Patterns of psychotropic drug prescriptions and general practice consultations among community-dwelling older people with dementia during the first two years of the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic and subsequent lockdown measures had serious implications for community-dwelling older people with dementia. While the short-term impacts of the pandemic on this population have been well studied, there is limited research on its long-term impacts. Quantifying the long-term impacts may provide insights into whether healthcare adaptations are needed after the acute phase of the pandemic to balance infection prevention measures with healthcare provision. This study aims to examine patterns of psychotropic drug prescriptions and general practice consultations in community-dwelling older people with dementia during the first two years of the pandemic. METHODS: We utilised routine electronic health records from three Dutch academic general practice research networks located in the North, East, and South, between 2019 and 2021. We (1) compared the weekly prescription rates of five groups of psychotropic drugs and two groups of tracer drugs, and weekly general practice consultation rates per 1000 participants, between the first two years of the pandemic and the pre-pandemic phase, (2) calculated changes in these rates during three lockdowns and two relaxation phases relative to the corresponding weeks in 2019, and (3) employed interrupted time series analyses for the prescription rates. Analyses were performed for each region separately. RESULTS: The study population sizes in the North, East, and South between 2019 and 2021 were 1726 to 1916, 93 to 117, and 904 to 960, respectively. Data from the East was excluded from the statistical analyses due to the limited sample size. During the first two years of the pandemic, the prescription rates of psychotropic drugs were either lower or similar to those in the pre-pandemic phase, with differences varying from -2.6‰ to -10.2‰. In contrast, consultation rates during the pandemic were higher than in the pre-pandemic phase, increasing by around 38‰. CONCLUSIONS: This study demonstrates a decrease in psychotropic drug prescriptions, but an increase in general practice consultations among community-dwelling older people with dementia during the first two years of the pandemic. However, reasons for the decrease in psychotropic drug prescriptions are unclear due to limited information on the presence of neuropsychiatric symptoms and the appropriateness of prescribing.

Quality indicators for collaborative care networks in persistent somatic symptoms and functional disorders: a modified delphi study.

BACKGROUND: Care for persistent somatic symptoms and functional disorders (PSS/FD) is often fragmented. Collaborative care networks (CCNs) may improve care quality for PSS/FD. Effectiveness likely depends on their functioning, but we lack a straightforward quality evaluation system. We therefore aimed to develop quality indicators to evaluate CCNs for PSS/FD. METHOD: Using an online three-round modified Delphi process, an expert panel provided, selected and ranked quality indicators for CCNs in PSS/FD. Recruited experts were diverse healthcare professionals with relevant experience in PSS/FD care in the Netherlands. RESULTS: The expert panel consisted of 86 professionals representing 15 disciplines, most commonly physiotherapists, psychologists and medical specialists. 58% had more than 10 years experience in PSS/FD care. Round one resulted in 994 quotations, which resulted in 46 unique quality indicators. These were prioritised in round two and ranked in round three by the panel, resulting in a final top ten. The top three indicators were: "shared vision of care for PSS/FD", "pathways tailored to the individual patient", and "sufficiently-experienced caregivers for PSS/FD". CONCLUSIONS: The identified quality indicators to evaluate CCNs in the field of PSS/FD can be implemented in clinical practice and may be useful in improving services and when assessing effectiveness.

Optimizing placebo and minimizing nocebo effects through communication: e-learning and virtual reality training development.

