[Respiratory complaints in the time of COVID-19]. / Luchtwegklachten in tijden van corona.

The current guidelines for diagnosis and treatment of primary respiratory infections are still useful during the COVID-19 epidemic.Telephone triage of patients with respiratory complaints aims to identify patients with complications or an increased risk of complications.There are no indications to test for SARS-CoV-2 virus in general practice.During this COVID-19 epidemic, protective clothing is recommended in all physical contacts with patients with respiratory complaints.There is no reason to be cautious about using NSAIDs in patients suspected of COVID-19.Amoxicillin is first choice treatment for respiratory infections during the COVID-19 epidemic; there is lack of evidence to support azithromycin as a first choice.Respiratory rate > 24 / min or saturation <92-94% indicate imminent respiratory decompensation and may be reasons for referral.

Is guideline-adherent prescribing associated with quality of life in patients with type 2 diabetes?

BACKGROUND: Guideline-adherent prescribing for treatment of multiple risk factors in type 2 diabetes (T2D) patients is expected to improve clinical outcomes. However, the relationship to Health-Related Quality of Life (HRQoL) is not straightforward since guideline-adherent prescribing can increase medication burden. OBJECTIVES: To test whether guideline-adherent prescribing and disease-specific medication burden are associated with HRQoL in patients with T2D. METHODS: Cross-sectional study including 1,044 T2D patients from the e-VitaDM/ZODIAC study in 2012 in the Netherlands. Data from the diabetes visit, such as laboratory and physical examinations and prescribed medication, and from two HRQoL questionnaires, the EuroQol 5 Dimensions 3 Levels (EQ5D-3L) and the World Health Organization Well-Being Index (WHO-5) were collected. Twenty indicators assessing prescribing of recommended glucose lowering drugs, statins, antihypertensives and renin-angiotensin-aldosterone system (RAAS)-inhibitors and potentially inappropriate drugs from a validated diabetes indicator set were included. Disease-specific medication burden was assessed using a modified version of the Medication Regimen Complexity Index (MRCI). Associations were tested with regression models, adjusting for age, gender, diabetes duration, comorbidity, body mass index and smoking. RESULTS: The mean MRCI was 7.1, the median EQ5D-3L-score was 0.86 and the mean WHO-5 score was 72. Seven indicators included too few patients and were excluded from the analysis. The remaining thirteen indicators focusing on recommended start, intensification, current and preferred use of glucose lowering drugs, statins, antihypertensives, RAAS inhibitors, and on inappropriate prescribing of glibenclamide and dual RAAS blockade were not significantly associated with HRQoL. Finally, also the MRCI was not associated with HRQoL. CONCLUSIONS: We found no evidence for associations between guideline-adherent prescribing or disease-specific medication burden and HRQoL in T2D patients. This gives no rise to refrain from prescribing intensive treatment in T2D patients as recommended, but the interpretation of these results is limited by the cross-sectional study design and the selection of patients included in some indicators.

Safe use of proton pump inhibitors in patients with cirrhosis.

AIMS: Proton pump inhibitors (PPIs) belong to the most frequently used drugs, also in patients with cirrhosis. PPIs are extensively metabolized by the liver, but practice guidance on prescribing in cirrhosis is lacking. We aim to develop practical guidance on the safe use of PPIs in patients with cirrhosis. METHODS: A systematic literature search identified studies on the safety (i.e. adverse events) and pharmacokinetics of PPIs in cirrhotic patients. This evidence and data from the product information was reviewed by an expert panel who classified drugs as safe; no additional risks known; additional risks known; unsafe; or unknown. Guidance was aimed at the oral use of PPIs and categorized by the severity of cirrhosis, using the Child-Turcotte-Pugh (CTP) classification. RESULTS: A total of 69 studies were included. Esomeprazole, omeprazole and rabeprazole were classified as having 'no additional risks known'. A reduction in maximum dose of omeprazole and rabeprazole is recommended for CTP A and B patients. For patients with CTP C cirrhosis, the only PPI advised is esomeprazole at a maximum dosage of 20 mg per day. Pantoprazole and lansoprazole were classified as unsafe because of 4- to 8-fold increased exposure. The use of PPIs in cirrhotic patients has been associated with the development of infections and hepatic encephalopathy and should be carefully considered. CONCLUSIONS: We suggest using esomeprazole, omeprazole or rabeprazole in patients with CTP A or B cirrhosis and only esomeprazole in patients with CTP C. Pharmacokinetic changes are also important to consider when prescribing PPIs to vulnerable, cirrhotic patients.

