Adherence to single inhaler triple therapy and digital inhalers in Chronic Obstructive Pulmonary Disease: a literature review and protocol for a randomized controlled trial (TRICOLON study).

BACKGROUND: Medication non-adherence is a significant problem in patients with Chronic Obstructive Pulmonary Disease (COPD). Efforts to address this issue are receiving increased attention. Simplifying treatment by prescribing single-inhaler triple therapy (SITT) as an alternative to multi-inhaler triple therapy (MITT) or with smart inhalers are often considered potential solutions. However, the actual impact of these innovations on adherence and clinical outcomes is unclear. METHODS: To address this knowledge gap we first conducted a literature review focusing on two research questions: 1) the difference in adherence between SITT and MITT users in COPD, and 2) the effect of smart inhalers on adherence in COPD. Separate searches were conducted in PubMed and two authors independently assessed the articles. In addition, we present a protocol for a study to acquire knowledge for the gaps identified. RESULTS: To address the first research question, 8 trials were selected for further review. All trials were observational, i.e. randomized controlled trials were lacking. Seven of these trials showed higher adherence and/or persistence in patients on SITT compared with patients on MITT. In addition, four studies showed a positive effect of SITT on various clinical outcomes. For the second research question, 11 trials were selected for review. While most of the studies showed a positive effect of smart inhalers on adherence, there was considerable variation in the results regarding their effect on other clinical outcomes. The TRICOLON (TRIple therapy COnvenience by the use of one or multipLe Inhalers and digital support in ChrONic Obstructive Pulmonary Disease) trial aims to improve understanding regarding the effectiveness of SITT and smart inhalers in enhancing adherence. This open-label, randomized, multi-center study will enroll COPD patients requiring triple therapy at ten participating hospitals. In total, 300 patients will be randomized into three groups: 1) MITT; 2) SITT; 3) SITT with digital support through a smart inhaler and an e-health platform. The follow-up period will be one year, during which three methods of measuring adherence will be used: smart inhaler data, self-reported data using the Test of Adherence to Inhalers (TAI) questionnaire, and drug analysis in scalp hair samples. Finally, differences in clinical outcomes between the study groups will be compared. DISCUSSION: Our review suggests promising results concerning the effect of SITT, as opposed to MITT, and smart inhalers on adherence. However, the quality of evidence is limited due to the absence of randomized controlled trials and/or the short duration of follow-up in many studies. Moreover, its impact on clinical outcomes shows considerable variation. The TRICOLON trial aims to provide solid data on these frequently mentioned solutions to non-adherence in COPD. Collecting data in a well-designed randomized controlled trial is challenging, but the design of this trial addresses both the usefulness of SITT and smart inhalers while ensuring minimal interference in participants' daily lives. TRIAL REGISTRATION: NCT05495698 (Clinicaltrials.gov), registered at 08-08-2022. Protocol version: version 5, date 27-02-2023.

Care needs of chronically ill patients with intellectual disabilities in Dutch general practice: patients' and providers' perspectives.

BACKGROUND: To reduce the impact of chronic diseases (cardiovascular disease, diabetes mellitus type 2, and chronic lung disease (asthma or chronic obstructive pulmonary disease (COPD)), it is imperative that care is of high quality and suitable to patients' needs. Patients with intellectual disabilities (ID) differ from the average patient population in general practice because of their limitations in adaptive behaviour and intellectual functioning, and concomitant difficulties recognising and reacting to disease symptoms, proactively searching health information, and independently managing diseases effectively. Because of these differences, information on their care needs is essential for suitable chronic disease management (CDM). Inadequate recognition of the care needs of this vulnerable population may hamper the harmonisation of evidence-based and person-centred care, compounded by issues such as stigma, misconceptions, and diagnostic overshadowing. This study therefore aimed to explore the needs of patients with ID from perspectives of both patients and of healthcare providers (HCPs) in the context of CDM in general practice. METHODS: This qualitative study recruited patients with ID for face-to-face individual interviews and HCPs for focus groups. With the Chronic Care Model as the underlying framework, semi-structured interviews and focus-group guides were defined to explore patients' care needs and HCPs' perspectives. All interviews and focus groups were audio-recorded and transcribed verbatim. Using Atlas.ti software, data were analysed using reflexive thematic analysis. RESULTS: Between June and September 2022, 14 patients with ID and cardiovascular disease, diabetes mellitus type 2, and/or asthma/COPD were interviewed; and 32 general practitioners and practice nurses participated in seven focus groups. We identified six care needs underpinning suitable CDM: trusting relationship between patient and HCP; clear expectations about the CDM process; support in disease management; directive decision-making; support in healthy lifestyle; accessible medical information. CONCLUSIONS: This vulnerable patient population has complex care needs that must be acknowledged for suitable CDM. Although HCPs largely recognise these needs, organisational factors and lack of training or experience with patients with ID hamper HCPs' ability to fully adjust care provision to these needs. Access to, and knowledge of, easy-language information on chronic diseases and communication guidelines could aid HCPs to facilitate patients in managing their diseases more adequately.

