,500 members of Nivel's Dutch Healthcare Consumer Panel, 796 respondents responded. In addition, two citizen platforms were organised in March and April 2022. A total of 23 citizens participated. RESULTS: Our results indicated that the following aspects are important for citizens in healthcare delivery: being treated by someone with expertise in the area of their need, familiarity with the healthcare provider and the treatment of less complex care close to home. When certain conditions are met, citizens prefer treatment for less complex care from their general practitioner rather than in a hospital. The most important condition is that the general practitioner has the right expertise regarding their health question. The willingness to relocate care from the general practitioner to other healthcare providers or to self-care is also present. One of the problems, however, is that citizens often do not know to which healthcare provider they should go or what they should do to increase self-care. CONCLUSION: From a citizens' perspective, relocating care is an acceptable solution for keeping healthcare sustainable in the future, provided that certain conditions are met.

Economic analysis of chromosome testing in couples with recurrent miscarriage to prevent handicapped offspring.

STUDY QUESTION: Which strategy is least expensive to prevent the birth of a handicapped child in couples with recurrent miscarriage (RM); parental chromosome analysis followed by amniocentesis in case of carrier status of one of the parents, or amniocentesis in all ongoing pregnancies without the knowledge of parental carrier status? SUMMARY ANSWER: For virtually all couples with RM amniocentesis in all ongoing pregnancies without the knowledge of parental carrier status is less expensive in preventing the birth of a handicapped child than parental chromosome analysis followed by amniocentesis in case of carrier status of one of the parents. WHAT IS KNOWN ALREADY: One of the causes of RM is a balanced chromosome abnormality in one of the partners. If one of the partners is carrier of a balanced structural chromosomal abnormality, the risk of offspring with an unbalanced structural chromosome abnormality is increased. Like all couples, couples with RM also have an age-dependent risk for fetal aneuploidy, of which trisomy 21 is most common. STUDY DESIGN, SIZE, DURATION: Model-based economic analysis to compare costs and effects of two strategies in couples with RM to prevent the birth of a handicapped child in case of ongoing pregnancy. PARTICIPANTS/MATERIALS, SETTING, METHODS: Comparison of two strategies in women with RM: strategy (I) parental chromosome analysis followed by amniocentesis in pregnancy in case of carrier status of one of the parents and strategy (II) amniocentesis in all ongoing pregnancies without the knowledge of carrier status. No testing was the reference strategy. Data on probabilities and costs were derived from the literature. Incremental costs and effects were calculated [incremental cost-effectiveness ratio (ICER)]. Effectiveness was expressed as the number of prevented births of handicapped child equivalents compared with no testing. In these calculations, the birth of a handicapped child was valued 10 times worse than the loss of a viable pregnancy due to amniocentesis. MAIN RESULTS AND THE ROLE OF CHANCE: Depending on the risk for carrier status, the ICER for Strategy I (parental chromosome analysis followed by amniocentesis in case of carrier status of one of the parents) varied between € 226,000 and € 6,556,000 per prevented handicapped child equivalent. For Strategy II (amniocentesis in all ongoing pregnancies without the knowledge of carrier status), the ICER varied between € 2000 and € 233 000 per prevented handicapped child equivalent. Strategy I was less expensive than Strategy II only for a small subgroup of couples with maternal age <23 years, three or more previous miscarriages and a family history of RM. LIMITATIONS, REASONS FOR CAUTION: Our analysis is not a plea for amniocentesis in all women with RM. Individual risk assessment with serum markers and nuchal translucency is probably more effective at lower cost. WIDER IMPLICATIONS OF THE FINDINGS: This analysis can be used by clinicians to explain the chances of adverse pregnancy outcome in couples with RM, as well as by policy makers in health-care economics. Future guidelines on RM might be more restrictive from the perspective of the limited health-care resources that we have available.

Consecutive or non-consecutive recurrent miscarriage: is there any difference in carrier status?

BACKGROUND: Carrier status of a structural balanced chromosome abnormality is associated with recurrent miscarriage. There is, at present, no evidence of the impact of the sequence of preceding pregnancies on the probability of carrier status. The aim of our study was therefore to examine whether the history of consecutive versus non-consecutive miscarriages in couples with two or more miscarriages has any impact on the probability of carrying a chromosome abnormality. METHODS: A nested case-control study was performed in six centres for clinical genetics in the Netherlands. Couples referred for chromosome analysis after two or more miscarriages were included: 279 couples with a carrier of a structural chromosomal abnormality and 428 non-carrier couples who served as controls. Univariable and multivariable logistic regression analyses, corrected for known risk factors for carrier status, were performed. The main outcome measure was the probability of carrier status. RESULTS: Two hundred and fifty-six of 279 (92%) carrier couples and 381 of 428 (89%) non-carrier couples had experienced consecutive miscarriages (P = 0.21). A history of two or three consecutive miscarriages did not alter the probability of carrier status when compared with two [odds ratio (OR) 0.90, 95% confidence interval (CI) 0.48-1.7] or three (OR 0.71, 95% CI 0.39-1.3) non-consecutive miscarriages. CONCLUSIONS: The sequence of preceding pregnancies is not a risk factor for carrier status. Therefore, couples with miscarriages interspersed with healthy child(ren) should be managed the same as couples with consecutive miscarriages regarding chromosome diagnosis.