Evidence-Based Recommendations to Improve the Safe Use of Drugs in Patients with Liver Cirrhosis.

INTRODUCTION: The presence of liver cirrhosis can have a major impact on pharmacodynamics and pharmacokinetics, but guidance for prescribing is lacking. OBJECTIVE: The aim of this study is to provide an overview of evidence-based recommendations developed for the safe use of drugs in liver cirrhosis. METHODS: Recommendations were based on a systematic literature search combined with expert opinion from a panel of 10 experts. The safety of each drug was classified as safe, no additional risks known, additional risks known, unsafe, unknown or the safety class was dependent on the severity of liver cirrhosis (Child-Pugh classification). If applicable, drug-specific dosing advice was provided. All recommendations were implemented in clinical decision support systems and on a website. RESULTS: We formulated 218 recommendations for a total of 209 drugs. For nine drugs, two recommendations were formulated for different administration routes or indications. Drugs were classified as 'safe' in 29 recommendations (13.3%), 'no additional risks known' in 60 (27.5%), 'additional risks known' in 3 (1.4%), and 'unsafe' in 30 (13.8%). In 57 (26.1%) of the recommendations, safety depended on the severity of liver cirrhosis and was 'unknown' in 39 (17.9%) recommendations. Large alterations in pharmacodynamics were the main reason for classifying a drug as 'unsafe'. For 67 drugs (31%), a dose adjustment was needed. CONCLUSIONS: Over 200 recommendations were developed for the safe use of drugs in patients with liver cirrhosis. Implementing these recommendations into clinical practice can possibly enhance medication safety in this vulnerable patient group.

Development and validation of prescribing quality indicators for patients with type 2 diabetes.

AIM: Quality indicators are used to measure whether healthcare professionals act according to guidelines, but few indicators focus on the quality of pharmacotherapy for diabetes. The aim of this study was to develop and validate a set of prescribing quality indicators (PQIs) for type 2 diabetes in primary care, and to apply this set in practice. To take into account the stepwise treatment of chronic disease, clinical action indicators were specifically considered. METHODS: Potential PQIs were derived from clinical practice guidelines and evaluated using the RAND/UCLA Appropriateness Method, a modified Delphi panel. Thereafter, the feasibility of calculating the PQIs was tested in two large Dutch primary care databases including >80 000 diabetes patients in 2012. RESULTS: 32 PQIs focusing on treatment with glucose, lipid, blood pressure and albuminuria lowering drugs, and on vaccination, medication safety and adherence were assessed by ten experts. After the Delphi panel, the final list of twenty PQIs was tested for feasibility. All PQIs definitions were feasible for measuring the quality of medication treatment using these databases. Indicator scores ranged from 18.8% to 90.8% for PQIs focusing on current medication use, clinical action and medication choice, and from 2.1% to 37.2% for PQIs focusing on medication safety. DISCUSSION AND CONCLUSIONS: Twenty PQIs focusing on treatment with glucose, lipid, blood pressure and albuminuria lowering drugs, and on medication safety in type 2 diabetes were developed, considered valid and operationally feasible. Results showed room for improvement, especially in initiation and intensification of treatment as measured with clinical action indicators.

Evaluating the safety and dosing of drugs in patients with liver cirrhosis by literature review and expert opinion.

INTRODUCTION: Liver cirrhosis can have a major impact on drug pharmacokinetics and pharmacodynamics. Patients with cirrhosis often suffer from potentially preventable adverse drug reactions. Guidelines on safe prescribing for these patients are lacking. The aim of this study is to develop a systematic method for evaluating the safety and optimal dosage of drugs in patients with liver cirrhosis. METHODS AND ANALYSIS: For each drug, a six-step evaluation process will be followed. (1) Available evidence on the pharmacokinetics and safety of a drug in patients with liver cirrhosis will be collected from the Summary of Product Characteristics (SmPC) and a systematic literature review will be performed. (2) Data regarding two outcomes, namely pharmacokinetics and safety, will be extracted and presented in a standardised assessment report. (3) A safety classification and dosage suggestion will be proposed for each drug. (4) An expert panel will discuss the validity and clinical relevance of this suggested advice. (5) Advices will be implemented in all relevant Clinical Decision Support Systems in the Netherlands and published on a website for patients and healthcare professionals. (6) The continuity of the advices will be guaranteed by a yearly check of new literature and comments on the advices. This protocol will be applied in the evaluation of a selection of drugs: (A) drugs used to treat (complications of) liver cirrhosis, and (B) drugs frequently prescribed to the general population. ETHICS AND DISSEMINATION: Since this study does not directly involve human participants, it does not require ethical clearance. Besides implementation on a website and in clinical decision support systems, we aim to publish the generated advices of one or two drug classes in a peer-reviewed journal and at conference meetings.

