The decision to continue or discontinue treatment: experiences and beliefs of users of selective serotonin-reuptake inhibitors in the initial months--a qualitative study.

BACKGROUND: Little is known about patients' views on taking selective serotonin-reuptake inhibitors (SSRIs) and their decision-making processes regarding either continuation or discontinuation within a few months of initiating therapy. OBJECTIVE: To explore the experiences and beliefs of SSRI users in relation to initiation and execution of treatment, with the intention to identify patterns leading to discontinuation or continuation of treatment. METHODS: Semistructured qualitative interview study. Eighteen patients, older than 18 years, were interviewed 3 months after starting SSRI treatment prescribed by a general practitioner (GP), 9 of whom had discontinued (discontinuers) and 9 of whom continued treatment (continuers). RESULTS: Two main patterns lead to either discontinuation or continuation of use. Continuers were satisfied with the GP's role during initiation and execution of SSRI treatment and fully trusted their decision. Continuers' attitudes toward treatment were predominantly positive; they seemed to have little doubt about the necessity of using an SSRI and hardly considered discontinuing for fear of relapse. Discontinuers, on the other hand, seemed to be less involved in decision making and often appeared to have little confidence in their GPs. Most discontinuers felt that they lacked knowledge, and their attitude toward taking SSRIs was rather negative. Discontinuers often were unconvinced about the necessity of using an SSRI and appeared to have a strong desire to discontinue treatment. CONCLUSION: Lack of shared decision making between patient and GP, limited counseling during treatment, lack of knowledge, and patients' negative attitudes toward SSRI use and the disease itself, hampered the acceptance of the SSRI and brought on the decisional conflict to discontinue treatment. Health care professionals could be more supportive during the initial months of SSRI treatment by eliciting patients' considerations for continuing or discontinuing treatment.

Patient evaluations of accessibility and co-ordination in general practice in Europe.

OBJECTIVE: To determine whether patient evaluations of the accessibility to general practice and co-ordination with other care providers were associated with characteristics of general practice organizations. BACKGROUND: In 1998 patients across Europe perceived that small general practices have better accessibility than large practices. Since then a number of changes in primary care have had impact on accessibility and co-ordination of care. DESIGN, SETTING AND PARTICIPANTS: The study was based on data from the European Practice Assessment study, an observational study in 284 general practices in 10 countries in 2004. MAIN OUTCOME MEASURES: Patient evaluations of general practice were measured with the 23-item Europep instrument, from which seven items on accessibility and co-ordination were selected in a principal factor analysis. Six practice characteristics were examined: percentage of female general practitioners, mean age of physicians, mean number of physician hours worked per week, number of general practitioners, number of care providers, urbanization level. Mixed regression models were applied, in which patients were clustered within practices, and practices within countries. RESULTS: Practices with a higher numbers of care providers received less positive patient evaluations (b= -0.112, P=0.004). The other practice characteristics were not related to patient evaluations. Only a small proportion of the total variation in patient evaluations of accessibility and co-ordination (1.8%) was explained by characteristics of the general practice organizations. CONCLUSIONS: General practices have become larger in most developed countries in recent years, but patients seemed to prefer general practice organizations with fewer health professionals.

The Patients Assessment Chronic Illness Care (PACIC) questionnaire in The Netherlands: a validation study in rural general practice.

BACKGROUND: Many patients with chronic illness receive health care in primary care settings, so a challenge is to provide well-structured chronic care in these settings. Our aim was to develop and test a Dutch version of the PACIC questionnaire, a measure for patient reported structured chronic care. METHODS: Observational study in 165 patients with diabetes or COPD from four general practices (72% response rate). Patients completed a written questionnaire, which included instruments for assessing chronic illness care (PACIC), evaluations of general practice (Europep), enablement (PEI), and individual characteristics. RESULTS: The patients had a mean age of 68.0 years and 47% comprised of women. Twenty-two to 35% of responding patients did not provide answers to specific items in the PACIC. In 11 items the lowest answering category was used by 30% or more of the responders and in 6 items the highest answering category was used by this number of responders. Principal factor analysis identified the previously defined five domains reasonably well. Cronbach's alpha per domain varied from 0.71 to 0.83, and the intraclass coefficient from 0.66 to 0.91. Diabetes patients reported higher presence of structured chronic care for 14 out of the 20 PACIC items. The effect of patient evaluations of general practice on the PACIC score was positive (b = 0.72, p < 0.004), but the effect of patient enablement on the PACIC score was negative (b = -1.13, p < 0.000). CONCLUSION: A translated and validated Dutch version of the PACIC questionnaire is now available. Further research on its validity is recommended.

