Preventing acute kidney injury in high-risk patients by temporarily discontinuing medication - an observational study in general practice.

BACKGROUND: Elderly, patients with chronic kidney disease (CKD) and patients with heart failure who continue using renin-angiotensin-aldosterone-system (RAAS) inhibitors, diuretics, or non-steroidal-anti-inflammatory drugs (NSAIDs) during times of fluid loss have a high risk of developing complications like acute kidney injury (AKI). The aim of this study was to assess how often advice to discontinue high-risk medication was offered to high-risk patients consulting the general practitioner (GP) with increased fluid loss. Furthermore, we assessed the number and nature of the complications that occurred after GP consultation. METHODS: We performed a cross-sectional study with patients from seven Dutch general practices participating in the Family Medicine Network between 1 and 6-2013 and 1-7-2018. We included patients who used RAAS-inhibitors, diuretics, or NSAIDs, and had at least one of the following risk factors: age ≥ 70 years, CKD, or heart failure. From this population, we selected patients with a 'dehydration-risk' episode (vomiting, diarrhoea, fever, chills, or gastrointestinal infection). We manually checked their electronic patient files and assessed the percentage of episodes in which advice to discontinue the high-risk medication was offered and whether a complication occurred in 3 months after the 'dehydration-risk' episode. RESULTS: We included 3607 high-risk patients from a total of 44.675 patients (8.1%). We found that patients were advised to discontinue the high-risk medication in 38 (4.6%) of 816 'dehydration-risk' episodes. In 59 of 816 episodes (7.1%) complications (mainly AKI) occurred. CONCLUSIONS: Dutch GPs do not frequently advise high-risk patients to discontinue high-risk medication during 'dehydration-risk' episodes. Complications occur frequently. Timely discontinuation of high-risk medication needs attention.

Diagnostic Accuracy of Skin Cancer by Family Physicians.

BACKGROUND: Skin cancer is the most common type of cancer worldwide. Family physicians (FPs) need to differentiate between nonmalignant and malignant skin conditions, but the diagnostic accuracy of FPs has never been studied in primary care. AIM: To assess the accuracy of skin cancer diagnoses by FPs. Our secondary aim was to analyze the number of patients with premalignant lesions and examine the diversity of skin-related questions in Dutch primary care. METHOD: This study is a retrospective cohort of all new skin-related health questions between January 1, 2018, and July 1, 2018, in a Dutch primary care registration network with data from 26 FPs in 6 practices, with a follow-up of at least 1 year. The initial FP diagnosis was dichotomized as malignant or nonmalignant and compared in a crosstab to the final diagnosis registered after the follow-up period (reference standard). RESULTS: Our study population included 2952 patients. During the research period, 35 patients received a final diagnosis of skin cancer. The sensitivity and specificity of the FP diagnosis of malignancy was 74.3% (95% confidence interval [CI], 56.7% to 87.5%) and 97.3% (95% CI, 96.7% to 97.8%), the positive predictive value and negative predictive value was 21.5% (95% CI, 17.2% to 26.5%) and 99.7% (95% CI, 99.5% to 99.8%), respectively. Seventy-two patients were diagnosed with a premalignant lesion. Included patients received 141 different diagnoses. CONCLUSION: The calculated diagnostic accuracy of FPs is high and shows that FPs are especially accurate in excluding malignancy. This research shows the variety of skin problems in primary care and shows that the FP can deliver safe and effective dermatologic care.

Urine cultures and antibiotics for urinary tract infections in Dutch general practice.

BACKGROUND: Urinary tract infections (UTIs) are common in general practice, and antibiotic resistance is often seen. Urine cultures are advised by the Dutch national UTI guideline for patients at high risk of UTI complications. Prudent use of antibiotics and taking into account national guidelines and urine culture results are important to combat antibiotic resistance in general practice. AIM: To identify subgroups of UTI patients in which the use of urine cultures and antibiotic prescriptions deviates from the national guidelines. METHODS: We investigated associations of several characteristics with urine culture orders in patients with UTI in 2015 from seven Dutch general practices (n=1295). These included subgroups at risk for UTI complications, comorbidities, age and history of UTI recurrence. In addition, we assessed the level of adherence to the guideline for antibiotic prescriptions in subgroups at risks for UTI complications. FINDINGS: Urine cultures were ordered in 17% (n=221) of patients, more frequently in high-risk patients (32%) than in low-risk patients (7%), for UTI complications (OR=6.4; 95% CI 4.6-9.0). In low-risk patients, 91% received antibiotics that were recommended in the guideline. For high-risk patients this percentage ranged widely, and was particularly low in the risk groups with signs of tissue invasion (29-50%). Diagnostic and therapeutic adequacy can still be improved by increasing the adherence to the guideline in UTI patients at high risk for complications. This may contribute to containing antibiotic resistance in UTI by ordering urine cultures and use the results to adjust prescriptions to antibiotic susceptibility of the uropathogen.