Chronic diseases and comorbidities in adults with and without intellectual disabilities: comparative cross-sectional study in Dutch general practice.

BACKGROUND: Chronic disease and comorbidity patterns in people with intellectual disabilities (ID) are more complex than in the general population. However, incomplete understanding of these differences limits care providers in addressing them. OBJECTIVE: To compare chronic disease and comorbidity patterns in chronically ill patients with and without ID in Dutch general practice. METHODS: In this population-based study, a multi-regional primary care database of 2018 was combined with national population data to improve identification of adults with ID. Prevalence was calculated using Poisson regression to estimate prevalence ratios and 95% confidence intervals for the highest-impact chronic diseases (ischemic heart disease (IHD), cerebrovascular disease (CVD), diabetes mellitus (DM), and chronic obstructive pulmonary disease (COPD)) and comorbidities. RESULTS: Information from 18,114 people with ID and 1,093,995 people without ID was available. When considering age and sex, CVD (PR = 1.1), DM (PR = 1.6), and COPD (PR = 1.5) times more prevalent in people with than without ID. At younger age, people with ID more often had a chronic disease and multiple comorbidities. Males with ID most often had a chronic disease and multiple comorbidities. Comorbidities of circulatory nature were most common. CONCLUSIONS: This study identified a younger onset of chronic illness and a higher prevalence of multiple comorbidities among people with ID in general practice than those without ID. This underlines the complexity of people with ID and chronic diseases in general practice. As this study confirmed the earlier onset of chronic diseases and comorbidities, it is recommended to acknowledge these age differences when following chronic disease guidelines.

Exploring chronic disease prevalence in people with intellectual disabilities in primary care settings: A scoping review.

BACKGROUND: Primary care providers require accurate evidence on chronic disease prevalence in people with intellectual disabilities in order to apply this information into practice. This study aimed to map the broadness of literature on chronic disease prevalence in people with and without intellectual disabilities, and to explore main characteristics of these studies. METHOD: A scoping review of peer-reviewed literature was conducted, covering 2000 to February 2020, including literature that discussed chronic disease prevalence in people with and without intellectual disabilities, with similar data collection method for both groups. RESULTS: Nineteen studies were included. Chronic disease prevalence varied considerably between people with and without intellectual disabilities. Studies differed in their methodologies, country and age groups that were enrolled. CONCLUSIONS: Primary care providers should interpret results on disease prevalence among people with intellectual disabilities in light of the study characteristics. Researchers should always interpret prevalence rates in the context of methodology.

The COVID-19 Pandemic in Nijmegen, the Netherlands: Changes in Presented Health Problems and Demand for Primary Care.

We studied the changes in presented health problems and demand for primary care since the outbreak of coronavirus disease 2019 (COVID-19) in the Netherlands. We analyzed prominent symptom features of COVID-19, and COVID-19 itself as the reason for encounter. Also, we analyzed the number and type of encounters for common important health problems. Respiratory tract symptoms related to COVID-19 were presented more often in 2020 than in 2019. We observed a dramatic increase of telephone/e-mail/Internet consultations in the months after the outbreak. Contacts for other health problems such as prevention and acute and chronic conditions plummeted substantially (P <0.001); mental health problems stabilized.