BACKGROUND: The effects of many treatments in healthcare are determined by factors other than the treatment itself. Patients' expectations and the relationship with their healthcare provider can significantly affect treatment outcomes and thereby play a major role in eliciting placebo and nocebo effects. We aim to develop and evaluate an innovative communication training, consisting of an e-learning and virtual reality (VR) training, for healthcare providers across all disciplines, to optimize placebo and minimize nocebo effects through healthcare provider-patient communication. The current paper describes the development, mid-term evaluation, optimization, and final evaluation of the communication training, conducted in The Netherlands. METHODS: The development of both the e-learning and the VR training consisted of four phases: 1) content and technical development, 2) mid-term evaluation by healthcare providers and placebo/communication researchers, 3) optimization of the training, and 4) final evaluation by healthcare providers. To ensure the success, applicability, authenticity, and user-friendliness of the communication training, there was ongoing structural collaboration with healthcare providers as future end users, experts in the field of placebo/communication research, and educational experts in all phases. RESULTS: Placebo/communication researchers and healthcare providers evaluated the e-learning positively (overall 7.9 on 0-10 scale) and the content was perceived as useful, accessible, and interesting. The VR training was assessed with an overall 6.9 (0-10 scale) and was evaluated as user-friendly and a safe method for practicing communication skills. Although there were some concerns regarding the authenticity of the VR training (i.e. to what extent the virtual patient reacts like a real patient), placebo and communication researchers, as well as healthcare providers, recognized the significant potential of the VR training for the future. CONCLUSIONS: We have developed an innovative and user-friendly communication training, consisting of an e-learning and VR training (2D and 3D), that can be used to teach healthcare providers how to optimize placebo effects and minimize nocebo effects through healthcare provider-patient communication. Future studies can work on improved authenticity, translate the training into other languages and cultures, expand with additional VR cases, and measure the expected effects on providers communication skills and subsequently patient outcomes.

Persistence of somatic symptoms after COVID-19 in the Netherlands: an observational cohort study.

BACKGROUND: Patients often report various symptoms after recovery from acute COVID-19. Previous studies on post-COVID-19 condition have not corrected for the prevalence and severity of these common symptoms before COVID-19 and in populations without SARS-CoV-2 infection. We aimed to analyse the nature, prevalence, and severity of long-term symptoms related to COVID-19, while correcting for symptoms present before SARS-CoV-2 infection and controlling for the symptom dynamics in the population without infection. METHODS: This study is based on data collected within Lifelines, a multidisciplinary, prospective, population-based, observational cohort study examining the health and health-related behaviours of people living in the north of the Netherlands. All Lifelines participants aged 18 years or older received invitations to digital COVID-19 questionnaires. Longitudinal dynamics of 23 somatic symptoms surrounding COVID-19 diagnoses (due to SARS-CoV-2 alpha [B.1.1.7] variant or previous variants) were assessed using 24 repeated measurements between March 31, 2020, and Aug 2, 2021. Participants with COVID-19 (a positive SARS-CoV-2 test or a physician's diagnosis of COVID-19) were matched by age, sex, and time to COVID-19-negative controls. We recorded symptom severity before and after COVID-19 in participants with COVID-19 and compared that with matched controls. FINDINGS: 76 422 participants (mean age 53·7 years [SD 12·9], 46 329 [60·8%] were female) completed a total of 883 973 questionnaires. Of these, 4231 (5·5%) participants had COVID-19 and were matched to 8462 controls. Persistent symptoms in COVID-19-positive participants at 90-150 days after COVID-19 compared with before COVID-19 and compared with matched controls included chest pain, difficulties with breathing, pain when breathing, painful muscles, ageusia or anosmia, tingling extremities, lump in throat, feeling hot and cold alternately, heavy arms or legs, and general tiredness. In 12·7% of patients, these symptoms could be attributed to COVID-19, as 381 (21·4%) of 1782 COVID-19-positive participants versus 361 (8·7%) of 4130 COVID-19-negative controls had at least one of these core symptoms substantially increased to at least moderate severity at 90-150 days after COVID-19 diagnosis or matched timepoint. INTERPRETATION: To our knowledge, this is the first study to report the nature and prevalence of post-COVID-19 condition, while correcting for individual symptoms present before COVID-19 and the symptom dynamics in the population without SARS-CoV-2 infection during the pandemic. Further research that distinguishes potential mechanisms driving post-COVID-19-related symptomatology is required. FUNDING: ZonMw; Dutch Ministry of Health, Welfare, and Sport; Dutch Ministry of Economic Affairs; University Medical Center Groningen, University of Groningen; Provinces of Drenthe, Friesland, and Groningen.

Improving the Reporting of Primary Care Research: Consensus Reporting Items for Studies in Primary Care-the CRISP Statement.