Effectiveness of melatonin treatment on circadian rhythm disturbances in dementia. Are there implications for delirium? A systematic review.

OBJECTIVE: Circadian rhythm disturbances, like sundowning, are seen in dementia. Because the circadian rhythm is regulated by the biological clock, melatonin might be effective in the treatment of these disturbances. We systematically studied the effect of melatonin treatment in patients with dementia. In addition, we elaborate on the possible effects one might expect of melatonin treatment in patients with delirium, since dementia and delirium are strongly related. Moreover, some evidence exists that sundowning in patients with dementia and the alterations in the sleep/wake cycle, seen in patients with delirium both originate from circadian rhythm disturbances. DESIGN: A systematic search of the literature, published between 1985 and April 2009, was performed using PubMed and other databases. All papers on melatonin treatment in dementia were retrieved. Effects of melatonin on circadian rhythm disturbances were scored by means of scoring sundowning/agitated behaviour, sleep quality and daytime functioning. RESULTS: Nine papers, including four randomised controlled trials (RCTs) (n = 243), and five case series (n = 87) were reviewed. Two of the RCTs found a significant improvement on sundowning/agitated behaviour. All five case series found an improvement. The results on sleep quality and daytime functioning were inconclusive. CONCLUSION: Sundowning/agitated behaviour improves with melatonin treatment in patients with dementia. There are several arguments that sundowning in patients with dementia and the alterations in the sleep/wake cycle in patients with delirium have a common background, namely a disturbance of the circadian rhythm. This suggests that melatonin treatment could also have the same positive effects in patients with delirium.

Implementation and Evaluation of a Fall Risk Screening Strategy Among Frail Older Adults for the Primary Care Setting: A Study Protocol.

BACKGROUND: Falls are an increasing problem among older people. There are several evidence-based interventions available to prevent falls. However, these are not always well implemented in the primary care setting. General practitioners (GPs) are often the first point of contact for health issues, making them the designated professionals for providing falls prevention. Because GPs are often unaware which patients have a high fall risk and patients themselves do not always know they have a high fall risk, this study aims to evaluate the implementation of a targeted fall risk screening strategy among independently living, frail older people in the primary care setting. MATERIALS AND METHODS: The targeted fall risk screening strategy used in this study consists of tools for screening high fall risk and for identifying the underlying cause(s) of the high fall risk, an accredited training course in falls prevention for professionals, and service provision by certified physio- and exercise therapists who are able to offer evidence-based falls prevention interventions. This targeted fall risk screening strategy will be implemented in the primary care setting and evaluated at the level of the GP practice and at the level of the patient by using the RE-AIM model of Glasgow et al. In a pre-posttest design, data will be collected of the total number of frail older people who are screened, referred and enrolled for fall-preventive care. Furthermore, barriers and facilitators of the implementation of the fall risk screening strategy will be identified by conducting focus groups and interviews with the care providers and frail older patients. Additionally, the influence of the falls prevention interventions on frail older patients will be evaluated by using a pre-posttest design with a 12-month follow-up period during which data are collected regarding patients' stability, mobility, strength, balance, self-efficacy, health status, and daily activities. STUDY REGISTRATION: This study is approved by the Medical Ethics Committee Brabant, the Netherlands (NL61582.028.17/ P1732) and registered at the Netherlands Trial Register, NL7917.

Patient-reported health problems and healthcare use after treatment for early-stage breast cancer.