Definition of a COPD self-management intervention: International Expert Group consensus.

There is an urgent need for consensus on what defines a chronic obstructive pulmonary disease (COPD) self-management intervention. We aimed to obtain consensus regarding the conceptual definition of a COPD self-management intervention by engaging an international panel of COPD self-management experts using Delphi technique features and an additional group meeting.In each consensus round the experts were asked to provide feedback on the proposed definition and to score their level of agreement (1=totally disagree; 5=totally agree). The information provided was used to modify the definition for the next consensus round. Thematic analysis was used for free text responses and descriptive statistics were used for agreement scores.In total, 28 experts participated. The consensus round response rate varied randomly over the five rounds (ranging from 48% (n=13) to 85% (n=23)), and mean definition agreement scores increased from 3.8 (round 1) to 4.8 (round 5) with an increasing percentage of experts allocating the highest score of 5 (round 1: 14% (n=3); round 5: 83% (n=19)).In this study we reached consensus regarding a conceptual definition of what should be a COPD self-management intervention, clarifying the requisites for such an intervention. Operationalisation of this conceptual definition in the near future will be an essential next step.

Characteristics of effective self-management interventions in patients with COPD: individual patient data meta-analysis.

It is unknown whether heterogeneity in effects of self-management interventions in patients with chronic obstructive pulmonary disease (COPD) can be explained by differences in programme characteristics. This study aimed to identify which characteristics of COPD self-management interventions are most effective.Systematic search in electronic databases identified randomised trials on self-management interventions conducted between 1985 and 2013. Individual patient data were requested for meta-analysis by generalised mixed effects models.14 randomised trials were included (67% of eligible), representing 3282 patients (75% of eligible). Univariable analyses showed favourable effects on some outcomes for more planned contacts and longer duration of interventions, interventions with peer contact, without log keeping, without problem solving, and without support allocation. After adjusting for other programme characteristics in multivariable analyses, only the effects of duration on all-cause hospitalisation remained. Each month increase in intervention duration reduced risk of all-cause hospitalisation (time to event hazard ratios 0.98, 95% CI 0.97-0.99; risk ratio (RR) after 6 months follow-up 0.96, 95% CI 0.92-0.99; RR after 12 months follow-up 0.98, 95% CI 0.96-1.00).Our results showed that longer duration of self-management interventions conferred a reduction in all-cause hospitalisations in COPD patients. Other characteristics are not consistently associated with differential effects of self-management interventions across clinically relevant outcomes.

Asthma and COPD management of patients with intellectual disabilities in general practice.

People with intellectual disabilities experience overall poorer health and healthcare access than the general population. It is largely unknown how this applies to asthma and chronic obstructive pulmonary disease (COPD) management by general practitioners (GPs). In a 10-year retrospective matched cohort study, n = 34,429, we examined year prevalence of asthma and COPD in adult patients with and without intellectual disabilities and potential differences in the delivery of asthma and COPD disease management activities in Dutch general practices (2010-2019). We collected information on patient characteristics, comorbidity, consultation patterns, use and outcomes of asthma/COPD control questionnaires, spirometry measurement, pulmonology referrals, and prescribed medication. Asthma patients with intellectual disabilities suffered more frequently from obesity (53.2% vs. 39.5% without intellectual disabilities), and both asthma and COPD patients with intellectual disabilities were more frequently current smokers (45.2% vs. 22.1% without intellectual disabilities, and 76.6% vs. 51.4% without intellectual disabilities, respectively). Also, a statistically significant larger number of asthma patients with intellectual disabilities were prescribed antibiotics (69.9% vs. 54.5%). COPD patients with intellectual disabilities, compared with matched controls without intellectual disabilities, received significantly more often either no COPD-related practice consultation at all (respectively 20.8% vs. 8.5%, p = 0.004) or a large number of practice consultations (>31 consultations, respectively 16.7% vs. 5.3%, p = 0.004). For asthma, there was no statistical difference between patients with or without intellectual disabilities regarding the number and type of consultations. The asthma year point prevalence in patients with intellectual disabilities was, from 2014 onward, significantly higher, and in 2019 was 8.7% vs. 6.0% for people without intellectual disabilities. For COPD, it was comparable in both groups. Both asthma and COPD patients with intellectual disabilities appeared considerably younger in age than patients without intellectual disabilities. Our findings warrant further research into the causes of the differences found for asthma and COPD and whether they also infer differences in the quality or the effectiveness of GP disease management, especially for young adults with intellectual disabilities.

