The focus on life-prolonging anticancer treatment hampers shared decision-making in people with advanced cancer: A qualitative embedded multiple-case study.

BACKGROUND: Implementing shared decision-making in oncology practice is often limited, particularly integrating the patient's context into decision-making. To improve this, we conducted a quality improvement project, CONtext. CONtext attempts to accomplish this by: (1) Integrating the patient's context into shared decision-making during consultation with the medical oncologist; (2) Actively involving the GP and case manager (a specialized oncology nurse), who often have knowledge about the patient's context, and; (3) Giving the person with advanced cancer a time-out period of up to 2 weeks to consider and discuss treatment options with others, including close family and friends. AIM: To explore how persons with advanced cancer and their involved professionals experienced shared decision-making after the introduction of CONtext. DESIGN: A qualitative embedded multiple-case study using in-depth interviews analysed with inductive content analysis. PARTICIPANTS: A purposive sample of 14 cases, each case consisting of a patient with advanced cancer and ideally their medical oncologist, case manager, and GP. RESULTS: Four themes were identified: shared decision-making is a dynamic and continuous process (1), in which the medical oncologist's treatment recommendation is central (2), fuelled by the patients' experience of not having a choice (3), and integrating the patient's context into shared decision-making was considered important but hampered (4), for example, by the association with the terminal phase. CONCLUSIONS: The prevailing tendency among medical oncologists and persons with advanced cancer to prioritize life-prolonging anticancer treatments restricts the potential for shared decision-making. This undermines integrating individual context into decision-making, a critical aspect of the palliative care continuum.

Documentation of shared decision-making in diagnostic testing for dementia in Dutch general practice: A retrospective study in electronic patient records.

OBJECTIVE: To explore (1) documentation of shared decision-making (SDM) in diagnostic testing for dementia in electronic patient records (EPR) in general practice and (2) study whether documentation of SDM is related to specific patient characteristics. METHODS: In this retrospective observational study, EPRs of 228 patients in three Dutch general practices were explored for the documentation of SDM elements using Elwyn's model (team talk, option talk, decision talk). Patient characteristics (gender, age, comorbidities, chronic polypharmacy, the number of consultations on memory complaints) and decision outcome (wait-and-see, GP diagnostics, referral) were also extracted. RESULTS: In EPRs of most patients (62.6 %), at least one SDM element was documented. Most often this concerned team talk (61.6 %). Considerably less often option talk (4.3 %) and decision talk (12.8 %) were documented. SDM elements were more frequently documented in patients with lower comorbidity scores and patients with a relatively high number of consultations. Decision talk was more frequently documented in referred patients. CONCLUSION: Patients' and significant others' needs, goals, and wishes on diagnostic testing for dementia are often documented in EPRs. PRACTICE IMPLICATIONS: Limited documentation of option and decision talk stresses the need for future SDM interventions to facilitate timely dementia diagnosis.

Improving personal continuity in general practice: a focus group study.

Background Personal continuity is an important dimension of continuity of care in general practice and is associated with many benefits including a higher quality of GP care and lower mortality rate. Over time, changes in society and healthcare have challenged the provision of personal continuity. Especially older patients experience more negative consequences from receiving discontinuous care. Aim To explore perspectives of general practitioners (GPs), older patients, practice nurses, and assistants on improving personal continuity in general practice, and to identify barriers and facilitators that affect this improvement process. Design and setting A Qualitative study using focus groups was conducted from May to August 2019. Method We organised four focus groups: two with GPs (n=17), one with patients (n=7), and one with practice assistants (n=4) and nurses (n=2). Focus groups were analysed using reflexive thematic analysis. Results Personal continuity was viewed as being provided by the entire general practice team and not just by the own GP. To improve personal continuity, it was suggested to invest in team communication and stability (e.g., by efficient use of the EHR) and retaining availability and accessibility of the own GP (e.g., by delegating tasks). Barriers and facilitators were perceived on individual (e.g., GPs' involvement in tasks), organisation (e.g., staff shortages) and societal level (e.g., payment system). Conclusion As general practice moves towards a more team-based approach to ensure personal continuity, efforts to improve personal continuity should focus on supporting team-based provision of continuous care.

Which patients are at risk of developing symptom diagnoses that persist for more than a year in primary care? Development and external validation of a prediction model.