Primary care (PC) is a unique clinical specialty and research discipline with its own perspectives and methods. Research in this field uses varied research methods and study designs to investigate myriad topics. The diversity of PC presents challenges for reporting, and despite the proliferation of reporting guidelines, none focuses specifically on the needs of PC. The Consensus Reporting Items for Studies in Primary Care (CRISP) Checklist guides reporting of PC research to include the information needed by the diverse PC community, including practitioners, patients, and communities. CRISP complements current guidelines to enhance the reporting, dissemination, and application of PC research findings and results. Prior CRISP studies documented opportunities to improve research reporting in this field. Our surveys of the international, interdisciplinary, and interprofessional PC community identified essential items to include in PC research reports. A 2-round Delphi study identified a consensus list of items considered necessary. The CRISP Checklist contains 24 items that describe the research team, patients, study participants, health conditions, clinical encounters, care teams, interventions, study measures, settings of care, and implementation of findings/results in PC. Not every item applies to every study design or topic. The CRISP guidelines inform the design and reporting of (1) studies done by PC researchers, (2) studies done by other investigators in PC populations and settings, and (3) studies intended for application in PC practice. Improved reporting of the context of the clinical services and the process of research is critical to interpreting study findings/results and applying them to diverse populations and varied settings in PC.Annals "Online First" article.

Primary Care Research: Looking Back and Moving Forward With Reflections on NAPCRG's First 50 Years.

NAPCRG celebrated 50 years of leadership and service at its 2022 meeting. A varied team of primary care investigators, clinicians, learners, patients, and community members reflected on the organization's past, present, and future. Started in 1972 by a small group of general practice researchers in the United States, Canada, and the United Kingdom, NAPCRG has evolved into an international, interprofessional, interdisciplinary, and intergenerational group devoted to improving health and health care through primary care research. NAPCRG provides a nurturing home to researchers and teams working in partnership with individuals, families, and communities. The organization builds upon enduring values to create partnerships, advance research methods, and nurture a community of contributors. NAPCRG has made foundational contributions, including identifying the need for primary care research to inform primary care practice, practice-based research networks, qualitative and mixed-methods research, community-based participatory research, patient safety, practice transformation, and partnerships with patients and communities. Landmark documents have helped define classification systems for primary care, responsible research with communities, the central role of primary care in health care systems, opportunities to revitalize generalist practice, and shared strategies to build the future of family medicine. The future of health and health care depends upon strengthening primary care and primary care research with stronger support, infrastructure, training, and workforce. New technologies offer opportunities to advance research, enhance care, and improve outcomes. Stronger partnerships can empower primary care research with patients and communities and increase commitments to diversity and quality care for all. NAPCRG offers a home for all partners in this work.

Sex and gender differences in primary care help-seeking for common somatic symptoms: a longitudinal study.

OBJECTIVE: Women are reported to consult general practitioners (GPs) more frequently than men. However, previous studies on sex differences in help-seeking behavior for somatic symptoms do not distinguish between sex and gender, do not account for sex differences in presented symptoms, and are frequently conducted in clinical settings, automatically excluding non-help seekers. Therefore, we aim to assess the independent associations of sex and gender with primary care help-seeking for somatic symptoms in the general population. DESIGN AND SETTING: Records from the longitudinal population-based Lifelines Cohort Study were linked to routine electronic health records from GPs. SUBJECTS: Participants reporting new-onset common somatic symptoms. MAIN OUTCOME MEASURES: Associations between sex and gender, operationalized via a novel gender-index, with primary care help-seeking for somatic symptoms and differences in the strength of the association between gender and help-seeking for somatic symptoms between women and men. RESULTS: Of 20,187 individuals with linked data, 8325 participants (67.5% female; mean age = 44.5 years [SD = 12.9]) reported at least one new-onset somatic symptom. Hereof, 255 (3.1%) consulted the GP within 6 weeks of symptom onset. Female sex was positively associated with consulting the GP (OR = 1.78; 95%CI = 1.13-2.80), whereas feminine gender was not (OR = 0.67; 95%CI = 0.39-1.16). The latter association did not differ in strength between men and women. More paid working days are negatively associated with help-seeking (OR = 0.95; 95%CI = 0.91-0.98). CONCLUSIONS: The results suggest that female sex rather than feminine gender is associated with primary care help-seeking behavior for somatic symptoms. Nevertheless, clinicians should be aware that gender-related variables, such as mean paid working days, may be associated with help-seeking behavior.

