Characteristics and preventability of medication-related admissions for acute kidney injury and dehydration in elderly patients.

PURPOSE: Patients with impaired renal function using medication that affects glomerular filtration rate are at increased risk of developing acute kidney injury (AKI) leading to hospital admissions. The risk increases during periods of dehydration due to diarrhoea, vomiting or fever (so-called "sick days"), or high environmental temperatures (heat wave). This study aims to gain insight into the characteristics and preventability of medication-related admissions for AKI and dehydration in elderly patients. METHODS: Retrospective case series study in patients aged ≥ 65 years with admission for acute kidney injury, dehydration or electrolyte imbalance related to dehydration that was defined as medication-related. General practitioner's (GP) patient records including medication history and hospital discharge letters were available. For each admission, patient and admission characteristics were collected to review the patient journey. A case-by-case assessment of preventability of hospital admissions was performed. RESULTS: In total, 75 admissions were included. Most prevalent comorbidities were hypertension, diabetes, and known impaired renal function. Diuretics and RAS-inhibitors were the most prevalent medication combination. Eighty percent of patients experienced non-acute onset of symptoms and 60% had contacted their GP within 2 weeks prior to admission. Around 40% (n = 29) of admissions were considered potentially preventable if pharmacotherapy had been timely and adequately adjusted. CONCLUSION: A substantial proportion of patients admitted with AKI or dehydration experience non-acute onset of symptoms and had contacted their GP within 2 weeks prior to admission. Timely adjusting of medication in these patients could have potentially prevented a considerable number of admissions.

Pharmacists' current and potential prescribing roles in primary care in the Netherlands: a case study.

In some countries, pharmacists have obtained prescribing rights to improve quality and accessibility of care and reduce physician workload. This case study explored pharmacists' current roles in and potential for prescribing in primary care in the Netherlands, where prescribing rights for pharmacists do not exist. Participatory observations of pharmacists working in either general practice or community pharmacy were conducted, as were semi-structured interviews about current and potential practice. The latter were extended to patients and other healthcare professionals, mainly general practitioners, resulting in 34 interviews in total. Thematic analyses revealed that pharmacists, in all cases, wrote prescriptions that were then authorized by a physician before dispensing. General practice-based pharmacists often prescribed medications during patient consultations. Community pharmacists mainly influenced prescribing through (a) medication reviews where the physician and/or practice nurse often were consulted to make treatment decisions, and (b) collaborative agreements with physicians to start or substitute medications in specific situations. These findings imply that the pharmacists' current roles in prescribing in the Netherlands resemble collaborative prescribing practices in other countries. We also identified several issues that should be addressed before formally introducing pharmacist prescribing, such as definitions of tasks and responsibilities and prescribing-specific training for pharmacists.

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.

How Do Care Transitions Work?: Unraveling the Working Mechanisms of Care Transition Interventions.

BACKGROUND: Failure of safe care transitions after hospital discharge results in unnecessary worsening of symptoms, extended period of illness or readmission to the hospital. OBJECTIVE: The objective of this study was to add to the understanding of the working of care transition interventions between hospital and home through unraveling the contextual elements and mechanisms that may have played a role in the success of these interventions, and by developing a conceptual model of how these components relate to each other. RESEARCH DESIGN: This was a qualitative study using in-person, semi-structured interviews, based on realist evaluation methods. SUBJECTS: A total of 26 researchers, designers, administrators, and/or practitioners of both current "leading" care transitions interventions and of less successful care transition intervention studies or practices. MEASURES: The contextual elements and working mechanisms of the different care transition intervention studies or practices. RESULTS: Three main contextual factors (internal environment, external environment, and patient population) and 7 working mechanisms (simplifiying, verifiying, connecting, translating, coaching, monitoring, and anticipating) were found to be relevant to the outcome of care transition interventions. Context, Intervention, Mechanism, and Outcome (CIMO) configurations revealed that, in response to these contextual factors, care transition interventions triggered one or several of the mechanisms, in turn generating outcomes, including a safer care transition. CONCLUSION: We developed a conceptual model which explains the working of care transition interventions within different contexts, and believe it can help support future successful implementation of care transition interventions.

Supervisors' pedagogies for supporting interns to learn intra- and interprofessional collaboration: a qualitative and quantitative ego network analysis.