OBJECTIVES: To train, test and externally validate a prediction model that supports General Practitioners (GPs) in early identification of patients at risk of developing symptom diagnoses that persist for more than a year. METHODS: We retrospectively collected and selected all patients having episodes of symptom diagnoses during the period 2008 and 2021 from the Family Medicine Network (FaMe-Net) database. From this group, we identified symptom diagnoses that last for less than a year and symptom diagnoses that persist for more than a year. Multivariable logistic regression analysis using a backward selection was used to assess which factors were most predictive for developing symptom diagnoses that persist for more than a year. Performance of the model was assessed using calibration and discrimination (AUC) measures. External validation was tested using data between 2018 and 2022 from AHON-registry, a primary care electronic health records data registry including 73 general practices from the north and east regions of the Netherlands and about 460,795 patients. RESULTS: From the included 47,870 patients with a symptom diagnosis in the FaMe-Net registry, 12,481 (26.1%) had a symptom diagnosis that persisted for more than a year. Older age (≥ 75 years: OR = 1.30, 95% CI [1.19, 1.42]), having more previous symptom diagnoses (≥ 3: 1.11, [1.05, 1.17]) and more contacts with the GP over the last 2 years (≥ 10 contacts: 5.32, [4.80, 5.89]) were predictive of symptom diagnoses that persist for more than a year with a marginally acceptable discrimination (AUC 0.70, 95% CI [0.69-0.70]). The external validation showed poor performance with an AUC of 0.64 ([0.63-0.64]). CONCLUSION: A clinical prediction model based on age, number of previous symptom diagnoses and contacts might help the GP to early identify patients developing symptom diagnoses that persist for more than a year. However, the performance of the original model is limited. Hence, the model is not yet ready for a large-scale implementation.

Optimising personal continuity for older patients in general practice: a cluster randomised stepped wedge pragmatic trial.

AIM: To evaluate the effectiveness, feasibility and acceptability of a multicomponent intervention for improving personal continuity for older patients in general practice. DESIGN: A cluster randomised three-wedged, pragmatic trial during 18 months. SETTING: 32 general practices in the Netherlands. PARTICIPANTS: 221 general practitioners (GPs), practice assistants and other practice staff were included. Practices were instructed to include a random sample of 1050 patients aged 65 or older at baseline and 12-month follow-up. INTERVENTION: The intervention took place at practice level and included opTimise persOnal cOntinuity for oLder (TOOL)-kit: a toolbox containing 34 strategies to improve personal continuity. OUTCOMES: Data were collected at baseline and at six 3-monthly follow-up measurements. Primary outcome measure was experienced continuity of care at the patient level measured by the Nijmegen Continuity Questionnaire (NCQ) with subscales for personal continuity (GP knows me and GP shows commitment) and team/cross-boundary continuity at 12-month follow-up. Secondary outcomes were measured in GPs, practice assistants and other practice staff and included work stress and satisfaction and perceived level of personal continuity. In addition, a process evaluation was undertaken among GPs, practice assistants and other practice staff to assess the acceptability and feasibility of the intervention. RESULTS: No significant effect of the intervention was observed on NCQ subscales GP knows me (adjusted mean difference: 0.05 (95% CI -0.05 to 0.15), p=0.383), GP shows commitment (0.03 (95% CI -0.08 to 0.14), p=0.668) and team/cross-boundary (0.01 (95% CI -0.06 to 0.08), p=0.911). All secondary outcomes did not change significantly during follow-up. Process evaluation among GPs, practice assistants and other practice staff showed adequate acceptability of the intervention and partial implementation due to the COVID-19 pandemic and a high perceived workload. CONCLUSION: Although participants viewed TOOL-kit as a practical and accessible toolbox, it did not improve personal continuity as measured with the NCQ. The absence of an effect may be explained by the incomplete implementation of TOOL-kit into practice and the choice of general outcome measures instead of outcomes more specific for the intervention. TRIAL REGISTRATION NUMBER: International Clinical Trials registry Platform (ICTRP), trial NL8132 (URL: ICTRP Search Portal (who.int).

Model-Informed Precision Dosing Using Machine Learning for Levothyroxine in General Practice: Development, Validation and Clinical Simulation Trial.