Process quality indicators for chronic kidney disease risk management: a systematic literature review.

BACKGROUND AND OBJECTIVES: Quality indicators (QIs) can be used for measuring the quality of actions of healthcare providers. This systematic review gives an overview of such QIs measuring processes of care for chronic kidney disease (CKD), and identifies the QIs that have content, face, operational and/or predictive validity. METHODS: PubMed and Embase were searched using a strategy combining the terms "quality of care," "quality indicators" and "chronic kidney disease". Papers were included if they focused on developing, testing or applying QIs for assessing the quality of care in adult patients with CKD not on renal replacement therapy. RESULTS: Two hundred and seventy-three QIs from thirty-one papers were extracted, including QIs on adequate monitoring of kidney function and vascular risk factors, on indicated treatment, drug safety, adherence and referral to a specialist. The QIs that were considered content, face and operational valid focused on monitoring of glomerular filtration rate, albumin-creatinine ratio, lipid levels and blood pressure, the use of non-steroidal anti-inflammatory drugs, nitrofurantoin and biphosphonates in patients with CKD, and QIs on monitoring haemoglobin and treatment with angiotensin-converting-enzyme-inhibitors/angiotensin-receptor-II-blockers in patients with CKD and comorbidities. No QIs were tested for predictive validity. In addition, only two QIs focused on diet and no other QIs focused on lifestyle management. CONCLUSIONS: Based on this review, sufficiently validated QIs can be selected for measuring the quality of CKD care. This review provides insight in QIs that need further validation, and in areas of care where QIs are still lacking.

Development and initial validation of prescribing quality indicators for patients with chronic kidney disease.

BACKGROUND: Quality assessment is a key element for improving the quality of care. Currently, a comprehensive indicator set for measuring the quality of medication treatment in patients with chronic kidney disease (CKD) is lacking. Our aim was to develop and validate a set of prescribing quality indicators (PQIs) for CKD care, and to test the feasibility of applying this set in practice. METHODS: Potential indicators were based on clinical practice guidelines and evaluated using the RAND/UCLA Appropriateness Method. This is a structured process in which an expert panel assesses the validity of the indicators. Feasibility was tested in a Dutch primary care database including >4500 diabetes patients with CKD. RESULTS: An initial list of 22 PQIs was assessed by 12 experts. After changing 10 PQIs, adding 2 and rejecting 8, a final list of 16 indicators was accepted by the expert panel as valid. These PQIs focused on the treatment of hypertension, albuminuria, mineral and bone disorder, statin prescribing and possible unsafe medication. The indicators were successfully applied to measure treatment quality in the primary care database, but for some indicators the number of eligible patients was too small for reliable calculation. Results showed that there was room for improvement in the treatment quality of this population. CONCLUSIONS: We developed a set of 16 PQIs for measuring the quality of treatment in CKD patients, which had sufficient content and face validity as well as operational feasibility. These PQIs can be used to point out priority areas for improvement.

[Revised NHG practice guideline 'Lumbosacral radicular syndrome']. / Herziene NHG-standaard 'Lumbosacraal radiculair syndroom'.

The Dutch College of General Practitioners (NHG) recently published the practice guideline 'Lumbosacral radicular syndrome'. This guideline provides general practitioners with guidance for the diagnostic workup and treatment of patients with lumbosacral radicular syndrome. In this article we discuss the most important changes and modifications to this guideline point by point. The most important recommendations for management are summarized in a flowchart.

Patient characteristics associated with measurement of routine diabetes care: an observational study.

BACKGROUND: Non-modifiable patient characteristics, including age, gender, ethnicity as well as the occurrence of multi-morbidities, are associated with processes and outcomes of diabetes care. Information on these factors can be used in case mix adjustment of performance measures. However, the practical relevance of such adjustment is not clear. The aim of this study was to assess the strength of associations between patient factors and diabetes care processes and outcomes. METHODS: We performed an observational study based on routinely collected data of 12,498 diabetes patients in 59 Dutch primary care practices. Data were collected on patient age, gender, whether the patient lived in a deprived area, body mass index and the co-occurrence of cardiovascular disease, chronic obstructive pulmonary disease, depression or anxiety. Outcomes included 6 dichotomous measures (3 process and 3 outcome related) regarding glycosylated hemoglobin, systolic blood pressure and low density lipoprotein-cholesterol. We performed separate hierarchical logistic mixed model regression models for each of the outcome measures. RESULTS: Each of the process measure models showed moderate effect sizes, with pooled areas under the curve that varied between 0.66 and 0.76. The frequency of diabetes related consultations as a measure of patient compliance to treatment showed the strongest association with all process measures (odds ratios between 5.6 and 14.5). The effect sizes of the outcome measure models were considerably smaller than the process measure models, with pooled areas under the curve varying from 0.57 to 0.61. CONCLUSIONS: Several non-modifiable patient factors could be associated with processes and outcomes of diabetes care. However, associations were small. These results suggest that case-mix correction or stratification in assessing diabetes care has limited practical relevance.