Transmural collaborative care model for the review of antipsychotics: a feasibility study of a complex intervention.

General practitioners (GPs) are often unaware of antipsychotic (AP)-induced cardiovascular risk (CVR) and therefore patients using atypical APs are not systematically monitored. We evaluated the feasibility of a complex intervention designed to review the use of APs and advise on CVR-lowering strategies in a transmural collaboration. A mixed methods prospective cohort study in three general practices in the Netherlands was conducted in 2021. The intervention comprised three steps: a digital information meeting, a multidisciplinary meeting, and a shared decision-making visit to the GP. We assessed patient recruitment and retention rates, advice given and adopted, and CVR with QRISK3 score and mental state with MHI-5 at baseline and three months post-intervention. GPs invited 57 of 146 eligible patients (39%), of whom 28 (19%) participated. The intervention was completed by 23 (82%) and follow-up by 18 participants (64%). At the multidisciplinary meeting, 22 (78%) patients were advised to change AP use. Other advice concerned medication (other than APs), lifestyle, monitoring, and psychotherapy. At 3-months post-intervention, 41% (28/68) of this advice was adopted. Our findings suggest that this complex intervention is feasible for evaluating health improvement in patients using AP in a trial.

Primary healthcare competencies needed in the management of person-centred integrated care for chronic illness and multimorbidity: Results of a scoping review.

BACKGROUND: Chronic disease management is important in primary care. Disease management programmes focus primarily on the respective diseases. The occurrence of multimorbidity and social problems is addressed to a limited extent. Person-centred integrated care (PC-IC) is an alternative approach, putting the patient at the centre of care. This asks for additional competencies for healthcare professionals involved in the execution of PC-IC. In this scoping review we researched which competencies are necessary for healthcare professionals working in collaborative teams where the focus lies within the concept of PC-IC. We also explored how these competencies can be acquired. METHODS: Six literature databases and grey literature were searched for guidelines and peer-reviewed articles on chronic illness and multimorbidity in primary care. A data synthesis was carried out resulting in an overview of the competencies that healthcare professionals need to deliver PC-IC. RESULTS: Four guidelines and 21 studies were included and four core competencies could be derived through the synthesis: 1. interprofessional communication, 2, interprofessional collaborative teamwork, 3. leadership and 4. patient-centred communication. Included papers mostly lack a clear description of the competencies in terms of knowledge, skills and attitudes which are necessary for a PC-IC approach and on how these competencies can be acquired. CONCLUSION: This review provides insight on competencies necessary to provide PC-IC within primary care. Research is needed in more depth on core concepts of these competencies which will then benefit educational programmes to ensure that healthcare professionals in primary care are better equipped to deliver PC-IC for patients with chronic illness and multimorbidity.

Chronic disease management in patients with intellectual disabilities: a matched study in Dutch general practice.