This work aims to understand intra- and interprofessional networks of general practitioners (GPs) and ear, nose, and throat specialists (ENT specialists), and in what manner supervisors in these specialties involve interns in their professional network to help them learn intra- and interprofessional collaboration. An egocentric social network approach was used to collect and analyze quantitative as well as qualitative data. For this, semi-structured interviews were held with ten GP and ten ENT specialists. GPs had significantly more interprofessional contacts than ENT specialists (p < .01), with no significant difference in the network sizes of both professions (p = .37). All supervisors involved interns in their (ego)network actively as well as more passively. They actively discussed how collaboration with other professionals evolved, or passively assumed that an intern would learn from observing the supervisors' network interactions. Many supervisors considered the interns' initiative essential in deciding to involve an intern in their network. Although the workplace of GPs differed notably from hospital settings where ENT specialists work, the network sizes of both were comparable. Clerkships at the general practice seemed to provide more opportunities to learn interprofessional collaboration, for example with the medical nurse. Supervisors in both specialties could involve interns more actively in their intra- and interprofessional network while interns could take more initiative to learn collaboration from their supervisors' network.

Non-dispensing pharmacists' actions and solutions of drug therapy problems among elderly polypharmacy patients in primary care.

OBJECTIVE: To evaluate the process of clinical medication review for elderly patients with polypharmacy performed by non-dispensing pharmacists embedded in general practice. The aim was to identify the number and type of drug therapy problems and to assess how and to what extent drug therapy problems were actually solved. METHOD: An observational cross-sectional study, conducted in nine general practices in the Netherlands between June 2014 and June 2015. On three pre-set dates, the non-dispensing pharmacists completed an online data form about the last 10 patients who completed all stages of clinical medication review. Outcomes were the type and number of drug therapy problems, the extent to which recommendations were implemented and the percentage of drug therapy problems that were eventually solved. Interventions were divided as either preventive (aimed at following prophylactic guidelines) or corrective (aimed at active patient problems). RESULTS: In total, 1292 drug therapy problems were identified among 270 patients, with a median of 5 (interquartile range 3) drug therapy problems per patient, mainly related to overtreatment (24%) and undertreatment (21%). The non-dispensing pharmacists most frequently recommended to stop medication (32%). Overall, 83% of the proposed recommendations were implemented; 57% were preventive, and 35% were corrective interventions (8% could not be assessed). Almost two-third (64%) of the corrective interventions actually solved the drug therapy problem. CONCLUSION: Non-dispensing pharmacists integrated in general practice identified a large number of drug therapy problems and successfully implemented a proportionally high number of recommendations that solved the majority of drug therapy problems.

In-hospital prescription changes and documentation in the medical records of the primary care provider: results from a medical record review study.

BACKGROUND: An increasing number of transitions due to substitution of care of more complex patients urges insight in and improvement of transitional medication safety. While lack of documentation of prescription changes and/or lack of information exchange between settings likely cause adverse drug events, frequency of occurrence of these causes is not clear. Therefore, we aimed at determining the frequency of in-hospital patients' prescription changes that are not or incorrectly documented in their primary care provider's (PCP) medical record. METHODS: A medical record review study was performed in a database linking patients' medical records of hospital and PCP. A random sample (n = 600) was drawn from all 1399 patients who were registered at a participating primary care practice as well as the gastroenterology or cardiology department in 2013 of the University Medical Center Utrecht, the Netherlands. Outcomes were the number of in-hospital prescription changes that was not or incorrectly documented in the medical record of the PCP, and timeliness of documentation. RESULTS: Records of 390 patients included one or more primary-secondary care transitions; in total we identified 1511 transitions. During these transitions, 408 in-hospital prescription changes were made, of which 31% was not or incorrectly documented in the medical record of the PCP within the next 3 months. In case changes were documented, the median number of days between hospital visit and documentation was 3 (IQR 0­18). CONCLUSIONS: One third of in-hospital prescription changes was not or incorrectly documented in the PCP's record, which likely puts patients at risk of adverse drug events after hospital visits. Such flawed reliability of a routine care process is unacceptable and warrants improvement and close monitoring.

Design of the POINT study: Pharmacotherapy Optimisation through Integration of a Non-dispensing pharmacist in a primary care Team (POINT).

