Cost-effectiveness of a stepwise cardiometabolic disease prevention program: results of a randomized controlled trial in primary care.

BACKGROUND: Cardiometabolic diseases (CMD) are the major cause of death worldwide and are associated with a lower quality of life and high healthcare costs. To prevent a further rise in CMD and related healthcare costs, early detection and adequate management of individuals at risk could be an effective preventive strategy. The objective of this study was to determine long-term cost-effectiveness of stepwise CMD risk assessment followed by individualized treatment if indicated compared to care as usual. A computer-based simulation model was used to project long-term health benefits and cost-effectiveness, assuming the prevention program was implemented in Dutch primary care. METHODS: A randomized controlled trial in a primary care setting in which 1934 participants aged 45-70 years without recorded CMD or CMD risk factors participated. The intervention group was invited for stepwise CMD risk assessment through a risk score (step 1), additional risk assessment at the practice in case of increased risk (step 2) and individualized follow-up treatment if indicated (step 3). The control group was not invited for risk assessment, but completed a health questionnaire. Results of the effectiveness analysis on systolic blood pressure (- 2.26 mmHg; 95% CI - 4.01: - 0.51) and total cholesterol (- 0.15 mmol/l; 95% CI - 0.23: - 0.07) were used in this analysis. Outcome measures were the costs and benefits after 1-year follow-up and long-term (60 years) cost-effectiveness of stepwise CMD risk assessment compared to no assessment. A computer-based simulation model was used that included data on disability weights associated with age and disease outcomes related to CMD. Analyses were performed taking a healthcare perspective. RESULTS: After 1 year, the average costs in the intervention group were 260 Euro higher than in the control group and differences were mainly driven by healthcare costs. No meaningful change was found in EQ 5D-based quality of life between the intervention and control groups after 1-year follow-up (- 0.0154; 95% CI - 0.029: 0.004). After 60 years, cumulative costs of the intervention were 41.4 million Euro and 135 quality-adjusted life years (QALY) were gained. Despite improvements in blood pressure and cholesterol, the intervention was not cost-effective (ICER of 306,000 Euro/QALY after 60 years). Scenario analyses did not allow for a change in conclusions with regard to cost-effectiveness of the intervention. CONCLUSIONS: Implementation of this primary care-based CMD prevention program is not cost-effective in the long term. Implementation of this program in primary care cannot be recommended. TRIAL REGISTRATION: Dutch Trial Register NTR4277 , registered on 26 November 2013.

Comparison of influenza surveillance systems in Australia, China, Malaysia and expert recommendations for influenza control.

BACKGROUND: The Western Pacific Region (WPR) is exposed each year to seasonal influenza and is often the source of new influenza virus variants and novel pathogen emergence. National influenza surveillance systems play a critical role in detecting emerging viruses, monitoring influenza epidemics, improving public disease awareness and promoting pandemic preparedness, but vary widely across WPR countries. The aim of this study is to improve existing influenza surveillance systems by systematically comparing selected WPR influenza surveillance systems. METHODS: Three national influenza surveillance systems with different levels of development (Australia, China and Malaysia) were compared and their adherence to World Health Organization (WHO) guidance was evaluated using a structured framework previously tested in several European countries consisting of seven surveillance sub-systems, 19 comparable outcomes and five evaluation criteria. Based on the results, experts from the Asia-Pacific Alliance for the Control of Influenza (APACI) issued recommendations for the improvement of existing surveillance systems. RESULTS: Australia demonstrated the broadest scope of influenza surveillance followed by China and Malaysia. In Australia, surveillance tools covered all sub-systems. In China, surveillance did not cover non-medically attended respiratory events, primary care consultations, and excess mortality modelling. In Malaysia, surveillance consisted of primary care and hospital sentinel schemes. There were disparities between the countries across the 5 evaluation criteria, particularly regarding data granularity from health authorities, information on data representativeness, and data communication, especially the absence of publicly available influenza epidemiological reports in Malaysia. This dual approach describing the scope of surveillance and evaluating the adherence to WHO guidance enabled APACI experts to make a number of recommendations for each country that included but were not limited to introducing new surveillance tools, broadening the use of specific existing surveillance tools, collecting and sharing data on virus characteristics, developing immunization status registries, and improving public health communication. CONCLUSIONS: Influenza monitoring in Australia, China, and Malaysia could benefit from the expansion of existing surveillance sentinel schemes, the broadened use of laboratory confirmation and the introduction of excess-mortality modelling. The results from the evaluation can be used as a basis to support expert recommendations and to enhance influenza surveillance capabilities.