Mind your words: Oncologists' communication that potentially harms patients with advanced cancer: A survey on patient perspectives.

BACKGROUND: Many complaints in medicine and in advanced illnesses are about communication. Little is known about which specific communications harm. This study explored the perspectives of patients with advanced cancer about potentially harmful communication behaviors by oncologists and helpful alternatives. METHODS: An online survey design was used that was based on literature scoping and patient/clinician/researcher input. Patients with advanced cancer (n = 74) reflected on the potential harmfulness of 19 communication situations. They were asked whether they perceived the situation as one in which communication could be harmful (yes/no). If they answered "yes," they were asked whether they perceived the examples as harmful (yes/no) or helpful (yes/no) and to provide open comments. Results were analyzed quantitatively and qualitatively (content analysis). RESULTS: Communication regarding information provision, prognosis discussion, decision-making, and empathy could be unnecessarily potentially harmful, and this occurred in various ways, such as making vague promises instead of concrete ones (92%), being too directive in decision-making (qualitative), and not listening to the patient (88%). Not all patients considered other situations potentially harmful (eg, introducing the option of refraining from anticancer therapy [49%] and giving too much [prognostic] information [60%]). Exploring each individual patients' needs/preferences seemed to be a precondition for helpful communication. CONCLUSIONS: This article provides patient perspectives on oncologists' unnecessarily potentially harmful communication behaviors and offers practical tools to improve communication in advanced cancer care. Both preventable pitfalls and delicate challenges requiring an individualized approach, where exploration might help, are described. Although providing difficult and unwelcome news is a core task for clinicians, this study might help them to do so while preventing potentially unnecessary harm.

Female sex and femininity independently associate with common somatic symptom trajectories.

BACKGROUND: Multiple predictors have been associated with persistent somatic symptoms. However, previous studies problematically defined the persistence of symptoms, conflated participants' sex and gender, and focused on patient populations. Therefore, we studied associations between predictors, especially sex and gender, and longitudinal patterns of somatic symptoms in the general adult population. We also assessed whether predictors for persisting symptoms differ between sexes. METHOD: To identify developmental trajectories of somatic symptoms, assessed by the SCL-90 SOM, we used latent class trajectory modeling in the Dutch Lifelines Cohort Study [N = 150 494; 58.6% female; median time to follow-up: 46.0 (min-max: 22.0-123.0) months]. To identify predictors of trajectories, we applied multiple logistic regression analyses. Predictors were measured by surveys at baseline and a composite gender index was previously developed. RESULTS: A five-class linear LCGA model fitted the data best: 93.7% of the population had a stable symptom trajectory, whereas 1.5% and 4.8% of the population had a consistently increasing or decreasing symptom trajectory, respectively. Female sex predicted severe, stable symptom severity (OR 1.74, 95% CI 1.36-2.22), but not increasing symptom severity (OR 1.15, 95% CI 0.99-1.40). Femininity was protective hereof (OR 0.60, 95% CI 0.44-0.82 and OR 0.66, 95% CI 0.51-0.85, respectively). Merely a few predictors of symptom severity, for instance hours of paid employment and physical functioning, differed in strength between sexes. Yet, effect sizes were small. CONCLUSION: Female sex and femininity predict symptom trajectories. No large sex differences in the strength of additional predictors were found, thus it may not be clinically useful to distinguish between predictors specific to male or female patients of persistent somatic symptoms.

Physicians' and Patients' Interruptions in Clinical Practice: A Quantitative Analysis.