Do elderly patients feel more enabled if they had been actively involved in primary care consultations?

OBJECTIVE: This study aimed to determine whether older patients' enablement was associated with their evaluation of the level of their involvement in primary care consultations. METHODS: Secondary analysis of data from an international cross-sectional study in seven European countries (n=625 patients). Patient enablement, preference for involvement in the consultation and evaluation of involvement in the consultation were measured with validated questionnaires. Random coefficient linear modelling was used to identify factors associated with patient enablement. RESULTS: The overall mean patient enablement score was 5.5 (theoretical range: 0-12; higher score indicated more enablement). Enablement was higher in patients who reported more positive compared to those reporting less positive evaluations of involvement (B=1.660; p<0.001). The impact of evaluation on enablement was higher in patients with a high preference for involvement compared to those with lower preference for involvement (B=0.743; p=0.015). CONCLUSION: Positive evaluations of involvement in primary care were associated with higher enablement in older patients, and even more if the patient had a high preference for involvement. PRACTICE IMPLICATIONS: Involving older patients actively may enhance their enablement, a particularly important goal for patients who have one or more chronic conditions.

Different accuracies of rapid enzyme-linked immunosorbent, turbidimetric, and agglutination D-dimer assays for thrombosis exclusion: impact on diagnostic work-ups of outpatients with suspected deep vein thrombosis and pulmonary embolism.

The requirement for a safe diagnostic strategy should be based on an overall posttest incidence of venous thromboembolism (VTE) of less than 1%, with a negative predictive value of more than 99 to 100% during 3-month follow-up. Compression ultrasonography (CUS) and spiral computed tomography (CT) currently are the methods of choice to confirm or rule out deep venous thrombosis (DVT) and pulmonary embolism (PE), respectively. CUS has a negative predictive value (NPV) of 97 to 98%, indicating the need to improve the diagnostic work-up of patients with suspected DVT by clinical score assessment and D-dimer testing. Spiral CT as a stand-alone method detects all clinically relevant PEs and a large number of alternative diagnoses. It rules out PE with a NPV of 98 to 99%. Spiral CT is expensive, emphasizing the need to improve the diagnostic work-up of patients with suspected PE by the use of clinical score assessment and D-dimer testing. Clinical score assessment for DVT and PE has not safely ruled out VTE in multicenter studies and in routine daily practices. Modification of the Wells clinical score assessment for DVT by elimination of the "minus 2 points" for alternative diagnosis will improve the reproducibility of the clinical score assessment. The combination of a first negative CUS and a negative SimpliRed or an enzyme-linked immunosorbent assay (ELISA) VIDAS D-dimer of < 1,000 ng/mL safely exclude DVT (NPV > 99%) irrespective of clinical score assessment and without the need to repeat CUS in approximately 60 to 70% of patients. The rapid quantitative and qualitative agglutination D-dimer assays for the exclusion of VTE are not sensitive enough as stand-alone tests and should be used in combination with clinical score assessment. A normal rapid ELISA VIDAS D-dimer test as a stand-alone test safely excludes DVT and PE, with a NPV of 99 to 100%, irrespective of clinical score, without the need of CUS or spiral CT. The combined strategy of a rapid ELISA VIDAS D-dimer followed by objective testing with CUS for DVT and by spiral CT for PE will reduce the need for noninvasive imaging techniques by 40 to 50%.

Screening for deep vein thrombosis and pulmonary embolism in outpatients with suspected DVT or PE by the sequential use of clinical score: a sensitive quantitative D-dimer test and noninvasive diagnostic tools.