Characteristics and motives of non-responders in a stepwise cardiometabolic disease prevention program in primary care.

BACKGROUND: A high response rate is an important condition for effective prevention programs. We aimed at gaining insight into the characteristics and motives of non-responders in different stages of a stepwise prevention program for cardiometabolic diseases (CMD) in primary care. METHODS: We performed a non-response analysis within a randomized controlled trial assessing the effectiveness of a stepwise CMD prevention program in the Netherlands. Patients between 45 and 70 years without known CMD were invited for stage 1 of the program, completing a CMD risk score. Patients with an increased risk were advised to visit their general practice for additional measurements, stage 2 of the program. We analyzed determinants of non-response using data from the risk score, electronic medical records, questionnaires and Statistics Netherlands. RESULTS: Non-response in stage 1 was associated with a younger age, male sex, a migration background, a low prosperity score, self-employment, being single and having lower consultations rates in general practice. Non-response in stage 2 was associated with a low prosperity score, being employed, having no chronic illness, smoking, a normal waist circumference, a negative family history for cardiovascular disease or diabetes and having a lower consultation rate. More than half of the non-responders in stage 2 reported not visiting the GP because they did not expect to have any CMD, despite their increased risk. CONCLUSIONS: To achieve a larger and more equal uptake of prevention programs for CMD, we should use methods adapted to characteristics of non-responders, such as targeted invitation methods and improved risk communication.

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

BACKGROUND: Continuity of care, in particular personal continuity, is a core principle of general practice and is associated with many benefits such as a better patient-provider relationship and lower mortality. However, personal continuity is under pressure due to changes in society and healthcare. This affects older patients more than younger patients. As the number of older patients will double the coming decades, an intervention to optimise personal continuity for this group is highly warranted. METHODS: Following the UK Medical Research Council framework for complex Interventions, we will develop and evaluate an intervention to optimise personal continuity for older patients in general practice. In phase 0, we will perform a literature study to provide the theoretical basis for the intervention. In phase I we will define the components of the intervention by performing surveys and focus groups among patients, general practitioners, practice assistants and practice nurses, concluded by a Delphi study among members of our group. In phase II, we will test and finalise the intervention with input from a pilot study in two general practices. In phase III, we will perform a stepped wedge cluster randomised pragmatic trial. The primary outcome measure is continuity of care from the patients' perspective, measured by the Nijmegen Continuity Questionnaire. Secondary outcome measures are level of implementation, barriers and facilitators for implementation, acceptability and feasibility of the intervention. In phase IV, we will establish the conditions for large-scale implementation. DISCUSSION: This is the first study to investigate an intervention for improving personal continuity for older patients in general practice. If proven effective, our intervention will enable General practitioners to improve the quality of care for their increasing population of older patients. The pragmatic design of the study will enable evaluation in real-life conditions, facilitating future implementation. TRIAL REGISTRATION NUMBER: Netherlands Trial Register, trial NL8132 . Registered 2 November 2019.

Transcending boundaries for collaborative patient care.

Dutch general practitioners (GPs) and medical specialists (MSs) create collaborative patient care agreements (CPCAs) to improve intraprofessional collaboration. We set out to identify contradictions between the activity systems of primary and secondary care that could result in expansive learning and new ways of working collaboratively. We analysed nineteen semi-structured interviews using activity theory (AT) as a theoretical framework and using these two activity systems as the units of analysis. There were contradictions within and between the activity systems related, for example, to different understandings of 'care' in generalist and specialist settings. GPs and MSs were able to identify contradictions and learn expansively when they iteratively co-created CPCAs in groups. They found it much harder to tackle contradictions, however, when they disseminated these tools within their respective professional communities, leaving unresolved contradictions and missed opportunities for collaboration. This research shows the educational benefits of taking collective responsibility for improving collaborative patient care.

Income-related differences in out-of-hours primary care telephone triage using national registration data.