PURPOSE: Physicians' interruptions have long been considered intrusive, masculine actions that inhibit patient participation, but a systematic analysis of interruptions in clinical interaction is lacking. This study aimed to examine when and how primary care physicians and patients interrupt each other during consultations. METHODS: We coded and quantitatively analyzed interruption type (cooperative vs intrusive) in 84 natural interactions between 17 primary care physicians and 84 patients with common somatic symptoms. Data were analyzed using a mixed-effects logistic regression model, with role, gender, and consultation phase as predictors. RESULTS: Of the 2,405 interruptions observed, 82.9% were cooperative. Among physicians, men were more likely to make an intrusive interruption than women (ß = 0.43; SE, 0.21; odds ratio [OR] = 1.54; 95% CI, 1.03-2.31), whereas among patients, men were less likely to make an intrusive interruption than women (ß = -0.35; SE, 0.17; OR = 0.70; 95% CI, 0.50-0.98). Patients' interruptions were more likely to be intrusive than physicians' interruptions in the phase of problem presentation (ß = 0.71; SE, 0.23; OR = 2.03; 95% CI, 1.30-3.20), but not in the phase of diagnosis and/or treatment plan discussion (ß = -0.17; SE, 0.15; OR = 0.85; 95% CI, 0.63-1.15). CONCLUSIONS: Most interruptions in clinical interaction are cooperative and may enhance the interaction. The nature of physicians' and patients' interruptions is the result of an interplay between role, gender, and consultation phase.

Post-acute and long-COVID-19 symptoms in patients with mild diseases: a systematic review.

BACKGROUND: It is expected that GPs are increasingly confronted with a large group of patients with symptoms persisting three weeks after initial symptoms of a mild (managed in the outpatient setting) COVID-19 infection. Currently, research on these persistent symptoms mainly focuses on patients with severe infections (managed in an inpatient setting) whereas patients with mild disease are rarely studied. OBJECTIVE: The main objective of this systematic review was to create an overview of the nature and frequency of persistent symptoms experienced by patients after mild COVID-19 infection. METHODS: Systematic literature searches were performed in Pubmed, Embase and PsychINFO on 2 February 2021. Quantitative studies, qualitative studies, clinical lessons and case reports were considered eligible designs. RESULTS: In total, nine articles were included in this literature review. The frequency of persistent symptoms in patients after mild COVID-19 infection ranged between 10% and 35%. Symptoms persisting after a mild COVID-19 infection can be distinguished into physical, mental and social symptoms. Fatigue was the most frequently described persistent symptom. Other frequently occurring persistent symptoms were dyspnoea, cough, chest pain, headache, decreased mental and cognitive status and olfactory dysfunction. In addition, it was found that persisting symptoms after a mild COVID-19 infection can have major consequences for work and daily functioning. CONCLUSION: There is already some evidence that symptoms of mild COVID-19 persist after 3 weeks in a third of patients. However, there is a lack of data about symptoms persisting after 3 months (long-COVID). More research is needed to help GPs in managing long-COVID.

How to learn skilled communication in primary care MUS consultations: a focus group study.

BACKGROUND: Many general practitioners (GPs) experience communication problems in medically unexplained symptoms (MUS) consultations as they are insufficiently equipped with adequate communication skills or do not apply these in MUS consultations. OBJECTIVE: To define the most important learnable communication elements during MUS consultations according to MUS patients, GPs, MUS experts and teachers and to explore how these elements should be taught to GPs and GP trainees. METHODS: Five focus groups were conducted with homogeneous groups of MUS patients, GPs, MUS experts and teachers. MUS patients and GPs formulated a list of important communication elements. MUS experts identified from this list the most important communication elements. Teachers explored how these elements could be trained to GPs and GP trainees. Two researchers independently analysed the data applying the principles of constant comparative analysis. RESULTS: MUS patients and GPs identified a list of important communication elements. From this list, MUS experts selected five important communication elements: (1) thorough somatic and psychosocial exploration, (2) communication with empathy, (3) creating a shared understanding of the problem, (4) providing a tangible explanation and (5) taking control. Teachers described three teaching methods for these communication elements: (1) awareness and reflection of GPs about their feelings towards MUS patients, (2) assessment of GPs' individual needs and (3) training and supervision in daily practice. CONCLUSION: Teachers consider a focus on personal attitudes and needs, which should be guided by opportunities to practice and receive supervision, as the best method to teach GPs about communication in MUS consultations.KEY POINTSMany GPs experience difficulties in communication with patients with MUS.There is a need to equip GPs with communication skills to manage MUS consultations more adequately.Role-playing with simulation patients, reflection on video-consultations and joint consultations with the supervisor may increase the GPs' awareness of their attitude towards MUS patients and may help GPs to identify their individual learning-points.