BACKGROUND: In the Netherlands, 5.6 % of acute hospital admissions are medication-related. Almost half of these admissions are potentially preventable. Reviewing medication in patients at risk in primary care might prevent these hospital admissions. At present, implementation of medication reviews in primary care is suboptimal: pharmacists lack access to patient information, pharmacists are short of clinical knowledge and skills, and working processes of pharmacists (focus on dispensing) and general practitioners (focus on clinical practice) match poorly. Integration of the pharmacist in the primary health care team might improve pharmaceutical care outcomes. The aim of this study is to evaluate the effect of integration of a non-dispensing pharmacist in general practice on the safety of pharmacotherapy in the Netherlands. METHODS: The POINT study is a non-randomised controlled intervention study with pre-post comparison in an integrated primary care setting. We compare three different models of pharmaceutical care provision in primary care: 1) a non-dispensing pharmacist as an integral member of a primary care team, 2) a pharmacist in a community pharmacy with a predefined training in performing medication reviews and 3) a pharmacist in a community pharmacy (care as usual). In all models, GPs remain accountable for individual medication prescription. In the first model, ten non-dispensing clinical pharmacists are posted in ten primary care practices (including 5 - 10 000 patients each) for a period of 15 months. These non-dispensing pharmacists perform patient consultations, including medication reviews, and share responsibility for the pharmaceutical care provided in the practice. The two other groups consist of ten primary care practices with collaborating pharmacists. The main outcome measurement is the number of medication-related hospital admissions during follow-up. Secondary outcome measurements are potential medication errors, drug burden index and costs. Parallel to this study, a qualitative study is conducted to evaluate the feasibility of introducing a NDP in general practice. DISCUSSION: As the POINT study is a large-scale intervention study, it should provide evidence as to whether integration of a non-dispensing clinical pharmacist in primary care will result in safer pharmacotherapy. The qualitative study also generates knowledge on the optimal implementation of this model in primary care. Results are expected in 2016. TRIAL REGISTRATION NUMBER: NTR4389 , The Netherlands National Trial Register, 07-01-2014.

Exploring patient safety culture in primary care.

OBJECTIVE: To explore perceptions of safety culture in nine different types of primary care professions and to study possible differences. DESIGN: Cross-sectional survey. SETTING: Three hundred and thirteen practices from nine types of primary care profession groups in the Netherlands. PARTICIPANTS: Professional staff from primary care practices. Nine professions participated: dental care, dietetics, exercise therapy, physiotherapy, occupational therapy, midwifery, anticoagulation clinics, skin therapy and speech therapy. MAIN OUTCOME MEASURES: Perceptions of seven patient safety culture dimensions were measured: 'open communication and learning from error', 'handover and teamwork', 'adequate procedures and working conditions', 'patient safety management', 'support and fellowship', 'intention to report events' and 'organizational learning'. Dimension means per profession were presented, and multilevel analyses were used to assess differences between professions. Also the so-called patient safety grade was self-reported. RESULTS: Five hundred and nineteen practices responded (response rate: 24%) of which 313 (625 individual questionnaires) were included for analysis. Overall, patient safety culture was perceived as being positive. Occupational therapy and anticoagulation therapy deviated most from other professions in a negative way, whereas physiotherapy deviated the most in a positive way. In addition, most professions graded their patient safety as positive (mean = 4.03 on a five-point scale). CONCLUSIONS: This study showed that patient safety culture in Dutch primary care professions on average is perceived positively. Also, it revealed variety between professions, indicating that a customized approach per profession group might contribute to successful implementation of safety strategies.

Home-based management of hypoxaemic COVID-19 patients: design of the Therapy@Home pilot study.

INTRODUCTION: During the COVID-19 pandemic, hospital capacity was strained. Home-based care could relieve the hospital care system and improve patient well-being if safely organised.We designed an intervention embedded in a regional collaborative healthcare network for the home-based management of acutely ill COVID-19 patients requiring oxygen treatment. Here, we describe the design and pilot protocol for the evaluation of the feasibility of this complex intervention. METHODS AND ANALYSIS: Following a participatory action research approach, the intervention was designed in four consecutive steps: (1) literature review and establishment of an expert panel; (2) concept design of essential intervention building blocks (acute medical care, acute nursing care, remote monitoring, equipment and technology, organisation and logistics); (3) safety assessments (prospective risk analysis and a simulation patient evaluation) and (4) description of the design of the pilot (feasibility) study aimed at including approximately 15-30 patients, sufficient for fine-tuning for a large-scale randomised intervention. ETHICS AND DISSEMINATION: All patients will provide written, informed consent. The study was approved by the Medical Ethics Review Committee of the University Medical Center Utrecht, the Netherlands (protocol NL77421.041.21). The preparatory steps (1-4) needed to perform the pilot are executed and described in this paper. The findings of the pilot will be published in academic journals. If we consider the complex intervention feasible, we aim to continue with a large-scale randomised controlled study evaluating the clinical effectiveness, safety and implementation of the complex intervention.