BACKGROUND: Telephone triage is used to facilitate efficient and adequate acute care allocation, for instance in out-of-hours primary care services (OPCSs). Remote assessment of health problems is challenging and could be impeded by a patient's ambiguous formulation of his or her healthcare need. Socioeconomically vulnerable patients may experience more difficulty in expressing their healthcare need. We aimed to assess whether income differences exist in the patient's presented symptoms, assessed urgency and allocation of follow-up care in OPCS. METHOD: Data were derived from Nivel Primary Care Database encompassing electronic health record data of 1.3 million patients from 28 OPCSs in 2017 in the Netherlands. These were linked to sociodemographic population registry data. Multilevel logistic regression analyses (contacts clustered in patients), adjusted for patient characteristics (eg, age, sex), were conducted to study associations of symptoms, urgency assessment and follow-up care with patients' income (standardised for household size as socioeconomic status (SES) indicator). RESULTS: The most frequently presented symptoms deduced during triage slightly differed across SES groups, with a larger relative share of trauma in the high-income groups. No SES differences were observed in urgency assessment. After triage, low income was associated with a higher probability of receiving telephone advice and home visits, and fewer consultations at the OPCS. CONCLUSIONS: SES differences in the patient's presented symptom and in follow-up in OPCS suggest that the underlying health status and the ability to express care needs affect the telephone triage process . Further research should focus on opportunities to better tailor the telephone triage process to socioeconomically vulnerable patients.

Effectiveness of a stepwise cardiometabolic disease prevention program: Results of a randomized controlled trial in primary care.

Effective preventive strategies for cardiometabolic disease (CMD) are needed. We aim to establish the effectiveness of a stepwise CMD risk assessment followed by individualized treatment if indicated compared to care as usual. We conducted a RCT between 2014 and 2017. Individuals (45-70 years) without CMD or CMD risk factors were invited for stepwise CMD risk assessment through a risk score (step1), additional risk assessment at the practice in case of high-risk (step2) and individualized follow-up treatment if indicated (step3). We compared newly detected CMD and newly prescribed drugs during one-year follow-up, and change in CMD risk profile between baseline and one-year follow-up among participants who completed step2 to matched controls. A CMD was diagnosed almost three times more often (OR 2.90, 95% CI 2.25: 3.72) in the intervention compared to the control group, in parallel with newly prescribed antihypertensive and lipid lowering drugs (OR 2.85, 95% CI 1.96: 4.15 and 3.23, 95% CI 2.03: 5.14 respectively). Waist circumference significantly decreased between the intervention compared to the control group (mean -3.08 cm, 95% CI -3.73: -2.43). No differences were observed for changes in BMI and smoking. Systolic blood pressure (mean -2.26 mmHg, 95% CI -4.01: -0.51) and cholesterol ratio (mean -0.11, 95% CI -0.19: -0.02) significantly decreased within intervention participants between baseline and one-year follow-up. In conclusion, implementation of the CMD prevention program resulted in the detection of two- to threefold more patients with CMD. A significant drop in systolic blood pressure and cholesterol levels was found after one year of treatment. Modelling of these results should confirm the effect on long term endpoints. Trial registration: Dutch trial Register number NTR4277.

Effectiveness of a guided ACT-based self-help resilience training for depressive symptoms during pregnancy: Study protocol of a randomized controlled trial embedded in a prospective cohort.