Sex differences in incidence of respiratory symptoms and management by general practitioners.

BACKGROUND: Differences between women and men play an important role in lung physiology and epidemiology of respiratory diseases, but also in the health care processes. OBJECTIVE: To analyse sex differences in patients encountering their general practitioner (GP) with respiratory symptoms with regard to incidence, GP's management and final diagnoses. METHODS: Retrospective cohort study, using data of the Dutch Practice Based Research Network. All patients who encountered their GP from 01-07-2013 until 30-06-2018 with a new episode of care starting with a reason for encounter in the respiratory category (R) of the ICPC-2 classification were included (n = 16 773). Multi-level logistic regression was used to analyse influence of patients' sex on management of GPs with adjustment for possible confounders. RESULTS: We found a significant higher incidence of respiratory symptoms in women than in men: 230/1000 patient years [95% confidence interval (CI) 227-232] and 186/1000 patient years (95% CI 183-189), respectively. When presenting with cough, GPs are more likely to perform physical examination [odds ratio (OR) 1.22; 95% CI 1.11-1.35] and diagnostic radiology (OR 1.25; 95% CI 1.08-1.44), but less likely to prescribe medication (OR 0.88; 95% CI 0.82-0.95) in men. When visiting the GP with dyspnoea, men more often undergo diagnostic imaging (OR 1.32; 95% CI 1.05-1.66) and are more often referred to a specialist (OR 1.35; 95% CI 1.13-1.62). CONCLUSIONS: Women encounter their GP more frequently with respiratory symptoms than men and GPs perform more diagnostic investigations in men. We suggest more research in general practice focussing on sex differences and possible confounders.

Explanations for medically unexplained symptoms: a qualitative study on GPs in daily practice consultations.

BACKGROUND: General practice is the centre of care for patients with medically unexplained symptoms (MUS). Providing explanations for MUS, i.e. making sense of symptoms, is considered to be an important part of care for MUS patients. However, little is known how general practitioners (GPs) do this in daily practice. OBJECTIVE: This study aimed to explore how GPs explain MUS to their patients during daily general practice consultations. METHODS: A thematic content analysis was performed of how GPs explained MUS to their patients based on 39 general practice consultations involving patients with MUS. RESULTS: GP provided explanations in nearly all consultations with MUS patients. Seven categories of explanation components emerged from the data: defining symptoms, stating causality, mentioning contributing factors, describing mechanisms, excluding explanations, discussing the severity of symptoms and normalizing symptoms. No pattern of how GPs constructed explanations with the various categories was observed. In general, explanations were communicated as a possibility and in a patient-specific way; however, they were not very detailed. CONCLUSION: Although explanations for MUS are provided in most MUS consultations, there seems room for improving the explanations given in these consultations. Further studies on the effectiveness of explanations and on the interaction between patients and GP in constructing these explanations are required in order to make MUS explanations more suitable in daily primary care practice.

"Constructing a health assessment questionnaire for people with intellectual disabilities: A cognitive interview study".

INTRODUCTION: Health assessment instruments can help to raise awareness among general practitioners of specific health problems in people with intellectual disabilities (PID). The present authors developed a health assessment questionnaire using the cognitive interview technique (CI) to improve the comprehensibility. The utility of this approach to questionnaire development involving PID is assessed. METHOD: A qualitative approach using the CI was employed. The study included PID and their caregivers. The present authors interviewed 14 participants in 5 subsequent rounds. After each round, the questionnaire was adjusted until saturation was reached. RESULTS: Three hundred and sixty three identified problems led to 316 changes to the questionnaire. Most problems (102) concerned the comprehension of the question, followed by problems in the "missing answer categories" and "inaccurate instruction" section. CONCLUSION: The comprehensible health assessment questionnaire can help PID to take an active role in communication with their GP. The use of CI helped to improve the questionnaire. CI is a usable and valuable procedure for PID.