BACKGROUND: A clear picture of treatment-related health problems following breast cancer treatment is useful in anticipating the informational and other needs of patients during follow-up. This study aimed to identify treatment-related health problems in breast cancer patients up to five years after diagnosis. Secondly, the use of care associated with these health problems was identified. METHODS: 876 surgically-treated female patients diagnosed between 2012 and 2016 with early-stage breast cancer were asked to complete an online survey about their current health problems and use of care. Multivariate logistic regression analyses were applied to determine the effect of patient and treatment characteristics on health problems. RESULTS: 404 patients responded (46%). The median age was 62.0 years (SD:10.9). Apart from breast surgery, patients had been treated with radiotherapy (72%), chemotherapy (49%), anti-hormonal therapy (57%), and axillary dissection (21%). Ninety-three percent experienced one or more health problems. Over 50% of respondents experienced fatigue, psychological problems, and health problems regarding the breast, and/or musculoskeletal, central nervous, and reproductive system. Treatment with chemotherapy was significantly associated (p < 0.05) with an increased risk of health problems, respectively fatigue (OR:2.00), respiratory (OR:1.81), gastrointestinal (OR:1.87), central nervous (OR:3.40), and skin problems (OR:2.62). Use of healthcare for one or more health problems was reported by 64% of respondents. DISCUSSION: Almost all patients experienced health problems up to five years after breast cancer diagnosis, with a range of complaints that were consistently present over time. Factors associated with the development of health problems are useful for better informing patients beforehand and targeting follow-up care.

Does adding metformin to clomifene citrate lead to higher pregnancy rates in a subset of women with polycystic ovary syndrome?

BACKGROUND: An RCT among newly diagnosed, therapy naive women with polycystic ovary syndrome (PCOS) showed no significant differences in ovulation rate, ongoing pregnancy rate or spontaneous abortion rate in favour of clomifene citrate plus metformin compared with clomifene citrate. We wanted to assess whether there are specific subgroups of women with PCOS in whom clomifene citrate plus metformin leads to higher pregnancy rates. METHODS: Subgroup analysis based on clinical and biochemical parameters of 111 women randomized to clomifene citrate plus metformin compared with 114 women randomized to clomifene citrate plus placebo. The data for age, BMI, waist-hip ratio (WHR) and plasma testosterone were available in all women, 2 h glucose in 80% of women and homeostatic model assessment for assessing insulin sensitivity (HOMA) in 50% of women. RESULTS: Of the women who were allocated to the metformin group, 44 women (40%) reached an ongoing pregnancy. In the placebo group, 52 women (46%) reached an ongoing pregnancy. There was a significantly different chance of an ongoing pregnancy for metformin versus placebo between subgroups based on age and WHR (P = 0.014). There was a positive effect of metformin versus placebo on pregnancy rate in older women (>or=28 years) with a high WHR, a negative effect of metformin versus placebo in young women (<28 years) regardless of their WHR and no effect in older, not viscerally obese women. No significant differences in effect of treatment were found for groups based on BMI, 2 h glucose, HOMA or plasma testosterone. CONCLUSIONS: Metformin may be an effective addition to clomifene citrate in infertile women with PCOS, especially in older and viscerally obese patients.

[Co-morbidity in acutely hospitalised older patients as a risk factor for death in hospital or within 3 months after discharge]. / Comorbiditeit bij acuut opgenomen oudere patiënten als risicofactor voor sterfte in het ziekenhuis of binnen 3 maanden na ontslag.

OBJECTIVE: To study the presence of co-morbidity and delirium and to determine whether these factors are predictors of hospital and shortterm mortality in elderly patients acutely admitted to a department of internal medicine. DESIGN: Prospective cohort study. METHOD: Social and demographic data as well as data on their physical and cognitive limitations were collected from consecutive patients of 65 years and older who were hospitalised in the period from I December 2002 to 30 June 2005 in the Academic Medical Centre in Amsterdam, the Netherlands. Co-morbidity and ICD diagnosis were determined on discharge from the hospital. Three months after discharge the patients' circumstances were assessed. RESULTS: A total of 461 patients, 195 men and 266 women with an average age of 78.2 years (SD: 7.8), were included. Of these patients, 132 (28.6%) had cognitive impairment and the mean number of limitations with regard to the activities of daily living (ADL) was 5.48 (10.4%) patients died in hospital and another 74 patients (16.1%) had died 3 months after discharge. The only independent predictor of hospital mortality was delirium at admission (OR: 2.28; 95% CI: 1.23-4.21). Independent risk factors for mortality within 3 months after discharge were: delirium at admission (OR: 2.20; 95% CI: 1.12-4.31), pre-admission ADL limitations (OR: 1.11; 95% CI: 1.02-1.21), a diagnosed malignancy (OR: 5.96; 95% CI: 2.45-14-52), and a higher Charlson co-morbidity index (OR: 1.19; 95% CI: 1.04-1-34). CONCLUSION: At discharge from the hospital, the risk of death within 3 months after discharge in acutely hospitalised patients of 65 years and older was determined by a combination of delirium at admission, pre-admission ADL limitations, a malignancy, and co-morbidity. These results can be used to identify elderly patients who might benefit from comprehensive geriatric assessment during hospitalisation and from a well-prepared discharge planning that takes their co-morbidity into consideration.