BACKGROUND: During pregnancy, about 10 to 20% of women experience depressive symptoms. Subclinical depression increases the risk of peripartum depression, maternal neuro-endocrine dysregulations, and adverse birth and infant outcomes. Current treatments often comprise face-to-face psychological or pharmacological treatments that may be too intensive for women with subclinical depression leading to drop-out and moderate effectiveness. Therefore, easily accessible, resilience enhancing and less stigmatizing interventions are needed to prevent the development of clinical depression. This paper describes the protocol of a prospective cohort study with an embedded randomized controlled trial (RCT) that aims to improve mental resilience in a sample of pregnant women through a self-help program based on the principles of Acceptance and Commitment Therapy (ACT). Maternal and offspring correlates of the trajectories of peripartum depressive symptoms will also be studied. METHODS: Pregnant women (≥ 18 years) receiving care in Dutch midwifery practices will participate in a prospective cohort study (n ~ 3500). Between 12 and 18 weeks of pregnancy, all women will be screened for depression with the Edinburgh Postnatal Depression Scale (EPDS). Women with an EPDS score ≥ 11 will be evaluated with a structured clinical interview. Participants with subclinical depression (n = 290) will be randomized to a 9-week guided self-help ACT-training or to care as usual (CAU). Primary outcomes (depressive symptoms and resilience) and secondary outcomes (e.g. anxiety and PTSD, bonding, infant development) will be collected via online questionnaires at four prospective assessments around 20 weeks and 30 weeks gestation and at 6 weeks and 4 months postpartum. Maternal hair cortisol concentrations will be assessed in a subsample of women with a range of depressive symptoms (n = 300). The intervention's feasibility will be assessed through qualitative interviews in a subsample of participants (n = 20). DISCUSSION: This is the first study to assess the effectiveness of an easy to administer intervention strategy to prevent adverse mental health effects through enhancing resilience in pregnant women with antepartum depressive symptomatology. This longitudinal study will provide insights into trajectories of peripartum depressive symptoms in relation to resilience, maternal cortisol, psychological outcomes, and infant developmental milestones. TRIAL REGISTRATION: Netherlands Trial Register (NTR), NL7499 . Registered 5 February 2019.

Socioeconomic inequalities in out-of-hours primary care use: an electronic health records linkage study.

BACKGROUND: Low socioeconomic position (SEP) is related to higher healthcare use in out-of-hours primary care services (OPCSs). We aimed to determine whether inequalities persist when taking the generally poorer health status of socioeconomically vulnerable individuals into account. To put OPCS use in perspective, this was compared with healthcare use in daytime general practice (DGP). METHODS: Electronic health record (EHR) data of 988 040 patients in 2017 (251 DGPs, 27 OPCSs) from Nivel Primary Care Database were linked to socio-demographic data (Statistics, The Netherlands). We analyzed associations of OPCS and DGP use with SEP (operationalized as patient household income) using multilevel logistic regression. We controlled for demographic characteristics and the presence of chronic diseases. We additionally stratified for chronic disease groups. RESULTS: An income gradient was observed for OPCS use, with higher probabilities within each lower income group [lowest income, reference highest income group: odds ratio (OR) = 1.48, 95% confidence interval (CI): 1.45-1.51]. Income inequalities in DGP use were considerably smaller (lowest income: OR = 1.17, 95% CI: 1.15-1.19). Inequalities in OPCS were more substantial among patients with chronic diseases (e.g. cardiovascular disease lowest income: OR = 1.60, 95% CI: 1.53-1.67). The inequalities in DGP use among patients with chronic diseases were similar to the inequalities in the total population. CONCLUSIONS: Higher OPCS use suggests that chronically ill patients with lower income had additional healthcare needs that have not been met elsewhere. Our findings fuel the debate how to facilitate adequate primary healthcare in DGP and prevent vulnerable patients from OPCS use.

Uptake and detection rate of a stepwise cardiometabolic disease detection program in primary care-a cohort study.

BACKGROUND: Early detection and treatment of cardiometabolic diseases (CMD) in high-risk patients is a promising preventive strategy to anticipate the increasing burden of CMD. The Dutch guideline 'the prevention consultation' provides a framework for stepwise CMD risk assessment and detection in primary care. The aim of this study was to assess the outcome of this program in terms of newly diagnosed CMD. METHODS: A cohort study among 30 934 patients, aged 45-70 years without known CMD or CMD risk factors, who were invited for the CMD detection program within 37 general practices. Patients filled out a CMD risk score (step 1), were referred for additional risk profiling in case of high risk (step 2) and received lifestyle advice and (pharmacological) treatment if indicated (step 3). During 1-year follow-up newly diagnosed CMD, prescriptions and abnormal diagnostic tests were assessed. RESULTS: Twelve thousand seven hundred and thirty-eight patients filled out the risk score of which 865, 6665 and 5208 had a low, intermediate and high CMD risk, respectively. One thousand seven hundred and fifty-five high-risk patients consulted the general practitioner, in 346 of whom a new CMD was diagnosed. In an additional 422 patients a new prescription and/or abnormal diagnostic test were found. CONCLUSIONS: Implementation of the CMD detection program resulted in a new CMD diagnosis in one-fifth of high-risk patients who attended the practice for completion of their risk profile. However, the potential yield of the program could be higher given the considerable number of additional risk factors-such as elevated glucose, blood pressure and cholesterol levels-found, requiring active follow-up and presumably treatment in the future.