Cognitive-behavioural and social factors do not predict recurrent secondary healthcare use in patients with fibromyalgia: a longitudinal study.

OBJECTIVES: Healthcare use in fibromyalgia (FM) is relatively high. Besides disease-related variables, cognitive-behavioural factors have been concurrently associated with healthcare use. It is unknown whether cognitive-behavioural and social factors also predict future healthcare use. The aim of this study was to identify cognitive-behavioural and social factors predicting recurrent secondary healthcare use in FM. METHODS: Using self-reported questionnaires, healthcare use, cognitive-behavioural, social, sociodemographic and disease-related variables including comorbidities were collected in 199 patients with FM, in a prospective longitudinal cohort spanning 18 months. Patients were recruited after receiving their diagnosis and protocolled treatment advice by a rheumatologist. Univariate and multivariate logistic regression models examined whether and which variables were predictors for recurrent secondary healthcare use. Internal validation was performed to correct for over-fit of the final multivariate model. RESULTS: Recurrent secondary healthcare use was lower than initial secondary healthcare use. Univariate analysis showed that having at least one comorbidity, depressive feelings, severe consequences of FM, low personal control and a high severity of fibromyalgia predicted recurrent secondary healthcare use. In the multivariate model, having at least one comorbidity was the only remaining predictor for recurrent secondary healthcare use. CONCLUSIONS: Our results suggest that the existence of comorbidities as communicated by the patient is the strongest warning signal for recurrent secondary healthcare use in FM. There seems no value in using cognitive-behavioural and social factors for early identification of patients with FM at risk for recurrent secondary healthcare use.

Shared decision-making in general practice: an observational study comparing 2007 with 2015.

BACKGROUND: Shared decision-making (SDM) is, largely, espoused as the preferred model for making decisions in everyday health care. Studies exploring the application of SDM in primary care practice are still lacking. OBJECTIVES: This study explores how GPs involve their patients in decision-making, if application of SDM has increased over time (2007-15), and what factors are associated with it. METHODS: We investigated the application of SDM by Dutch GPs by analysing a random set of real-life video-recorded consultations collected in 2007 (n = 50) and 2015 (n = 50). SDM was assessed by observing patient involvement in decision making (OPTION), a reliable and valid instrument measuring the extent to which clinicians involve patients in decision-making by coding 12 behavioural items. In addition, GPs and patients completed questionnaires about their background characteristics. The potential determinants for application of SDM by Dutch GPs (including year of measurement, sex and age of patients and GPs, the nature of complaints, consultation duration and the type of decision discussed) were analysed using multilevel analysis [with patients (Level 1) nested within GPs (Level 2)]. RESULTS: In 2015, GPs applied SDM more often compared with 2007 according to OPTION. In consultations with older patients, there is less application of SDM by GPs. CONCLUSIONS: Although application of SDM by Dutch GPs has increased, low overall SDM scores still leave room for improvement. GPs should elicit the patient's preferred role in the decision-making process at any time, in particular in consultations with older patients.

The association between patients' expectations and experiences of task-, affect- and therapy-oriented communication and their anxiety in medically unexplained symptoms consultations.