BACKGROUND: Disease management programmes (DMPs) aim to deliver standardised, high- quality care to patients with chronic diseases. Although chronic diseases are common among people with intellectual disabilities (ID), this approach may be suboptimal for meeting their care needs. AIM: To examine differences between patients with and without ID who have a chronic illness in DMP enrolment and disease monitoring in Dutch general practice. DESIGN AND SETTING: Observational study utilising the Nivel Primary Care Database (2015-2018) comparing patients with ID and cardiovascular disease, diabetes mellitus, or chronic obstructive pulmonary disease (COPD) with matched (1:5) controls with these conditions but without ID. METHOD: Using conditional logistic regression, enrolment in DMP per chronic disease was examined and differences tested between groups in the frequencies of consultations, medication prescriptions, and routine examinations. RESULTS: A total of 2653 patients with chronic illness with ID were matched with 13 265 controls without ID. Patients with both diabetes mellitus and ID were more likely than controls to be enrolled in DMP (odds ratio [OR] = 1.44, 95% confidence interval [CI] = 1.27 to 1.64). Independent of DMP enrolment, patients with chronic illness with ID were more likely than controls to have frequent consultations. Patients with both diabetes mellitus and ID and patients with both COPD and ID who were not enrolled in DMPs had more medication prescriptions than non-enrolled patients with diabetes or COPD but without ID (OR = 1.46, 95% CI = 1.10 to 1.95; OR = 1.28, 95% CI = 0.99 to 1.66, respectively). Most patients with ID and their controls enrolled in DMPs received routine examinations at similar frequencies. CONCLUSION: Although DMPs do not specifically address the needs of patients with both chronic illness and ID, these patients do not seem underserved in the management of chronic diseases in terms of consultation, medication, and tests.

How Can a Bundled Payment Model Incentivize the Transition from Single-Disease Management to Person-Centred and Integrated Care for Chronic Diseases in the Netherlands?

To stimulate the integration of chronic care across disciplines, the Netherlands has implemented single-disease management programmes (SDMPs) in primary care since 2010; for example, for COPD, type 2 diabetes mellitus, and cardiovascular diseases. These disease-specific chronic care programmes are funded by bundled payments. For chronically ill patients with multimorbidity or with problems in other domains of health, this approach was shown to be less fit for purpose. As a result, we are currently witnessing several initiatives to broaden the scope of these programmes, aiming to provide truly person-centred integrated care (PC-IC). This raises the question if it is possible to design a payment model that would support this transition. We present an alternative payment model that combines a person-centred bundled payment with a shared savings model and pay-for-performance elements. Based on theoretical reasoning and results of previous evaluation studies, we expect the proposed payment model to stimulate integration of person-centred care between primary healthcare providers, secondary healthcare providers, and the social care domain. We also expect it to incentivise cost-conscious provider-behaviour, while safeguarding the quality of care, provided that adequate risk-mitigating actions, such as case-mix adjustment and cost-capping, are taken.

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.

Effects of Adherence to an mHealth Tool for Self-Management of COPD Exacerbations.

Purpose: Poor adherence to COPD mobile health (mHealth) has been reported, but its association with exacerbation-related outcomes is unknown. We explored the effects of mHealth adherence on exacerbation-free weeks and self-management behavior. We also explored differences in self-efficacy and stages of grief between adherent and non-adherent COPD patients. Patients and Methods: We conducted secondary analyses using data from a recent randomized controlled trial (RCT) that compared the effects of mHealth (intervention) with a paper action plan (comparator) for COPD exacerbation self-management. We used data from the intervention group only to assess differences in exacerbation-free weeks (primary outcome) between patients who were adherent and non-adherent to the mHealth tool. We also assessed differences in the type and timing of self-management actions and scores on self-efficacy and stages of grief (secondary outcomes). We used generalized negative binomial regression analyses with correction for follow-up length to analyze exacerbation-free weeks and multilevel logistic regression analyses with correction for clustering for secondary outcomes. Results: We included data of 38 patients of whom 13 (34.2%) (mean (SD) age 69.2 (11.2) years) were adherent and 25 (65.8%) (mean (SD) age 68.7 (7.8) years) were non-adherent. Adherent patients did not differ from non-adherent patients in exacerbation-free weeks (mean (SD) 31.5 (14.5) versus 33.5 (10.2); p=0.63). Although statistically not significant, adherent patients increased their bronchodilator use more often and more timely, contacted a healthcare professional and/or initiated prednisolone and/or antibiotics more often, and showed at baseline higher scores of self-efficacy and disease acceptance and lower scores of denial, resistance, and sorrow, compared with non-adherent patients. Conclusion: Adherence to mHealth may be positively associated with COPD exacerbation self-management behavior, self-efficacy and disease acceptance, but its association with exacerbation-free weeks remains unclear. Our results should be interpreted with caution by this pilot study's explorative nature and small sample size.