Levothyroxine is one of the most prescribed drugs in the western world. Dosing is challenging due to high-interindividual differences in effective dosage and the narrow therapeutic window. Model-informed precision dosing (MIPD) using machine learning could assist general practitioners (GPs), but no such models exist for primary care. Furthermore, introduction of decision-support algorithms in healthcare is limited due to the substantial gap between developers and clinicians' perspectives. We report the development, validation, and a clinical simulation trial of the first MIPD application for primary care. Stable maintenance dosage of levothyroxine was the model target. The multiclass model generates predictions for individual patients, for different dosing classes. Random forest was trained and tested on a national primary care database (n = 19,004) with a final weighted AUC across dosing options of 0.71, even in subclinical hypothyroidism. TSH, fT4, weight, and age were most predictive. To assess the safety, feasibility, and clinical impact of MIPD for levothyroxine, we performed clinical simulation studies in GPs and compared MIPD to traditional prescription. Fifty-one GPs selected starting dosages for 20 primary hypothyroidism cases without and then with MIPD 2 weeks later. Overdosage and underdosage were defined as higher and lower than 12.5 µg relative to stable maintenance dosage. MIPD decreased overdosage in number (30.5 to 23.9%, P < 0.01) and magnitude (median 50 to 37.5 µg, P < 0.01) and increased optimal starting dosages (18.3 to 30.2%, P < 0.01). GPs considered lab results more often with MIPD and most would use the model frequently. This study demonstrates the clinical relevance, safety, and effectiveness of MIPD for levothyroxine in primary care.

Towards reducing diagnostic delay in endometriosis in primary care: a qualitative study.

BACKGROUND: Due to a heterogeneity of symptoms, a lack of an adequate diagnostic test, and a lack of awareness, diagnostic delay in endometriosis in primary care on average amounts to 35 months. AIM: To determine which interventions are most feasible to reduce time to diagnosis in primary care, focusing on GPs' preferences, the intervention's content, design, and implementation. DESIGN & SETTING: We conducted a qualitative study by performing focus groups with GPs and GP trainees between July and October 2021. METHOD: Data collection was continued until saturation was obtained. Focus groups were transcribed and openly encoded. Themes were formulated by three independent researchers. RESULTS: Divided over five focus groups 22 GPs and 13 GP trainees participated. Three themes were formulated: increasing awareness, combined intervention, and reaching unaware GPs. Suggestions for a combined intervention strategy were adaptation of guidelines, a diagnostic support tool, and compulsory education. To reach unaware GPs, participants felt that education should be offered in regional networks and education for GP trainees should be mandatory. A guideline on menstrual symptoms should be considered and the term endometriosis should be added to the differential diagnosis paragraphs of existing guidelines. A diagnostic support tool should be linked to a guideline and consist of a flowchart with steps starting with the first presentation of symptoms leading to the diagnosis of endometriosis. CONCLUSION: According to GPs, a combined intervention strategy consisting of an adapted guideline, a diagnostic support tool, and education might be successful interventions in reducing diagnostic delay in endometriosis.

Are specialist-provided end-of-life scenarios key to initiation of advance care planning in primary care? A mixed-methods study.

OBJECTIVES: Specialist-provided end-of-life scenarios (SP-EOLS) may improve advance care planning (ACP) implementation in primary care by helping overcome barriers such as uncertain prognosis and poor interprofessional collaboration. We aimed to explore the current use and potential impact of SP-EOLS on ACP in Dutch primary care. METHODS: We performed a mixed-methods study. From patients discussed in a hospital-based academic palliative care multidisciplinary team meeting between 2016 and 2019 and died, we collected primary care electronic medical records data on SP-EOLS, actual EOLS, and ACP initiation and applied descriptive and comparative analyses. Subsequently, we interviewed general practitioners (GPs) and thematically analyzed the transcripts. RESULTS: In 69.7% of 66 reviewed patient files, SP-EOLS were found. In patients whose GP had received SP-EOLS, ACP conversations were more often reported (92.0 vs. 61.0%, p = 0.006). From 11 GP interviews, we identified 4 themes: (1) SP-EOLS guide GPs, patients, and relatives when dealing with an uncertain future perspective; (2) SP-EOLS provide continuity of care between primary and secondary/tertiary care; (3) SP-EOLS should be tailored to the individual patient; and (4) SP-EOLS need to be personalized and uniformly transferred to GPs. SIGNIFICANCE OF RESULTS: SP-EOLS may facilitate ACP conversations by GPs. They have the potential to help overcome existing barriers to ACP implementation by providing guidance and supporting interprofessional collaboration. Future research should focus on improving SP-EOLS and tailor them to the needs of all end users, focusing on improving their effect on ACP conversations.