BACKGROUND: It is unknown whether patients with medically unexplained symptoms (MUS) differ from patients with medically explained symptoms (MES) regarding their expectations and experiences on task-oriented communication (ie, communication in which the primary focus is on exchanging medical content), affect-oriented communication (ie, communication in which the primary focus is on the emotional aspects of the interaction) and therapy-oriented communication (ie, communication in which the primary focus is on therapeutic aspects) of the consultation and the extent to which GPs meet their expectations. OBJECTIVE: This study aims to explore (a) differences in patients' expectations and experiences in consultations with MUS patients and patients with MES and (b) the influence of patients' experiences in these consultations on their post-visit anxiety level. STUDY DESIGN: Prospective cohort. SETTING: Eleven Dutch general practices. MEASUREMENTS: Patients completed the QUOTE-COMM (Quality Of communication Through the patients' Eyes) questionnaire before and after the consultation to assess their expectations and experiences and these were related to changes in patients' state anxiety (abbreviated State-Trait Anxiety Inventory; STAI). RESULTS: Expectations did not differ between patients with MUS and MES. Patients presenting with either MUS or MES rated their experiences for task-related and affect-oriented communication of their GP higher than their expectations. GPs met patients' expectations less often on task-oriented communication in MUS patients compared to MES patients (70.2% vs 80.9%; P = Ë‚0.001). Affect-oriented communication seems to be most important in reducing the anxiety level of MUS patients (ß -0.63, 95% Cl = -1.07 to -0.19). DISCUSSION: Although the expectations of MUS patients are less often met compared to those of MES patients, GPs often communicate according to patients' expectations. Experiencing affect-oriented communication is associated with a stronger reduction in anxiety in patients with MUS than in those with MES. CONCLUSION: GPs communicate according to patients' expectations. However, GPs met patients' expectations on task-oriented communication less often in patients with MUS compared to patients with MES. Experiencing affect-oriented communication had a stronger association with the post-consultation anxiety for patients with MUS than MES.

Which difficulties do GPs experience in consultations with patients with unexplained symptoms: a qualitative study.

BACKGROUND: Many general practitioners (GPs) struggle with the communication with patients with medically unexplained symptoms (MUS). This study aims to identify GPs' difficulties in communication during MUS consultations. METHODS: We video-recorded consultations and asked GPs immediately after the consultation whether MUS were presented. GPs and patients were then asked to reflect separately on the consultation in a semi-structured interview while watching the consultation. We selected the comments where GPs experienced difficulties or indicated they should have done something else and analysed these qualitatively according to the principles of constant comparative analysis. Next, we selected those video-recorded transcripts in which the patient also experienced difficulties; we analysed these to identify problems in the physician-patient communication. RESULTS: Twenty GPs participated, of whom two did not identify any MUS consultations. Eighteen GPs commented on 39 MUS consultations. In 11 consultations, GPs did not experience any difficulties. In the remaining 28 consultations, GPs provided 84 comments on 60 fragments where they experienced difficulties. We identified three issues for improvement in the GPs' communication: psychosocial exploration, structure of the consultation (more attention to summaries, shared agenda setting) and person-centredness (more attention to the reason for the appointment, the patient's story, the quality of the contact and sharing decisions). Analysis of the patients' views on the fragments where the GP experienced difficulties showed that in the majority of these fragments (n = 42) the patients' comments were positive. The video-recorded transcripts (n = 9) where the patient experienced problems too were characterised by the absence of a dialogue (the GP being engaged in exploring his/her own concepts, asking closed questions and interrupting the patient). CONCLUSION: GPs were aware of the importance of good communication. According to them, they could improve their communication further by paying more attention to psychosocial exploration, the structure of the consultation and communicating in a more person-centred way. The transcripts where the patient experienced problems too, were characterised by an absence of dialogue (focussing on his/her own concept, asking closed questions and frequently interrupting the patient).

Development of a health assessment instrument for people with intellectual disabilities: a Delphi study.

Background: People with intellectual disabilities (IDs) experience health inequalities. Applying health assessments is one way of diminishing these inequalities. A health assessment instrument can support general practitioners (GPs) in providing better medical care to people with ID. Objectives: The aim of this study was to determine which items should be part of a health assessment instrument for people with ID to be used in primary care. Methods: This Delphi consensus study was conducted among 24 GP experts and 21 ID physicians. We performed three anonymous sequential online questionnaire rounds. We started with 82 'general' items and 14 items concerning physical and additional examinations derived from the international literature and a focus group study among Dutch GPs. We definitely included items if more than 75% of the GP experts agreed on their inclusion. Results: The participation rate in all rounds was above 88%. The expert groups proposed 10 new items. Consensus was reached on 64 'general' items related to highly prevalent diseases, public health and health promotion. Consensus was also reached on 18 physical and additional examination items. Conclusions: For the first time, experts in a Delphi study were able to arrive at a selection of items for a health assessment instrument for people with ID. The overall agreement among the GPs and ID physicians was good. Because the experts prefer that patients complete the health assessment questionnaire at home, questions that cover these items must be formulated clearly.