[The NHG guideline 'Sleep problems and sleeping pills']. / De NHG-standaard 'Slaapproblemen en slaapmiddelen'.

The Dutch College of General Practitioners' (NHG) guideline 'Sleep problems and sleeping pills' provides recommendations for the diagnosis and treatment of the most prevalent sleep problems and for the management of chronic users of sleeping pills. The preferred approach for sleeplessness is not to prescribe medication but to give information and behavioural advice. Practice assistants of the Dutch Association of Mental Health and Addiction Care are also expected to be able to undertake this management. The GP may consider prescribing sleeping pills for a short period only in cases of severe insomnia with considerable distress. Chronic users of sleeping pills should be advised by the GP to stop using them or to reduce the dose gradually (controlled dose reduction). The GP may refer patients with suspected obstructive sleep apnoea (OSA) to a pulmonary or ear, nose and throat specialist or neurologist for further diagnosis depending on the regional arrangements. The GP may then consider the cardiovascular risk factors commonly present with OSA. In patients with restless legs syndrome (RLS) who continue to experience major distress despite being given advice without the prescription of medication, the GP may consider prescribing a dopamine agonist.

Effectiveness of improvement plans in primary care practice accreditation: a clustered randomized trial.

BACKGROUND: Accreditation of healthcare organizations is a widely used method to assess and improve quality of healthcare. Our aim was to determine the effectiveness of improvement plans in practice accreditation of primary care practices, focusing on cardiovascular risk management (CVRM). METHOD: A two-arm cluster randomized controlled trial with a block design was conducted with measurements at baseline and follow-up. Primary care practices allocated to the intervention group (n = 22) were instructed to focus improvement plans during the intervention period on CVRM, while practices in the control group (n = 23) could focus on any domain except on CVRM and diabetes mellitus. Primary outcomes were systolic blood pressure <140 mmHg, LDL cholesterol <2.5 mmol/l and prescription of antiplatelet drugs. Secondary outcomes were 17 indicators of CVRM and physician's perceived goal attainment for the chosen improvement project. RESULTS: No effect was found on the primary outcomes. Blood pressure targets were reached in 39.8% of patients in the intervention and 38.7% of patients in the control group; cholesterol target levels were reached in 44.5% and 49.0% respectively; antiplatelet drugs were prescribed in 82.7% in both groups. Six secondary outcomes improved: smoking status, exercise control, diet control, registration of alcohol intake, measurement of waist circumference, and fasting glucose. Participants' perceived goal attainment was high in both arms: mean scores of 7.9 and 8.2 on the 10-point scale. CONCLUSIONS: The focus of improvement plans on CVRM in the practice accreditation program led to some improvements of CVRM, but not on the primary outcomes. ClinicalTrials.gov NCT00791362.

Effect of accreditation on the quality of chronic disease management: a comparative observational study.

BACKGROUND: Practice accreditation is widely used to assess and improve quality of healthcare providers. Little is known about its effectiveness, particularly in primary care. In this study we examined the effect of accreditation on quality of care regarding diabetes, chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD). METHODS: A comparative observational study with two cohorts was performed. We included 138 Dutch family practices that participated in the national accreditation program for primary care. A first cohort of 69 practices was measured at start and completion of a 3-year accreditation program. A second cohort of 69 practices was included and measured simultaneously with the final measurement of the first cohort. In separate multilevel regression analyses, we compared both within-group changes in the first cohort and between-groups differences at follow-up (first cohort) and start (second cohort). Outcome measures consisted of 24 systematically developed indicators of quality of care in targeted chronic diseases. RESULTS: In the within-group comparison, we found improvements on 6 indicators related to diabetes (feet examination, cholesterol measurement, lipid lowering medication prescription) and COPD (spirometry performance, stop smoking advice). In the between-groups comparison we found that first cohort practices performed better on 4 indicators related to diabetes (cholesterol outcome) and CVD (blood pressure outcome, smoke status registration, glucose measurement). CONCLUSIONS: Improvements of the quality of primary care for patients with chronic diseases were found, but few could be attributed to the accreditation program. Further development of accreditation is needed to enhance its effectiveness on chronic disease management.