Trends in low-value GP care during the COVID-19 pandemic: a retrospective cohort study.

BACKGROUND: Several studies showed that during the pandemic patients have refrained from visiting their general practitioner (GP). This resulted in medical care being delayed, postponed or completely forgone. The provision of low-value care, i.e. care which offers no net benefit for the patient, also could have been affected. We therefore assessed the impact of the COVID-19 restrictions on three types of low-value GP care: 1) imaging for back or knee problems, 2) antibiotics for otitis media acuta (OMA), and 3) repeated opioid prescriptions, without a prior GP visit. METHODS: We performed a retrospective cohort study using registration data from GPs part of an academic GP network over the period 2017-2022. The COVID-19 period was defined as the period between April 2020 to December 2021. The periods before (January 2017 to April 2020) and after the COVID-19 period (January 2022 to December 2022) are the pre- and post-restrictions periods. The three clinical practices examined were selected by two practicing GPs from a top 30 of recommendations originating from the Dutch GP guidelines, based on their perceived prevalence and relevance in practice (van Dulmen et al., BMC Primary Care 23:141, 2022). Multilevel Poisson regression models were built to examine changes in the incidence rates (IR) of both registered episodes and episodes receiving low-value treatment. RESULTS: During the COVID-19 restrictions period, the IRs of episodes of all three types of GP care decreased significantly. The IR of episodes of back or knee pain decreased by 12%, OMA episodes by 54% and opioid prescription rate by 13%. Only the IR of OMA episodes remained significantly lower (22%) during the post-restrictions period. The provision of low-value care also changed. The IR of imaging for back or knee pain and low-value prescription of antibiotics for OMA both decreased significantly during the COVID-restrictions period (by 21% and 78%), but only the low-value prescription rate of antibiotics for OMA remained significantly lower (by 63%) during the post-restrictions period. The IR of inappropriately repeated opioid prescriptions remained unchanged over all three periods. CONCLUSIONS: This study shows that both the rate of episodes as well as the rate at which low-value care was provided have generally been affected by the COVID-19 restrictions. Furthermore, it shows that the magnitude of the impact of the restrictions varies depending on the type of low-value care. This indicates that deimplementation of low-value care requires tailored (multiple) interventions and may not be achieved through a single disruption or intervention alone.

The burden of persistent symptom diagnoses in primary care patients: a cross-sectional study.

INTRODUCTION: The burden of symptoms is a subjective experience of distress. Little is known on the burden of feeling unwell in patients with persistent symptom diagnoses. The aim of this study was to assess the burden in primary care patients with persistent symptom diagnoses compared to other primary care patients. METHODS: A cross-sectional study was performed in which an online survey was sent to random samples of 889 patients with persistent symptom diagnoses (>1 year) and 443 other primary care patients after a transactional identification in a Dutch primary care data registry. Validated questionnaires were used to assess the severity of symptoms (PHQ-15), Symptom Intensity and Symptom Interference questionnaires, depression (PHQ-9), anxiety (GAD-7), quality of life (SF-12 and EQ-5D-5L)) and social functioning (SPF-ILs). RESULTS: Overall, 243 patients completed the survey: 178 (73.3%) patients in the persistent symptom diagnoses group and 65 (26.7%) patients in the control group. In the persistent group, 65 (36.5%) patients did not have persistent symptom(s) anymore according to the survey response. Patients who still had persistent symptom diagnoses (n = 113, 63.5%) reported significantly more severe somatic symptoms (mean difference = 3.6, [95% CI: 0.24, 4.41]), depression (mean difference = 3.0 [95% CI: 1.24, 3.61]) and anxiety (mean difference = 2.3 [95% CI: 0.28, 3.10]) and significantly lower physical functioning (mean difference = - 6.8 [95% CI: -8.96, -3.92]). CONCLUSION: Patients with persistent symptom diagnoses suffer from high levels of symptoms burden. The burden in patient with persistent symptoms should not be underestimated as awareness of this burden may enhance person-centered care.