Measuring safety culture in Dutch primary care: psychometric characteristics of the SCOPE-PC questionnaire.

BACKGROUND: Patient safety has been a priority in primary healthcare in the last years. The prevailing culture is seen as an important condition for patient safety in practice and several tools to measure patient safety culture have therefore been developed. Although Dutch primary care consists of different professions, such as general practice, dental care, dietetics, physiotherapy and midwifery, a safety culture questionnaire was only available for general practices. The purpose of this study was to modify and validate this existing questionnaire to a generic questionnaire for all professions in Dutch primary care. METHODS: A validated Dutch questionnaire for general practices was modified to make it usable for all Dutch primary care professions. Subsequently, this questionnaire was administered to a random sample of 2400 practices from eleven primary care professions. The instrument's factor structure, reliability and validity were examined using confirmatory and explorative factor analyses. RESULTS: 921 questionnaires were returned. Of these, 615 were eligible for factor analysis. The resulting SCOPE-PC questionnaire consisted of seven dimensions: 'open communication and learning from errors', 'handover and teamwork', 'adequate procedures and working conditions', 'patient safety management', 'support and fellowship', 'intention to report events' and 'organisational learning' with a total of 41 items. All dimensions had good reliability with Cronbach's alphas ranging from 0.70-0.90, and the questionnaire had a good construct validity. CONCLUSIONS: The SCOPE-PC questionnaire has sound psychometric characteristics for use by the different professions in Dutch primary care to gain insight in their safety culture.

Cluster randomized, controlled trial on patient safety improvement in general practice: a study protocol.

BACKGROUND: An open, constructive safety culture is key in healthcare since it is seen as a main condition for patient safety. Studies have examined culture improvement strategies in hospitals. In primary care, however, not much is known about effective strategies to improve the safety culture yet. The purpose of this study is to examine the effect of two patient safety culture interventions: a patient safety culture questionnaire solely, the SCOPE, or the SCOPE questionnaire combined with a patient safety workshop. The purpose of this paper is to describe the rationale and design of this trial. METHODS/DESIGN: The SCOPE Intervention Study is a cluster randomized, three-armed controlled trial, that will be conducted in 30 general practices in the Netherlands. Ten practices in the first intervention arm will complete the SCOPE questionnaire and are expected to draw and implement their own improvement initiatives based on a computerised feedback report. In the second intervention arm, staff of the ten practices also will be asked to complete the SCOPE questionnaire and in addition will be given a complementary workshop. This workshop is theoretical and interactive, educating staff and facilitating discussion, leading to a practice specific action plan for patient safety improvement. The results of the SCOPE questionnaire are incorporated in the workshop. The ten practices in the control arm continue care as usual. Baseline and follow-up measurements will be conducted with an implementation period of one year. The primary outcome will include the number of incidents reported and secondary several quality and safety indicators and the patient safety culture. Moreover, interviews will be conducted at follow-up to evaluate the implementation process of the intervention. DISCUSSION: Results of this study will give insight in the effect of administering a culture questionnaire or the questionnaire with a complementary workshop. This knowledge will aid implementation of patient safety tools and future research. Attention has been given to the strengths and limitations of the study. TRIAL REGISTRATION: Netherlands Trial Register: NTR3277.

[Treatment of traumatic rib fractures]. / Behandeling van traumatische ribfracturen.

Patients with rib fractures are a heterogenous group of patients who are treated by general practitioners as well as by specialized trauma surgeons. We present three patients with rib fractures with different degrees of thoracic trauma and therefore treatments differ significantly. The cornerstone in the treatment of rib fractures remains attaining adequate analgesia and breathing exercises. The last decade, there has been an increase in the utilization of rib fixation, however, precise indications remain unknown. It has proven effective in patients with flail chest on mechanical ventilation in whom it decrease intensive care and hospital length and reduces mortality. In case of prolonged (> 3 months) pain, dyspnea or a clicking sensation one could think of a nonunion of the rib fracture. Rib fixation can relieve these complaints in about 60% of the patients, however due to a high implant irritation rate and secondary operation to remove the osteosynthesis is common.