Organizational determinants of high-quality routine diabetes care.

OBJECTIVE: Randomized trials showed that changes in healthcare organization improved diabetes care. This study aimed to identify which organizational determinants were associated with patient outcomes in routine diabetes care. DESIGN: Observational study, in which multilevel regression analyses were applied to examine the impact of 12 organizational determinants on diabetes care as separate measures and as a composite score. SETTING: Primary care practices in the Netherlands. SUBJECTS: 11,751 patients with diabetes in 354 practices. MAIN OUTCOME MEASURES: Patients' recorded glycated hemoglobin (HbA1c), systolic blood pressure, and serum cholesterol levels. RESULTS: A higher score on the composite measure of organizational determinants was associated with better control of systolic blood pressure (p = 0.017). No effects on HbA1C or cholesterol levels were found. Exploration of specific organizational factors found significant impact of use of an electronic patient registry on HbA1c (OR = 1.80, 95% CI 1.12-2.88), availability of patient leaflets on systolic blood pressure control (OR = 2.59, 95% CI 1.06-6.35), and number of hours' nurse education on cholesterol control (OR = 2.51, 95% CI 1.02-6.15). CONCLUSION: In routine primary care, it was found that favorable healthcare organization was associated with a number of intermediate outcomes in diabetes care. This finding lends support to the findings of trials on organizational changes in diabetes care. Notably, the composite measure of organizational determinants had most impact.

[Summary of the NHG guideline 'The STD consultation']. / Samenvatting van de NHG-standaard 'Het soa-consult'.

The guideline 'The STD consultation' of the Dutch College of General Practitioners provides guidelines for the diagnosis and management of patients with symptoms of a sexually transmitted disease (STD), patients at high risk of being infected with a STD (risk groups), and patients with questions or concerns about STDs. The test policy depends on the patient's symptoms and risks and is extensively described in the guideline. Men who have sex with men (MSM), prostitutes, people who visit prostitutes, people from countries in which STDs are endemic, people with multiple sexual partners, and people with a partner from one of these groups are at increased risk of contracting one of the five major STDs (chlamydia, gonorrhoea, syphilis, hepatitis B, and HIV). Patients originating from HIV-endemic regions or MSM can be offered HIV and, if appropriate, hepatitis B testing. Young men and women (< 25 years) can be offered chlamydia testing.- Treatment is dependent on the causative agent.

[Practice guideline on 'Acute diarrhoea' from the Dutch College of General Practitioners]. / NHG-standaard 'Acute diarree'.

The revised guideline on 'Acute diarrhoea' from the Dutch College of General Practitioners covers the diagnosis and management of suspected acute infectious diarrhoea. Acute diarrhoea resulting from infectious gastroenteritis is often caused by a virus and is usually self-limiting; stool testing is rarely indicated. The main complication of acute diarrhoea is dehydration, although this is rare in the Netherlands. Children under 2 years old and patients over 70 are at an increased risk of dehydration. Dehydration is a clinical diagnosis based on a combination of patient history and physical examination. DNA diagnostic methods such as polymerase chain reaction (PCR) are now available for stool testing, in addition to stool culture and the triple faeces test (TFT). PCR is preferred for its better test properties. Treatment with oral rehydration salts (ORS) is indicated for patients with dehydration and may also be useful in patients at an increased risk of this event. Acute diarrhoea after hospitalisation or after visiting the tropics or subtropics merits special attention on account of the risk of infection with unusual pathogens and the consequences with regard to management.

[Summary of the 'Thyroid disorders' guideline of the Dutch College of General Practitioners' (NHG)]. / Samenvatting van de NHG-standaard 'Schildklieraandoeningen'.

The 'Thyroid disorders' guideline of the Dutch College of General Practitioners (NHG) provides recommendations for the diagnosis and management of hypothyroidism, hyperthyroidism and changes in the size of the thyroid gland, such as goitre and thyroid nodules. Hypothyroid patients younger than 60 years and without cardiac comorbidity should receive the full substitution dose of levothyroxine at treatment onset. In case of hypothyroidism in pregnancy, the levothyroxine dose should be immediately increased by 25%. All pregnant patients with (a history of) thyroid diseases should be tested for TSH-receptor antibodies at the start of the pregnancy. Management of subclinical hypo- and hyperthyroidism consists of monitoring laboratory values due to the great likelihood of normalization of the TSH value. All patients with a solitary nodule or a dominant nodule in a multinodular goitre should be referred to an endocrinologist for further investigation.