Identifying high-need patients with multimorbidity from their illness perceptions and personal resources to manage their health and care: a longitudinal study.

BACKGROUND: A proactive person-centred care process is advocated for people with multimorbidity. To that aim, general practitioners may benefit from support in the identification of high-need patients, i.e. patients who are high or suboptimal users of health services and/or have a poor quality of life. To develop such support, we examined whether knowledge about patients' illness perceptions and personal resources to manage their health and care is useful to identify high-need patients among multimorbid general practice populations. METHODS: Survey data, collected in 2016 and 2017, of 601 patients with two or more chronic diseases (e.g. COPD, diabetes, Parkinson's disease) registered with 40 general practices in the Netherlands were analysed by logistic regression analysis to predict frequent contact with the general practice, contact with general practice out-of-office services, unplanned hospitalisations and poor health related quality of life. Patients' illness perceptions and personal resources (education, health literacy, mastery, mental health status, financial resources, social support) were included as predictors. RESULTS: The four outcomes were only weakly associated among themselves (Phi .07-.19). Patients' illness perceptions and personal resources were of limited value to predict potentially suboptimal health service use, but they were important predictors of health related quality of life. Patients with a poor health related quality of life could be identified by their previously reported illness perceptions (attributing many symptoms to their chronic conditions (B = 1.479, P < .001), a high level of concern (B = 0.844, P = .002) and little perceived control over their illness (B = -0.728, P = .006)) combined with an experienced lack of social support (B = -0.527, P = .042) and a poor mental health status (B = -0.966, P = .001) (sensitivity 80.7%; specificity 68.1%). CONCLUSIONS: Multimorbid patients who frequently contact the general practice, use general practice out-of-office services, have unplanned hospitalisations or a poor health related quality of life are largely distinct high-need subgroups. Multimorbid patients at risk of developing a poor quality of life can be identified from specific illness beliefs, a poor mental health status and unmet social needs.

Communication between general practitioners and medical specialists in the referral process: a cross-sectional survey in 34 countries.

BACKGROUND: The communication of relevant patient information between general practitioners (GPs) and medical specialists is important in order to avoid fragmentation of care thus achieving a higher quality of care and ensuring physicians' and patients' satisfaction. However, this communication is often not carried out properly. The objective of this study is to assess whether communication between GPs and medical specialists in the referral process is associated with the organisation of primary care within a country, the characteristics of the GPs, and the characteristics of the primary care practices themselves. METHODS: An analysis of a cross-sectional survey among GPs in 34 countries was conducted. The odds ratios of the features that were expected to relate to higher rates of referral letters sent and communications fed back to GPs were calculated using ordered logistic multilevel models. RESULTS: A total of 7183 GPs from 34 countries were surveyed. Variations between countries in referral letters sent and feedback communication received did occur. Little of the variance between countries could be explained. GPs stated that they send more referral letters, and receive more feedback communications from medical specialists, in countries where they act as gatekeepers, and when, in general, they interact more with specialists. GPs reported higher use of referral letters when they had a secretary and/or a nurse in their practice, used health information technologies, and had greater job satisfaction. CONCLUSIONS: There are large differences in communication between GPs and medical specialists. These differences can partly be explained by characteristics of the country, the GP and the primary care practice. Further studies should also take the organisation of secondary care into account.

Feasibility and success rates of response enhancing strategies in a stepwise prevention program for cardiometabolic diseases in primary care.

BACKGROUND: Prevention programs for cardiometabolic diseases (CMD), including cardiovascular disease, diabetes mellitus and chronic kidney disease are feasible, but evidence for the cost-effectiveness of selective CMD prevention programs is lacking. Response rates have an important role in effectiveness, but methods to increase response rates have received insufficient attention. The aim of the current study is to determine the feasibility and the success rate of a variety of response enhancing strategies to increase the participation in a selective prevention program for CMD. METHODS: The INTEGRATE study is a Dutch randomised controlled trial to assess the effectiveness and cost-effectiveness of a stepwise program for CMD prevention. During the INTEGRATE study we developed ten different response enhancing strategies targeted at different stages of non-response and different patient populations and evaluated these in 29 general practices. RESULTS: A face-to-face reminder by the GP increased the response significantly. Digital reminders targeted at patients with an increased CMD risk showed a positive trend towards participation. Sending invitations and reminders by e-mail generated similar response rates, but at lower costs and time investment than the standard way of dissemination. Translated materials, information gatherings at the practice, self-management toolkits, reminders by telephone, information letters, local media attention and SMS text reminders did not increase the response to our program. CONCLUSIONS: Inviting or reminding patients by e-mail or during GPs consultation may enhance response rates in a selective prevention program for CMD. Different response-enhancing strategies have different patient target populations and implementation issues, therefore practice characteristics need to be taken into account when implementing such strategies. TRIAL REGISTRATION: Dutch trial Register number NTR4277 . Registered 26 November 2013.