The requirement for a safe diagnostic strategy should be based on an overall posttest incidence of venous thromboembolism (VTE) of less than 1% during 3-month follow-up. The negative predictive value (NPV) during 3 months of follow-up is 98.1 to 99% after a normal venogram, 97 to 98% after a normal compression ultrasonography (CUS), and > 99% after serial CUS testing. Serial CUS testing is safe but 100 CUS must be repeated to find one or two CUS positive for deep vein thrombosis (DVT), which is not cost-effective and indicates the need to improve the diagnostic workup of DVT by the use of clinical score assessment and D-dimer testing. The NPV varies from 97.6 to 99.4% for low clinical score followed by a negative SimpiRED test, indicating the need for a first CUS. The NPV is 98.4 to 99.3% for a normal rapid enzyme-linked immunosorbent assay (ELISA) VIDAS D-dimer test result (< 500 ng/mL) irrespective of clinical score. The NPV is more than 99% for a negative CUS followed by either a negative SimpiRED test or an ELISA VIDAS test result of < 1000 ng/mL without the need to repeat a second CUS within 1 week. The sequential use of a sensitive, rapid ELISA D-dimer and clinical score assessment will safely reduce the need for CUS testing by 40 to 60%. Large prospective outcome studies demonstrate that with one negative examination with complete duplex color ultrasonography (CCUS) of the proximal and distal veins of the affected leg with suspected DVT, it is safe to withhold anticoagulant treatment, with a negative predictive value of 99.5%. This may indicates that CCUS is equal to serial CUS or the combined use of clinical score, D-dimer testing, and CUS. Pulmonary angiography is the gold standard for segmental pulmonary embolism (PE) but not for subsegmental PE. A normal perfusion lung scan and a normal rapid ELISA VIDAS D-dimer test safely excludes PE. Helical spiral computed tomography (CT) detects all clinically relevant PE and a large number of alternative diagnoses in symptomatic patients with suspected PE and can replace both the ventilation perfusion scan and pulmonary angiography to safely rule in PE and to rule out PE with an NPV of > 99%. The combination of clinical assessment, a rapid ELISA VIDAS D-dimer, followed by CUS will reduce the need for helical spiral CT by 40 to 50%.

Variation in requests for imaging investigations by general practitioners: a multilevel analysis.

OBJECTIVES: To describe the variation in the numbers of imaging investigations requested by general practitioners (GPs) and to find likely explanations for this variation. METHODS: Cross-sectional survey of the use of eight imaging investigations by 229 GPs collaborating in 40 local GP groups from five regions in the Netherlands during 1997. A multivariable, multilevel regression analysis was used to link these data with survey data on professional characteristics such as knowledge about and attitude towards test ordering, and with data on contextual factors such as practice type or experience with feedback on test-ordering data. RESULTS: Data for 221 GPs (97%) were available. After adjustment for practice size and working time, the median number of imaging investigations ordered per GP was 148 (interquartile range 71 to 300), with large differences (up to twofold) between the regions (P<0.001). Overall, chest X-rays were the largest single category (median = 48 interquartile range 17 to 100). GPs working in a group practice requested, on average, 34% fewer investigations than their colleagues working in single-person practices (95% confidence interval 17 to 48%). CONCLUSIONS: Only practice type was found to be associated with the number of imaging investigations requested, adjusted for practice size and working time factor. No further explanations were found for the inter-regional differences. Future studies on the ordering of imaging investigations by GPs should attempt to delineate contextual from regional factors.

Improving test ordering in primary care: the added value of a small-group quality improvement strategy compared with classic feedback only.

PURPOSE: We wanted to evaluate the added value of small peer-group quality improvement meetings compared with simple feedback as a strategy to improve test-ordering behavior. Numbers of tests ordered by primary care physicians are increasing, and many of these tests seem to be unnecessary according to established, evidence-based guidelines. METHODS: We enrolled 194 primary care physicians from 27 local primary care practice groups in 5 health care regions (5 diagnostic centers). The study was a cluster randomized trial with randomization at the local physician group level. We evaluated an innovative, multifaceted strategy, combining written comparative feedback, group education on national guidelines, and social influence by peers in quality improvement sessions in small groups. The strategy was aimed at 3 specific clinical topics: cardiovascular issues, upper abdominal complaints, and lower abdominal complaints. The mean number of tests per physician per 6 months at baseline and the physicians' region were used as independent variables, and the mean number of tests per physician per 6 months was the dependent variable. RESULTS: The new strategy was executed in 13 primary care groups, whereas 14 groups received feedback only. For all 3 clinical topics, the decrease in mean total number of tests ordered by physicians in the intervention arm was far more substantial (on average 51 fewer tests per physician per half-year) than the decrease in mean number of tests ordered by physicians in the feedback arm (P = .005). Five tests considered to be inappropriate for the clinical problem of upper abdominal complaints decreased in the intervention arm, with physicians in the feedback arm ordering 13 more tests per 6 months (P = .002). Interdoctor variation in test ordering decreased more in the intervention arm. CONCLUSION: Compared with only disseminating comparative feedback reports to primary care physicians, the new strategy of involving peer interaction and social influence improved the physicians' test-ordering behavior. To be effective, feedback needs to be integrated in an interactive, educational environment.