Development and validation of a prediction rule for patients suspected of acute coronary syndrome in primary care: a cross-sectional study.

OBJECTIVE: To develop and validate a symptom-based prediction rule for early recognition of acute coronary syndrome (ACS) in patients with acute chest discomfort who call out-of-hours services for primary care (OHS-PC). DESIGN: Cross-sectional study. A diagnostic prediction rule was developed with multivariable regression analyses. All models were validated with internal-external cross validation within seven OHS-PC locations. Both age and sex were analysed as statistical interaction terms, applying for age non-linear effects. SETTING: Seven OHS-PC in the Netherlands. PARTICIPANTS: 2192 patients who called OHS-PC for acute chest discomfort (pain, pressure, tightness or discomfort) between 2014 and 2017. Backed up recordings of telephone triage conversations were analysed. PRIMARY AND SECONDARY OUTCOMES MEASURES: Diagnosis of ACS retrieved from the patient's medical records in general practice, including hospital specialists discharge letters. Performance of the prediction rules was calculated with the c-statistic and the final model was chosen based on net benefit analyses. RESULTS: Among the 2192 patients who called the OHS-PC with acute chest discomfort, 8.3% females and 15.3% males had an ACS. The final diagnostic model included seven predictors (sex, age, acute onset of chest pain lasting less than 12 hours, a pressing/heavy character of the pain, radiation of the pain, sweating and calling at night). It had an adjusted c-statistic of 0.77 (95% CI 0.74 to 0.79) with good calibration. CONCLUSION: The final prediction model for ACS has good discrimination and calibration and shows promise for replacing the existing telephone triage rules for patients with acute chest discomfort in general practice and OHS-PC. TRIAL REGISTRATION NUMBER: NTR7331.

Patient safety culture measurement in general practice. Clinimetric properties of 'SCOPE'.

BACKGROUND: A supportive patient safety culture is considered to be an essential condition for improving patient safety. Assessing the current safety culture in general practice may be a first step to target improvements. To that end, we studied internal consistency and construct validity of a safety culture questionnaire for general practice (SCOPE) which was derived from a comparable questionnaire for hospitals (Dutch-HSOPS). METHODS: The survey was conducted among caregivers of Dutch general practice as part of an ongoing quality accreditation process using a 46 item questionnaire. We conducted factor analyses and studied validity by calculating correlations between the subscales and testing the hypothesis that respondents' patient safety grade of their practices correlated with their scores on the questionnaire. RESULTS: Of 72 practices 294 respondents completed the questionnaire. Eight factors were identified concerning handover and teamwork, support and fellowship, communication openness, feedback and learning from error, intention to report events, adequate procedures and staffing, overall perceptions of patient safety and expectations and actions of managers. Cronbach's alpha of the factors rated between 0.64 and 0.85. The subscales intercorrelated moderately, except for the factor about intention to report events. Respondents who graded patient safety highly scored significantly higher on the questionnaire than those who did not. CONCLUSIONS: The SCOPE questionnaire seems an appropriate instrument to assess patient safety culture in general practice. The clinimetric properties of the SCOPE are promising, but future research should confirm the factor structure and construct of the SCOPE and delineate its responsiveness to changes in safety culture over time.

Call Characteristics of Patients Suspected of Transient Ischemic Attack (TIA) or Stroke During Out-of-Hours Service: A Comparison Between Men and Women.