Exploring diagnostic strategies for memory complaints in older adults: A retrospective general practice database study.

OBJECTIVES: For older people who worry about their memory, their general practitioner (GP) is often the first healthcare professional they turn to. This study aims to increase knowledge of GPs' daily practice on diagnostic strategies for patients who present themselves with memory complaints and/or worries about dementia for the first time in general practice and to explore associations of patients' characteristics with these strategies. METHOD: Retrospective observational study using electronic patient records from patients presenting with memory complaints between 2012 and 2019. The patient records are derived from a Dutch primary care registration network. The decision on diagnostic strategy was extracted and categorized as (1) wait and see, (2) diagnostic testing in primary care, or (3) referral. Patient characteristics (gender, age, general practice, level of comorbidities, chronic polypharmacy, and the number of consultations on memory complaints), fear of developing dementia, and information on why the first consultation on memory complaints was scheduled were extracted. RESULTS: A total of 228 patients were included. Most patients were cared for within primary care, either for further primary care diagnostics (56.1%) or because a wait-and-see strategy was pursued (14.9%). One-third (28.9%) of patients were referred. Differences between diagnostic strategies in patient characteristics, fear of developing dementia, or reason for first consultation between these diagnostic strategies were not found, nor were these variables predictive of referral. CONCLUSION: Most Dutch patients with memory complaints and/or worries about dementia who seek help from their GP for the first time are cared for in the primary care setting for the following 6 months. The lack of association between included patient characteristics and diagnostic strategies highlights the complexity of the decision-making process on diagnostic testing for dementia in general practice.

Needs and challenges among general practitioners in the management of actinic keratosis: a qualitative study.

BACKGROUND: Because of the increasing incidence of actinic keratosis (AK), optimal use of limited healthcare resources is essential. Although most patients can be managed in primary care, dermatology referrals are common. More profound knowledge of general practitioners' (GPs) considerations might assist in enhancing AK care. METHODS: The aim of the current study was to gain insight into AK management in primary care by exploring the needs and challenges among GPs in the Netherlands. A qualitative study was conducted based on semi-structured in-depth interviews with 15 conveniently sampled Dutch GPs, focusing on the needs and challenges in AK management. A literature-informed, predefined topic list guided the interviews, which were recorded, transcribed ad verbatim, and thematically analysed using the Framework Method. RESULTS: All GPs reported AK to be a clinical diagnosis and most GPs indicated that most AK patients could be managed in primary care. Cryotherapy was preferred and experience with 5-FU therapy was limited. Most GPs applied cryotherapy without discussing other treatment options with patients. Reasons for dermatology referrals included an incomplete treatment response, extensive lesions, difficult-to-treat areas, and serious doubts about the diagnosis. GPs reported a need for more education, especially on 5-FU therapy. Their main challenges were dealing with diagnostic uncertainty, treating extensive lesions, managing treatment-related skin reactions, and reconciling patient misconceptions. CONCLUSIONS: This study shows various AK management approaches among Dutch GPs with suboptimal guideline compliance due to diverse underlying barriers. It suggests that more education might contribute to a more standardised and uniform AK management and supports further transition of AK care from hospital to primary care.

Home-based initiatives for acute management of COVID-19 patients needing oxygen: differences across The Netherlands.

OBJECTIVE: During the COVID-19 pandemic new collaborative-care initiatives were developed for treating and monitoring COVID-19 patients with oxygen at home. Aim was to provide a structured overview focused on differences and similarities of initiatives of acute home-based management in the Netherlands. METHODS: Initiatives were eligible for evaluation if (i) COVID-19 patients received oxygen treatment at home; (ii) patients received structured remote monitoring; (iii) it was not an 'early hospital discharge' program; (iv) at least one patient was included. Protocols were screened, and additional information was obtained from involved physicians. Design choices were categorised into: eligible patient group, organization medical care, remote monitoring, nursing care, and devices used. RESULTS: Nine initiatives were screened for eligibility; five were included. Three initiatives included low-risk patients and two were designed specifically for frail patients. Emergency department (ED) visit for an initial diagnostic work-up and evaluation was mandatory in three initiatives before starting home management. Medical responsibility was either assigned to the general practitioner or hospital specialist, most often pulmonologist or internist. Pulse-oximetry was used in all initiatives, with additional monitoring of heart rate and respiratory rate in three initiatives. Remote monitoring staff's qualification and authority varied, and organization and logistics were covered by persons with various backgrounds. All initiatives offered remote monitoring via an application, two also offered a paper diary option. CONCLUSIONS: We observed differences in the organization of interprofessional collaboration for acute home management of hypoxemic COVID-19 patients. All initiatives used pulse-oximetry and an app for remote monitoring. Our overview may be of help to healthcare providers and organizations to set up and implement similar acute home management initiatives for critical episodes of COVID-19 (or other acute disorders) that would otherwise require hospital care.