Acceptability of risk-based triage in cervical cancer screening: A focus group study.

BACKGROUND: Compared to the previous cytology-based program, the introduction of primary high-risk human papillomavirus (hrHPV) based screening in 2017 has led to an increased number of referrals. To counter this, triage of hrHPV-positive women in cervical cancer screening can potentially be optimized by taking sociodemographic and lifestyle risk factors for cervical abnormalities into account. Therefore, it is essential to gain knowledge of the views of women (30-60 years) eligible for cervical cancer screening. OBJECTIVE: The main goal of this qualitative study was to gain insight in the aspects that influence acceptability of risk-based triage in cervical cancer screening. DESIGN: A focus group study in which participants were recruited via four general medical practices, and purposive sampling was used to maximize heterogeneity with regards to age, education level, and cervical cancer screening experiences. APPROACH: The focus group discussions were transcribed verbatim and analyzed using reflexive thematic analysis. PARTICIPANTS: A total of 28 women (average age: 45.2 years) eligible for cervical cancer screening in The Netherlands participated in seven online focus group discussions. Half of the participants was higher educated, and the participants differed in previous cervical cancer screening participation and screening result. KEY RESULTS: In total, 5 main themes and 17 subthemes were identified that determine the acceptability of risk-stratified triage. The main themes are: 1) adequacy of the screening program: an evidence-based program that is able to minimize cancer incidence and reduce unnecessary referrals; 2) personal information (e.g., sensitive topics and stigma); 3) emotional impact: fear and reassurance; 4) communication (e.g., transparency); and 5) autonomy (e.g., prevention). CONCLUSION: The current study highlights several challenges regarding the development and implementation of risk-based triage that need attention in order to be accepted by the target group. These challenges include dealing with sensitive topics and a transparent communication strategy.

Performance of the SCORE and Globorisk cardiovascular risk prediction models: a prospective cohort study in Dutch general practice.

BACKGROUND: GPs frequently use 10-year-risk estimations of cardiovascular disease (CVD) to identify high- risk patients. AIM: To assess the performance of four models for predicting the 10-year risk of CVD in Dutch general practice. DESIGN AND SETTING: Prospective cohort study. Routine data (2009- 2019) was used from 46 Dutch general practices linked to cause of death statistics. METHOD: The outcome measures were fatal CVD for SCORE and first diagnosis of fatal or non- fatal CVD for SCORE fatal and non-fatal (SCORE- FNF), Globorisk-laboratory, and Globorisk-office. Model performance was assessed by examining discrimination and calibration. RESULTS: The final number of patients for risk prediction was 1981 for SCORE and SCORE-FNF, 3588 for Globorisk-laboratory, and 4399 for Globorisk- office. The observed percentage of events was 18.6% (n = 353) for SCORE- FNF, 6.9% (n = 230) for Globorisk-laboratory, 7.9% (n = 323) for Globorisk-office, and 0.3% (n = 5) for SCORE. The models showed poor discrimination and calibration. The performance of SCORE could not be examined because of the limited number of fatal CVD events. SCORE-FNF, the model that is currently used for risk prediction of fatal plus non-fatal CVD in Dutch general practice, was found to underestimate the risk in all deciles of predicted risks. CONCLUSION: Wide eligibility criteria and a broad outcome measure contribute to the model applicability in daily practice. The restriction to fatal CVD outcomes of SCORE renders it less usable in routine Dutch general practice. The models seriously underestimate the 10-year risk of fatal plus non-fatal CVD in Dutch general practice. The poor model performance is possibly because of differences between patients that are eligible for risk prediction and the population that was used for model development. In addition, selection of higher-risk patients for CVD risk assessment by GPs may also contribute to the poor model performance.

Development of a Person-Centred Integrated Care Approach for Chronic Disease Management in Dutch Primary Care: A Mixed-Method Study.