Background: In the Netherlands, a digital decision support system for telephone triage at out-of-hours services in primary care (OHS-PC) is used. Differences in help-seeking behavior between men and women when transient ischemic attack (TIA) or stroke is suspected could potentially affect telephone triage and allocation of urgency. Aim: To assess patient and call characteristics and allocated urgencies between women and men who contacted OHS-PC with suspected TIA/stroke. Methods: A cross-sectional study of 1,266 telephone triage recordings of subjects with suspected neurological symptoms calling the OHS-PC between 2014 and 2016. The allocated urgencies were derived from the electronic medical records of the OHS-PC and the final diagnosis from the patient's own general practitioner, including diagnoses based on hospital specialist letters. Results: Five hundred forty-six men (mean age = 67.3 ± 17.1) and 720 women (mean age = 69.6 ± 19.5) were included. TIA/stroke was diagnosed in 294 men (54%) (mean age = 72.3 ± 13.6) and 366 women (51%) (mean age = 78.0 ± 13.8). In both genders, FAST (face-arm-speech test) symptoms were common in TIA/stroke (men 78%, women 82%) but also in no TIA/stroke (men 63%, women 62%). Men with TIA/stroke had shorter call durations than men without TIA/stroke (7.10 vs. 8.20 min, p = 0.001), whereas in women this difference was smaller and not significant (7.41 vs. 7.56 min, p = 0.41). Both genders were allocated high urgency in 75% of the final TIA/stroke cases. Conclusion: Overall, patient and call characteristics are mostly comparable between men and women, and these only modestly assist in identifying TIA/stroke. There were no gender differences in allocated urgencies after telephone triage in patients with TIA/stroke.

Developing a regional transmural care database: A roadmap.

INTRODUCTION: In primary care health care systems, primary care physicians (PCPs) provide most basic care services, and if necessary, refer to secondary care for specialized work-up and treatment. If hospital care is required, agreement between PCPs and secondary care physicians (SCPs) on the conditions for patient referral and back-referral are considered crucial to providing high quality patient care. The regional healthcare network of Utrecht, a region in the Netherlands, developed a set of collaborative patient care agreements (CPCAs) for specific chronic conditions. Even though these CPCA are endorsed by all relevant regional health care organisations, the adoption of these agreements in practice remains substandard. In this project, through linkage of routine care data, as registered in daily practice by PCPs and SCPs, a regional transmural care database (RTD) was developed for monitoring the use of the CPCAs. Its data was transformed into' mirror data' used to support PCPs and SCPs in discussing and improving current practice and to support a learning healthcare system within the region. METHODS: The development of the RTD is part of a larger action research project on joint care, called ZOUT (an acronym which is translated as "The right care at the right place in the Utrecht region"). The RTD includes data from three regional hospitals, and about 70 affiliated primary care practices which are united in the Julius General Practitioners Network (JGPN). These data were extracted, linked and presented in the form of mirror data, following simple methods to allow replication of our approach. CPCAs addressing transmural care for three chronic conditions were selected. Data from the primary care practices and the hospitals were linked by an independent trusted third party. This enabled relevant hospital data to be added to the primary care dataset, thereby providing transmural routine care data for individual patients. RESULTS: During the development of the RTD, a roadmap was created including a detailed step-by-step checklist of the organizational, administrative, technical and legal arrangements which needed to be made. Legal and administrative challenges proved most challenging. Also, incompleteness of data and the impossibility to translate several agreements into extractable data limited the potential for providing a comprehensive overview of the extent to which agreements in the CPCA were adhered to in daily care. DISCUSSION: We present a systematic, comprehensive (technical as well as practical) and reproducible roadmap to developing a regional transmural care database suitable for generating mirror data on joint transmural care between PCPs and SCPs. This approach includes all technical steps in data selection and linkage, as well as the substantive steps that need to be taken in the analysis and application of the results. The mirror data, which reflects the follow-up of agreements formulated in the CPCAs, enabled shared reflection and discussion between PCPs and SCPs. This supports the search for bottlenecks and potentialities for improving daily collaborative care, thereby showing great potential to serve a learning regional healthcare system.

Common Infections and Antibiotic Prescribing during the First Year of the COVID-19 Pandemic: A Primary Care-Based Observational Cohort Study.

Presentation and antibiotic prescribing for common infectious disease episodes decreased substantially during the first COVID-19 pandemic wave in Dutch general practice. We set out to determine the course of these variables during the first pandemic year. We conducted a retrospective observational cohort study using routine health care data from the Julius General Practitioners' Network. All patients registered in the pre-pandemic year (n = 425,129) and/or during the first pandemic year (n = 432,122) were included. Relative risks for the number of infectious disease episodes (respiratory tract/ear, urinary tract, gastrointestinal, and skin), in total and those treated with antibiotics, and proportions of episodes treated with antibiotics (prescription rates) were calculated. Compared to the pre-pandemic year, primary care presentation for common infections remained lower during the full first pandemic year (RR, 0.77; CI, 0.76-0.78), mainly attributed to a sustained decline in respiratory tract/ear and gastrointestinal infection episodes. Presentation for urinary tract and skin infection episodes declined during the first wave, but returned to pre-pandemic levels during the second and start of the third wave. Antibiotic prescription rates were lower during the full first pandemic year (24%) as compared to the pre-pandemic year (28%), mainly attributed to a 10% lower prescription rate for respiratory tract/ear infections; the latter was not accompanied by an increase in complications. The decline in primary care presentation for common infections during the full first COVID-19 pandemic year, together with lower prescription rates for respiratory tract/ear infections, resulted in a substantial reduction in antibiotic prescribing in Dutch primary care.