Diagnosing knee osteoarthritis in patients, differences between general practitioners and orthopedic surgeons: a retrospective cohort study.

BACKGROUND: knee complaints are one of the most common reasons to consult the general practitioners in the Netherlands and contribute to the increasing burden on general practitioners. A proportion of patients that are referred to orthopedic outpatient clinics are potentially referred unnecessarily. We believe osteoarthritis is not always considered by general practitioners as the cause of atraumatic knee complaints. This may impede early recognition and timely care of osteoarthritis complaints and lead to unnecessary referrals. METHODS: the aim of this study was to compare the frequency of (differential) diagnosis of osteoarthritis mentioned in referral letters of general practitioners with the frequency of osteoarthritis mentioned as orthopedic diagnosis at the outpatient clinic. Therefore we conducted a retrospective cohort study based on data collected from referral letters and the corresponding outpatient clinic reports of patients with atraumatic knee complaints of 45 years or older referred to a regional hospital in Nijmegen, The Netherlands in the period from 1-6-2019 until 1-01-2020. RESULTS: a total of 292 referral letters were included. In the younger aged patients (45-54 years) osteoarthritis was mentioned less frequent and meniscal lesions were mentioned more frequent in referral letters when compared to diagnoses made at the outpatient clinic. Differences in differential diagnosis of osteoarthritis as well as meniscal lesions between orthopedic surgeon and general practitioners were found (both p < 0.001, McNemar). Matching diagnoses were present in 58.2% when all referral letters were analyzed (n = 292) and 75.2% when only referrals containing a differential diagnosis were analyzed (n = 226). Matching diagnoses were present in 31.6% in the younger age categories (45-54 years). A linear trend showing fewer matching diagnoses in younger patient categories was observed (p < 0.001). CONCLUSIONS: Osteoarthritis was less frequently mentioned in general practitioner referral letters among the differential diagnosis then it was diagnosed at the outpatient clinic, especially in younger patients (45-54 years). Also matching diagnoses in younger patients were evidently lower than in older patients, partly explained by underdiagnosing of osteoarthritis in younger patients in this cohort. Better recognition of osteoarthritis in younger patients and changing the diagnostic approach of general practitioners might improve efficacy in knee care. Future research should focus on the effectiveness of musculoskeletal triage, the need for multidisciplinary educational programs for patients and promotion of conservative treatment modalities among general practitioners.

Personal Continuity and Appropriate Prescribing in Primary Care.

PURPOSE: Personal continuity between patient and physician is a core value of primary care. Although previous studies suggest that personal continuity is associated with fewer potentially inappropriate prescriptions, evidence on continuity and prescribing in primary care is scarce. We aimed to determine the association between personal continuity and potentially inappropriate prescriptions, which encompasses potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs), by family physicians among older patients. METHODS: We conducted an observational cohort study using routine care data from patients enlisted in 48 Dutch family practices from 2013 to 2018. All 25,854 patients aged 65 years and older having at least 5 contacts with their practice in 6 years were included. We calculated personal continuity using 3 established measures: the usual provider of care measure, the Bice-Boxerman Index, and the Herfindahl Index. We used the Screening Tool of Older Person's Prescriptions (STOPP) and the Screening Tool to Alert doctors to Right Treatment (START) specific to the Netherlands version 2 criteria to calculate the prevalence of potentially inappropriate prescriptions. To assess associations, we conducted multilevel negative binomial regression analyses, with and without adjustment for number of chronic conditions, age, and sex. RESULTS: The patients' mean (SD) values for the usual provider of care measure, the Bice-Boxerman Continuity of Care Index, and the Herfindahl Index were 0.70 (0.19), 0.55 (0.24), and 0.59 (0.22), respectively. In our population, 72.2% and 74.3% of patients had at least 1 PIM and PPO, respectively; 30.9% and 34.2% had at least 3 PIMs and PPOs, respectively. All 3 measures of personal continuity were positively and significantly associated with fewer potentially inappropriate prescriptions. CONCLUSIONS: A higher level of personal continuity is associated with more appropriate prescribing. Increasing personal continuity may improve the quality of prescriptions and reduce harmful consequences.