Patient-related factors, antibiotic prescribing and antimicrobial resistance of the commensal Staphylococcus aureus and Streptococcus pneumoniae in a healthy population - Hungarian results of the APRES study.

BACKGROUND: Antimicrobial resistance (AMR) is an increasing public health problem worldwide. We studied some patient-related factors that might influence the antimicrobial resistance. and whether the volume of antibiotic prescribing of the primary care physicians correlate with the antibiotic resistance rates of commensal nasal Staphylococcus aureus and Streptococcus pneumoniae. METHODS: The socio-demographic questionnaires, the antibiotic prescription and resistance data of commensal nasal S. aureus and S. pneumoniae were collected in the 20 participating Hungarian practices of the APRES study. Multivariate logistic regression analyses were performed on the patient-related data and the antimicrobial resistance of the S. aureus and S. pneumoniae on individual, patient level. Ecological analyses were performed with Spearman's rank correlations at practice level, the analyses were performed in the whole sample (all practices) and in the cohorts of primary care practices taking care of adults (adult practices) or children (paediatric practices). RESULTS: According to the multivariate model, age of the patients significantly influenced the antimicrobial resistance of the S. aureus (OR = 0.42, p = 0.004) and S. pneumoniae (OR = 0.89, p < 0.001). Living with children significantly increased the AMR of the S. pneumoniae (OR = 1.23, p = 0.019). In the cohorts of adult or paediatric practices, neither the age nor other variables influenced the AMR of the S. aureus and S. pneumoniae. At practice level, the prescribed volume of penicillins significantly correlated with the resistance rates of the S. aureus isolates to penicillin (rho = 0.57, p = 0.008). The volume of prescribed macrolides, lincosamides showed positive significant correlations with the S. pneumoniae resistance rates to clarithromycin and/or clindamycin in all practices (rho = 0.76, p = 0.001) and in the adult practices (rho = 0.63, p = 0.021). CONCLUSIONS: The age is an important influencing factor of antimicrobial resistance. The results also suggest that there may be an association between the antibiotic prescribing of the primary care providers and the antibiotic resistance of the commensal S. aureus and S. pneumoniae. The role of the primary care physicians in the appropriate antibiotic prescribing is very important to avoid the antibiotic resistance.

Epidemiology and burden of influenza in healthy children aged 6 to 35 months: analysis of data from the placebo arm of a phase III efficacy trial.

BACKGROUND: Despite World Health Organization recommendations, in many countries young children are not targeted for influenza vaccination. To help inform influenza vaccination policy, we examined the occurrence and burden of influenza in healthy children aged 6 to 35 months using data from a recent phase III placebo-controlled influenza vaccine trial conducted in countries in the Northern and Southern Hemispheres. METHODS: This was an analysis of data from participants included in the placebo arm of a phase III clinical trial in healthy children aged 6 to 35 months (EudraCT no. 2013-001231-51). Included children had never been vaccinated for influenza and were observed for one influenza season. Outcome measures included the occurrence of influenza-like illness (ILI), laboratory-confirmed influenza, virus types/subtypes, severe symptoms and complications of confirmed influenza, and healthcare use associated with confirmed influenza. RESULTS: Data from 2210 participants were analysed. ILI was reported for 811 participants (36.7%). Of these, 255 participants (31.4%) had 263 virologically confirmed episodes of influenza. The overall influenza attack rate was 11.5%. The most common influenza virus detected was A(H3N2) (40.7%), followed by B/Yamagata (23.6%), A(H1N1) (18.6%), and B/Victoria (8.0%). Grade 3 fever was reported in 24.3% of confirmed episodes, acute lower respiratory infection in 8.7%, acute otitis media in 6.1%, and pneumonia in 1.9%. In most influenza episodes (93.2%), antipyretics, analgesics, or non-steroidal anti-inflammatory drugs were taken. Antibiotics were prescribed for 41.4% of influenza episodes. More than half of the influenza episodes (57.0%) resulted in outpatient visits. Influenza resulted in overnight hospitalisation in 1.1% of episodes. CONCLUSIONS: Influenza is associated with a significant burden of disease in healthy children. This analysis also revealed that antibiotics continue to be frequently used for young children with influenza. TRIAL REGISTRATION: EudraCT no. 2013-001231-51 .