[Risk factors for structural chromosomal abnormality in > or = 2 miscarriages, as an instrument for selective karyotyping]. / Risicofactoren voor structurele chromosoomafwijking bij > or = 2 miskramen als instrument voor selectieve karyotypering.

OBJECTIVE: To identify additional risk factors and the corresponding probability of carrying a chromosome abnormality in couples with two or more miscarriages. DESIGN: Nested case-control study. METHOD: In 6 centres for clinical genetics in the Netherlands, data were collected from couples referred for karyotyping after 2 2 miscarriages from 1992-2000. Factors influencing the probability of carrier status were examined. The corresponding probability of carrier status was calculated for the various combinations of these factors. RESULTS: In total 279 carrier couples and 428 non-carrier couples were included. 4 independent factors influencing the probability of carrier status were identified: a younger maternal age at the time of second miscarriage, a history of > or = 3 miscarriages, a history of > 2 miscarriages in a brother or sister of either partner, and a history of> 2 miscarriages in parents of either partner. The calculated probability of carrier status in couples referred for chromosome analysis after two or more miscarriages, varied between 0.5-10.2%. In 18% of couples included, the risk was found to be so low (< 2.2%), that in couples with comparable risk factors, it may not be necessary to perform karyotyping. CONCLUSION: This study demonstrated that the probability of carrier status in couples with > or = 2 miscarriages is modified by additional factors. Selective chromosome analysis would result in a more effective referral policy and therefore decrease the number of chromosome analyses and lower the costs.

[Inter-practice variation in polypharmacy prevalence amongst older patients in primary care]. / Bij iedere huisarts evenveel pillen?

PURPOSE: Complex medication management in older people with multiple chronic conditions can introduce practice variation in polypharmacy prevalence. This study aimed to determine the inter-practice variation in polypharmacy prevalence and examine how this variation was influenced by patient and practice characteristics. METHODS: This cohort study included 45,731 patients aged 55 years and older with at least one prescribed medication from 126 general practices that participated in NIVEL Primary Care Database in the Netherlands. Medication dispensing data of the year 2012 were used to determine polypharmacy. Polypharmacy was defined as the chronic and simultaneous use of at least five different medications. Multilevel logistic regression models were constructed to quantify the polypharmacy prevalence variation between practices. Patient characteristics (age, gender, socioeconomic status, number, and type of chronic conditions) and practice characteristics (practice location and practice population) were added to the models. RESULTS: After accounting for differences in patient and practice characteristics, polypharmacy rates varied with a factor of 2.4 between practices (from 12.4% to 30.1%) and an overall mean of 19.8%. Age and type of conditions were highly positively associated with polypharmacy, and to a lesser extent a lower socioeconomic status. CONCLUSIONS: Considerable variation in polypharmacy rates existed between general practices, even after accounting for patient and practice characteristics, which suggests that there is not much agreement concerning medication management in this complex patient group. Initiatives that could reduce inappropriate heterogeneity in medication management can add value to the care delivered to these patients.

[Time trends in prevalence of chronic diseases and multimorbidity not only due to aging: data from general practices and health surveys]. / Toename in chronische ziekten en multimorbiditeit.

INTRODUCTION: Chronic diseases and multimorbidity are common and expected to rise over the coming years. The objective of this study is to examine the time trend in the prevalence of chronic diseases and multimorbidity over the period 2001 till 2011 in the Netherlands, and the extent to which this can be ascribed to the aging of the population. METHODS: Monitoring study, using two data sources: 1) medical records of patients listed in a nationally representative network of general practices over the period 2002-2011, and 2) national health interview surveys over the period 2001-2011. Regression models were used to study trends in the prevalence-rates over time, with and without standardization for age. RESULTS: An increase from 34.9% to 41.8% (p<0.01) in the prevalence of chronic diseases was observed in the general practice registration over the period 2004-2011 and from 41.0% to 46.6% (p<0.01) based on self-reported diseases over the period 2001-2011. Multimorbidity increased from 12.7% to 16.2% (p<0.01) and from 14.3% to 17.5% (p<0.01), respectively. Aging of the population explained part of these trends: about one-fifth based on general practice data, and one-third for chronic diseases and half of the trend for multimorbidity based on health surveys. CONCLUSIONS: The prevalence of chronic diseases and multimorbidity increased over the period 2001-2011. Aging of the population only explained part of the increase, implying that other factors such as health care and society-related developments are responsible for a substantial part of this rise.