Patients with Clinically Suspected Gallstone Disease: A More Selective Ultrasound May Improve Treatment Related Outcomes.

This study aimed to quantify the confirmation of gallstones on ultrasound (US) in patients with suspicion of gallstone disease. To aid general practitioners (GPs) in diagnostic workup, a model to predict gallstones was developed. A prospective cohort study was conducted in two Dutch general hospitals. Patients (≥18 years) were eligible for inclusion when referred by GPs for US with suspicion of gallstones. The primary outcome was the confirmation of gallstones on US. A multivariable regression model was developed to predict the presence of gallstones. In total, 177 patients were referred with a clinical suspicion of gallstones. Gallstones were found in 64 of 177 patients (36.2%). Patients with gallstones reported higher pain scores (VAS 8.0 vs. 6.0, p < 0.001), less frequent pain (21.9% vs. 54.9%, p < 0.001), and more often met criteria for biliary colic (62.5% vs. 44.2%, p = 0.023). Predictors for the presence of gallstones were a higher pain score, frequency of pain less than weekly, biliary colic, and an absence of heartburn. The model showed good discrimination between patients with and without gallstones (C-statistic 0.73, range: 0.68-0.76). Clinical diagnosis of symptomatic gallstone disease is challenging. The model developed in this study may aid in the selection of patients for referral and improve treatment related outcomes.

Patients' Characteristics and General Practitioners' Management of Patients with Symptom Diagnoses.

INTRODUCTION: Symptom diagnoses are diagnoses used in primary care when the relevant diagnostic criteria of a disease are not fulfilled. Although symptom diagnoses often get resolved spontaneously without a clearly defined illness nor treatment, up to 38% of these symptoms persist more than 1 year. It is largely unknown how often symptom diagnoses occur, which symptoms persist, and how general practitioners (GPs) manage them. AIM: Explore morbidity rates, characteristics and management of patients with nonpersistent (≤1 year) and persistent (>1 year) symptom diagnoses. METHODS: A retrospective cohort study was performed in a Dutch practice-based research network including 28,590 registered patients. We selected symptom diagnosis episodes with at least 1 contact in 2018. We performed descriptive statistics, Student's T and χ2 tests to summarize and compare patients' characteristics and GP management strategies in the nonpersistent and persistent groups. RESULTS: The incidence rate of symptom diagnoses was 767 episodes per 1000 patient-years. The prevalence rate was 485 patients per 1000 patient-years. Out of the patients who had a contact with their GPs, 58% had at least 1 symptom diagnosis, from which 16% were persistent (>1 year). In the persistent group, we found significantly more females (64% vs 57%), older patients (mean: 49 vs 36 years of age), patients with more comorbidities (71% vs 49%), psychological (17% vs 12%) and social (8% vs 5%) problems. Prescriptions (62% vs 23%) and referral (62.7% vs 30.6%) rates were significantly higher in persistent symptom episodes. CONCLUSION: Symptom diagnoses are highly prevalent (58%) of which a considerable part (16%) persists more than a year.

Beliefs of rheumatologists and general practitioners on urate lowering therapy: a cross-sectional study.