Non-adherence to antidepressants among older patients with depression: a longitudinal cohort study in primary care.

Background: Depression is common among older adults and is typically treated with antidepressants. Objective: To determine the non-adherence rates to antidepressants among older adults in primary care, based on non-initiation, suboptimal implementation or non-persistence. Methods: We selected all patients aged ≥60 years and diagnosed with depression in 2012, from the Netherlands Institute for Health Services Research (NIVEL) Primary Care Database. Non-initiation was defined as no dispensing within 14 days of the first prescription; suboptimal implementation, as fewer than 80% of the days covered by dispensed dosages; and non-persistence, as discontinuation within 294 days after first dispense. First, we determined the antidepressant non-initiation, suboptimal implementation and non-persistence rates. Second, we examined whether comorbidity and chronic drug use were associated with non-adherence by mixed-effects logistic regression (non-initiation or suboptimal implementation as dependent variables) and a clustered Cox regression (time to non-persistence). Results: Non-initiation, suboptimal implementation and non-persistence rates were 13.5%, 15.2% and 37.1%, respectively. As the number of chronically used drugs increased, the odds of suboptimal implementation (odds ratio, 0.89; 95% confidence interval, 0.83-0.95) and of non-persistence (hazard ratio, 0.87; 95% confidence interval, 0.82-0.92) reduced. Conclusions: Non-adherence to antidepressants is high among older patients with depression in primary care settings. Adherence is better when patients are accustomed to taking larger numbers of prescribed drugs, but this only provides partial explanation of the variance. GPs should be aware of the high rates of non-adherence. Emphasizing the importance of adhering to the optimal length of antidepressant therapy might be prudent first steps to improving adherence.

Epidemiology and timing of seasonal influenza epidemics in the Asia-Pacific region, 2010-2017: implications for influenza vaccination programs.

BACKGROUND: Description of the epidemiology of influenza is needed to inform influenza vaccination policy. Here we examined influenza virus circulation in countries in the Asia-Pacific region and compared the timing of seasonal epidemics with the timing of influenza vaccination. METHODS: Data were obtained from the World Health Organization (WHO) FluNet database for 2010-2017 for countries in the WHO Asia-Pacific region. Data from countries covering ≥5 consecutive seasons and ≥ 100 influenza positive cases per year were included. Median proportions of cases for each influenza virus type were calculated by country and season. The timing and amplitude of the epidemic peaks were determined by Fourier decomposition. Vaccination timing was considered appropriate for each country if it was recommended ≤4 months before the primary peak of influenza circulation. RESULTS: Seven hundred eleven thousand seven hundred thirty-four influenza cases were included from 19 countries. Peak circulation coincided with the winter seasons in most countries, although patterns were less clear in some countries in the inter-tropical area due to substantial secondary peaks. Influenza A/H3N2 dominated overall, but proportions of A and B strains varied by year and by country. Influenza B represented 31.4% of all cases. The WHO-recommended timing for influenza vaccination was appropriate in 12 countries. Vaccination timing recommendations were considered inappropriate in Laos, Cambodia, and Thailand, and were inconclusive for India, Sri Lanka, Singapore, and Vietnam due to unclear seasonality of influenza virus circulation. CONCLUSIONS: Influenza virus circulation varied considerably across the Asia-Pacific region with an unusually high burden of influenza B. The recommended timing for vaccination was appropriate in most countries, except for several countries with unclear seasonality, mainly located in the inter-tropical area.

Calculating incidence rates and prevalence proportions: not as simple as it seems.