To reduce the burden of chronic diseases on society and individuals, European countries implemented chronic Disease Management Programs (DMPs) that focus on the management of a single chronic disease. However, due to the fact that the scientific evidence that DMPs reduce the burden of chronic diseases is not convincing, patients with multimorbidity may receive overlapping or conflicting treatment advice, and a single disease approach may be conflicting with the core competencies of primary care. In addition, in the Netherlands, care is shifting from DMPs to person-centred integrated care (PC-IC) approaches. This paper describes a mixed-method development of a PC-IC approach for the management of patients with one or more chronic diseases in Dutch primary care, executed from March 2019 to July 2020. In Phase 1, we conducted a scoping review and document analysis to identify key elements to construct a conceptual model for delivering PC-IC care. In Phase 2, national experts on Diabetes Mellitus type 2, cardiovascular diseases, and chronic obstructive pulmonary disease and local healthcare providers (HCP) commented on the conceptual model using online qualitative surveys. In Phase 3, patients with chronic conditions commented on the conceptual model in individual interviews, and in Phase 4 the conceptual model was presented to the local primary care cooperatives and finalized after processing their comments. Based on the scientific literature, current practice guidelines, and input from a variety of stakeholders, we developed a holistic, person-centred, integrated approach for the management of patients with (multiple) chronic diseases in primary care. Future evaluation of the PC-IC approach will show if this approach leads to more favourable outcomes and should replace the current single-disease approach in the management of chronic conditions and multimorbidity in Dutch primary care.

Validity of an automated telephonic system to assess COPD exacerbation rates.

Current tools for recording chronic obstructive pulmonary disease (COPD) exacerbations are limited and often lack validity testing. We assessed the validity of an automated telephonic exacerbation assessment system (TEXAS) and compared its outcomes with existing tools. Over 12 months, 86 COPD patients (22.1% females; mean age 66.5 yrs; mean post-bronchodilator forced expiratory volume in 1 s 53.4% predicted) were called once every 2 weeks by TEXAS to record changes in respiratory symptoms, unscheduled healthcare utilisation and use of respiratory medication. The responses to TEXAS were validated against exacerbation-related information collected by observations made by trained research assistants during home visits. No care assistance was provided in any way. Diagnostic test characteristics were estimated using commonly used definitions of exacerbation. Detection rates, compliance and patient preference were assessed, and compared with paper diary cards and medical record review. A total of 1,824 successful calls were recorded, of which 292 were verified by home visits (median four calls per patient, interquartile range three to five calls per patient). Independent of the exacerbation definition used, validity was high, with sensitivities and specificities between 66% and 98%. Detection rates and compliance differed extensively between the different tools, but were highest with TEXAS. Patient preference did not differ. TEXAS is a valid tool to assess COPD exacerbation rates in prospective clinical studies. Using different tools to record exacerbations strongly affects exacerbation occurrence rates.

Oral immunotherapy for the treatment of peanut allergy: systematic review of six case series studies.

BACKGROUND: Allergy to peanuts is associated with considerable morbidity and, in a minority of cases, mortality. Natural resolution to peanut allergy occurs in only a few cases, hence the need to find effective interventions. Peanut oral immunotherapy (OIT) is a potentially important new therapeutic development. AIMS: To assess the benefits and harms of OIT for peanut allergy. METHODS: Fourteen databases were searched for published reports and unpublished/in-progress studies. We included studies employing randomised controlled trial (RCT), quasi-RCT, controlled clinical trial, controlled before-and-after, interrupted time series, and case series designs. RESULTS: Six studies enrolling a total of 85 participants satisfied our inclusion criteria. All studies employed a case series design and were thus judged to be at high risk of bias. Overall, this body of evidence provided suggestive evidence that it is possible for many participants to increase their threshold dose for peanut exposure whilst receiving treatment. Adverse reactions were common and, whilst most of these were relatively minor, some were potentially life-threatening. CONCLUSIONS: OIT appears to be a potentially promising new therapy for the short- to medium-term management of carefully selected and monitored patients with peanut allergy. The effectiveness and cost-effectiveness of OIT - particularly over the longer term - need to be clearly established using more robust designs before its clinical use can be contemplated. Given the risk of triggering serious adverse reactions, OIT should not be administered outside clinical trial settings.