Objective: To describe beliefs of physicians and patients in primary and secondary care about urate-lowering therapy (ULT), to examine differences in physicians' medication beliefs and to examine the association of physicians' medication beliefs with the prescribed dosage of ULT, gout outcomes and patients' medication beliefs. Methods: We conducted a cross-sectional study among rheumatologists and general practitioners (GPs) and their patients using ULT in The Netherlands. All participants filled out the Beliefs About Medication Questionnaire (BMQ). Demographics of physicians were collected through questionnaires. Patient and disease characteristics were collected through questionnaires and electronic medical records. Differences between rheumatologists and GPs in the BMQ subscales Necessity and Concern and the necessity-concern difference (NCD) score were analysed by two-sample t-tests. Multilevel analyses were performed to examine the association of physicians' BMQ scores with the prescribed dosage of ULT, gout outcomes (number of gout flares, serum urate) and patients' BMQ scores. Results: A total of 28 rheumatologists, 443 rheumatology patients, 45 GPs and 294 GP patients were included. The mean NCD scores were 7.1 (s.d. 3.6), 4.0 (s.d. 4.0), and 4.2 (s.d. 5.0) for rheumatologists, GPs and patients, respectively. Rheumatologists scored higher on necessity beliefs [mean difference 1.4 (95% CI 0.0, 2.8)] and lower on concern beliefs [mean difference -1.7 (95% CI -2.7, -0.7)] compared with GPs. No associations between physicians' beliefs and prescribed dosage of ULT, gout outcomes or patients' beliefs were found. Conclusion: Rheumatologists had higher necessity and lower ULT concern beliefs compared with GPs and patients. Physicians' beliefs were not related to prescribed ULT dosage and patient outcomes. The role of physicians' beliefs in gout management in patients using ULT seems limited. Future qualitative research can provide more insights into physicians' views of gout management.

Prognostic factors for persistent fatigue after COVID-19: a prospective matched cohort study in primary care.

BACKGROUND: Persistent fatigue after COVID-19 is common; however, the exact incidence and prognostic factors differ between studies. Evidence suggests that age, female sex, high body mass index, and comorbidities are risk factors for long COVID. AIM: To investigate the prevalence of persistent fatigue after COVID-19 in patients with a mild infection (managed in primary care) during the first wave of the pandemic and to determine prognostic factors for persistent fatigue. DESIGN AND SETTING: This was a prospective cohort study in Dutch general practice, combining online questionnaires with data from electronic health records. METHOD: Patients who contacted their GP between March and May 2020 and were diagnosed with COVID-19 during the first wave of the pandemic were included. Patients were matched to controls without COVID-19 based on age, sex, and GP practice. Fatigue was measured at 3, 6, and 15 months, using the Checklist of Individual Strength. RESULTS: All the participants were GP attendees and included 179 with suspected COVID-19, but who had mild COVID and who had not been admitted to hospital with COVID, and 122 without suspected COVID-19. Persistent fatigue was present in 35% (49/142) of the suspected COVID-19 group and 13% (14/109) of the non-COVID-19 group (odds ratio 3.65; 95% confidence interval = 1.82 to 7.32). Prognostic factors for persistent fatigue included low education level, absence of a partner, high neuroticism (using the Eysenck Personality Questionnaire Revised-Short Form), low resilience, high frequency of GP contact, medication use, and threatening experiences in the past. The latter three factors appeared to be prognostic factors for persistent fatigue specifically after COVID-19 infection. CONCLUSION: GP patients with COVID-19 (who were not admitted to hospital with COVID) have a fourfold higher chance of developing persistent fatigue than GP patients who had not had COVID-19. This risk is even higher in psychosocially vulnerable patients who had COVID-19.

Optimising personal continuity: a survey of GPs' and older patients' views.

BACKGROUND: Personal continuity - having a GP who knows their patients and keeps track of them - is an important dimension of continuity of care and is associated with lower mortality rates, higher quality of life, and reduced healthcare costs. In recent decades it has become more challenging for GPs to provide personal continuity owing to changes in society and health care. AIM: To investigate GPs' and older patients' views on personal continuity and how personal continuity can be improved. DESIGN & SETTING: Cross sectional survey study in The Netherlands. METHOD: A digital and postal survey was sent to 499 GPs and 1599 patients aged 65 years or older. Results were analysed using descriptive statistics for quantitative data and thematic analysis for open questions. RESULTS: In total, 249 GPs and 582 patients completed the surveys. A large majority of GPs (92-99%) and patients (91-98%) felt it was important for patients to see their own GP for life events or psychosocial issues. GPs and patients provided suggestions on how personal continuity can be improved. The thematic analysis of these suggestions identified nine themes: 1) personal connection, 2) GP accessibility and availability, 3) communication about (dis)continuity, 4) GP responsibility, 5) triage, 6) time for the patient, 7) actions by third parties, 8) team continuity, and 9) GP vocational training. CONCLUSION: Both GPs and older patients still place high value on personal continuity in the context of a changing society. GPs and patients provided a wide range of suggestions for improving personal continuity. The authors will use these suggestions to develop interventions for optimising personal continuity in general practice.