Gender-stratified analyses of symptoms associated with acute coronary syndrome in telephone triage: a cross-sectional study.

OBJECTIVES: To identify clinical variables that are associated with the diagnosis acute coronary syndrome (ACS) in women and men with chest discomfort who contact out-of-hours primary care (OHS-PC) by telephone, and to explore whether there are indications whether these variables differ among women and men. DESIGN: Cross-sectional study in which we compared patient and call characteristics of triage call recordings between women with and without ACS, and men with and without ACS. SETTING: Nine OHS-PC in the Netherlands. PARTICIPANTS: 993 women and 802 men who called OHS-PC for acute chest discomfort (pain, pressure, tightness or discomfort) between 2014 and 2016. PRIMARY OUTCOME MEASURE: Diagnosis of ACS retrieved from the patient's medical record in general practice, including hospital specialists' discharge letters. RESULTS: Among 1795 patients (mean age 58.8 (SD 19.5) years, 55.3% women), 15.0% of men and 8.6% of women had an ACS. In both sexes, retrosternal chest pain was associated with ACS (women with ACS vs without 62.3% vs 40.3%, p=0.002; men with ACS vs without 52.5% vs 39.7%, p=0.032; gender interaction, p=0.323), as was pressing/heavy/tightening pain (women 78.6% vs 61.5%, p=0.011; men 82.1% vs 57.4%, p=<0.001; gender interaction, p=0.368) and radiation to the arm (women 75.6% vs 45.9%, p<0.001; men 56.0% vs 34.8%, p<0.001; gender interaction, p=0.339). Results indicate that only in women were severe pain (65.4% vs 38.1%, p=0.006; gender interaction p=0.007) and radiation to jaw (50.0% vs 22.9%, p=0.007; gender interaction p=0.015) associated with ACS.Ambulances were dispatched equally in women (72.9%) and men with ACS (70.0%). CONCLUSION: Our results indicate there were more similarities than differences in symptoms associated with the diagnosis ACS for women and men. Important exceptions were pain severity and radiation of pain in women. Whether these differences have an impact on predicting ACS needs to be further investigated with multivariable analyses. TRIAL REGISTRATION NUMBER: NTR7331.

Remote Hospital Care for Recovering COVID-19 Patients Using Telemedicine: A Randomised Controlled Trial.

BACKGROUND: To ensure availability of hospital beds and improve COVID-19 patients' well-being during the ongoing pandemic, hospital care could be offered at home. Retrospective studies show promising results of deploying remote hospital care to reduce the number of days spent in the hospital, but the beneficial effect has yet to be established. METHODS: We conducted a single centre, randomised trial from January to June 2021, including hospitalised COVID-19 patients who were in the recovery stage of the disease. Hospital care for the intervention group was transitioned to the patient's home, including oxygen therapy, medication and remote monitoring. The control group received in-hospital care as usual. The primary endpoint was the number of hospital-free days during the 30 days following randomisation. Secondary endpoints included health care consumption during the follow-up period and mortality. RESULTS: A total of 62 patients were randomised (31 control, 31 intervention). The mean difference in hospital-free days was 1.7 (26.7 control vs. 28.4 intervention, 95% CI of difference -0.5 to 4.2, p = 0.112). In the intervention group, the index hospital length of stay was 1.6 days shorter (95% CI -2.4 to -0.8, p < 0.001), but the total duration of care under hospital responsibility was 4.1 days longer (95% CI 0.5 to 7.7, p = 0.028). CONCLUSION: Remote hospital care for recovering COVID-19 patients is feasible. However, we could not demonstrate an increase in hospital-free days in the 30 days following randomisation. Optimising the intervention, timing, and identification of patients who will benefit most from remote hospital care could improve the impact of this intervention.