BACKGROUND: Incidence rates and prevalence proportions are commonly used to express the populations health status. Since there are several methods used to calculate these epidemiological measures, good comparison between studies and countries is difficult. This study investigates the impact of different operational definitions of numerators and denominators on incidence rates and prevalence proportions. METHODS: Data from routine electronic health records of general practices contributing to NIVEL Primary Care Database was used. Incidence rates were calculated using different denominators (person-years at-risk, person-years and midterm population). Three different prevalence proportions were determined: 1 year period prevalence proportions, point-prevalence proportions and contact prevalence proportions. RESULTS: One year period prevalence proportions were substantially higher than point-prevalence (58.3 - 206.6%) for long-lasting diseases, and one year period prevalence proportions were higher than contact prevalence proportions (26.2 - 79.7%). For incidence rates, the use of different denominators resulted in small differences between the different calculation methods (-1.3 - 14.8%). Using person-years at-risk or a midterm population resulted in higher rates compared to using person-years. CONCLUSIONS: All different operational definitions affect incidence rates and prevalence proportions to some extent. Therefore, it is important that the terminology and methodology is well described by sources reporting these epidemiological measures. When comparing incidence rates and prevalence proportions from different sources, it is important to be aware of the operational definitions applied and their impact.

Selective prevention of cardiometabolic diseases: activities and attitudes of general practitioners across Europe.

Background: Cardiometabolic diseases (CMDs) are the number one cause of death. Selective prevention of CMDs by general practitioners (GPs) could help reduce the burden of CMDs. This measure would entail the identification of individuals at high risk of CMDs-but currently asymptomatic-followed by interventions to reduce their risk. No data were available on the attitude and the extent to which European GPs have incorporated selective CMD prevention into daily practice. Methods: A survey among 575 GPs from the Czech Republic, Denmark, Greece, the Netherlands and Sweden was conducted between September 2016 and January 2017, within the framework of the SPIMEU-project. Results: On average, 71% of GPs invited their patients to attend for CMD risk assessment. Some used an active approach (47%) while others used an opportunistic approach (53%), but these values differed between countries. Most GPs considered selective CMD prevention as useful (82%) and saw it as part of their normal duties (84%). GPs who did find selective prevention useful were more likely to actively invite individuals compared with their counterparts who did not find prevention useful. Most GPs had a disease management programme for individuals with risk factor(s) for cardiovascular disease (71%) or diabetes (86%). Conclusions: Although most GPs considered selective CMD prevention as useful, it was not universally implemented. The biggest challenge was the process of inviting individuals for risk assessment. It is important to tailor the implementation of selective CMD prevention in primary care to the national context, involving stakeholders at different levels.

Patients' perception of communication at the interface between primary and secondary care: a cross-sectional survey in 34 countries.

BACKGROUND: Poor communication between general practitioners (GPs) and medical specialists can lead to poorer quality, and continuity, of care. Our study aims to assess patients' perceptions of communication at the interface between primary and secondary care in 34 countries. It will analyse, too, whether this communication is associated with the organisation of primary care within a country, and with the characteristics of GPs and their patients. METHODS: We conducted a cross-sectional survey among patients in 34 countries. Following a GP consultation, patients were asked two questions. Did they take to understand that their GP had informed medical specialists about their illness upon referral? And, secondly, did their GP know the results of the treatment by a medical specialist? We used multi-response logistic multilevel models to investigate the association of factors related to primary care, the GP, and the patient, with the patients' perceptions of communication at the interface between primary and secondary care. RESULTS: In total, 61,931 patients completed the questionnaire. We found large differences between countries, in both the patients' perceptions of information shared by GPs with medical specialists, and the patients' perceptions of the GPs' awareness of the results of treatment by medical specialists. Patients whose GPs stated that they 'seldom or never' send referral letters, also less frequently perceived that their GP communicated with their medical specialists about their illness. Patients with GPs indicating they 'seldom or never' receive feedback from medical specialists, indicated less frequently that their GP would know the results of treatment by a medical specialist. Moreover, patients with a personal doctor perceived higher rates of communication in both directions at the interface between primary and secondary care. CONCLUSION: Generally, patients perceive there to be high rates of communication at the interface between primary and secondary care, but there are large differences between countries. Policies aimed at stimulating personal doctor arrangements could, potentially, enhance the continuity of care between primary and secondary care.