Predominant symptom behavior in patients with persistent dyspepsia during treatment.

BACKGROUND: Grouping of patients based on a predominant dyspeptic symptom is frequently employed in management strategies for dyspepsia. Such subdivision, however, suggests that dyspeptic symptom patterns are constant over time. OBJECTIVE: To investigate the behavior of symptoms over time and to study the effects of diagnostic procedures and treatment on the pattern and severity of dyspeptic symptoms. METHODS: Patients with persistent dyspeptic symptoms completed a validated questionnaire at regular time intervals as part of a clinical trial in primary care. Based on predominant symptoms, patients were classified into ulcer-like dyspepsia, reflux-like dyspepsia, dysmotility-like dyspepsia, and unspecific dyspepsia according to the Rome II criteria. RESULTS: Questionnaires were returned at baseline, 1, 3, and 6 months by 185, 172, 169, and 170 patients, respectively. At baseline, 35% of patients reported predominantly reflux-like dyspepsia, 34% had ulcer-like dyspepsia, 16% had dysmotility-like dyspepsia, and in 15% symptoms were not specific. During the 6-month follow-up period, only 35% of patients kept the same predominant symptom. Symptom (in)stability was not dependent on diagnostic procedures or on therapy with proton pump inhibitors, H2-receptor antagonists, prokinetics, or antacids. CONCLUSION: In the majority of dyspeptic patients, symptoms change continuously as time goes on. Symptom instability is not influenced by diagnostic procedures or therapy. Thus, there is little sense in symptom-based management of dyspepsia in primary care.

Effect of a practice-based strategy on test ordering performance of primary care physicians: a randomized trial.

CONTEXT: Numbers of diagnostic tests ordered by primary care physicians are growing and many of these tests seem to be unnecessary according to established, evidence-based guidelines. An innovative strategy that focused on clinical problems and associated tests was developed. OBJECTIVE: To determine the effects of a multifaceted strategy aimed at improving the performance of primary care physicians' test ordering. DESIGN: Multicenter, randomized controlled trial with a balanced, incomplete block design and randomization at group level. Thirteen groups of primary care physicians underwent the strategy for 3 clinical problems (arm A; cardiovascular topics, upper and lower abdominal complaints), while 13 other groups underwent the strategy for 3 other clinical problems (arm B; chronic obstructive pulmonary disease and asthma, general complaints, degenerative joint complaints). Each arm acted as a control for the other. SETTING: Primary care physician groups in 5 regions in the Netherlands with diagnostic centers recruited from May to September 1998. STUDY PARTICIPANTS: Twenty-six primary care physician groups, including 174 primary care physicians. INTERVENTION: During the 6 months of intervention, physicians discussed 3 consecutive, personal feedback reports in 3 small group meetings, related them to 3 evidence-based clinical guidelines, and made plans for change. MAIN OUTCOME MEASURE: According to existing national, evidence-based guidelines, a decrease in the total numbers of tests ordered per clinical problem, and of some defined inappropriate tests, is considered a quality improvement. RESULTS: For clinical problems allocated to arm A, the mean total number of requested tests per 6 months per physician was reduced from baseline to follow-up by 12% among physicians in the arm A intervention, but was unchanged in the arm B control, with a mean reduction of 67 more tests per physician per 6 months in arm A than in arm B (P =.01). For clinical problems allocated to arm B, the mean total number of requested tests per 6 months per physician was reduced from baseline to follow-up by 8% among physicians in the arm B intervention, and by 3% in the arm A control, with a mean reduction of 28 more tests per physician per 6 months in arm B than in arm A (P =.22). Physicians in arm A had a significant reduction in mean total number of inappropriate tests ordered for problems allocated to arm A, whereas the reduction in inappropriate test ordered physicians in arm B for problems allocated to arm B was not statistically significant. CONCLUSION: In this study, a practice-based, multifaceted strategy using guidelines, feedback, and social interaction resulted in modest improvements in test ordering by primary care physicians.