Non-dispensing pharmacists integrated into general practices as a new interprofessional model: a qualitative evaluation of general practitioners' experiences and views.

BACKGROUND: A new interprofessional model incorporating non-dispensing pharmacists in general practice teams can improve the quality of pharmaceutical care. However, results of the model are dependent on the context. Understanding when, why and how the model works may increase chances of successful broader implementation in other general practices. Earlier theories suggested that the results of the model are achieved by bringing pharmacotherapeutic knowledge into general practices. This mechanism may not be enough for successful implementation of the model. We wanted to understand better how establishing new interprofessional models in existing healthcare organisations takes place. METHODS: An interview study, with a realist informed evaluation was conducted. This qualitative study was part of the Pharmacotherapy Optimisation through Integration of a Non-dispensing pharmacist in primary care Teams (POINT) project. We invited the general practitioners of the 9 general practices who (had) worked closely with a non-dispensing pharmacist for an interview. Interview data were analysed through discussions about the coding with the research team where themes were developed over time. RESULTS: We interviewed 2 general practitioners in each general practice (18 interviews in total). In a context where general practitioners acknowledge the need for improvement and are willing to work with a non-dispensing pharmacist as a new team member, the following mechanisms are triggered. Non-dispensing pharmacists add new knowledge to current general practice. Through everyday talk (discursive actions) both general practitioners and non-dispensing pharmacists evolve in what they consider appropriate, legitimate and imaginable in their work situations. They align their professional identities. CONCLUSIONS: Not only the addition of new knowledge of non-dispensing pharmacist to the general practice team is crucial for the success of this interprofessional healthcare model, but also alignment of the general practitioners' and non-dispensing pharmacists' professional identities. This is essentially different from traditional pharmaceutical care models, in which pharmacists and GPs work in separate organisations. To induce the process of identity alignment, general practitioners need to acknowledge the need to improve the quality of pharmaceutical care interprofessionally. By acknowledging the aspect of interprofessionality, both general practitioners and non-dispensing pharmacists will explore and reflect on what they consider appropriate, legitimate and imaginable in carrying out their professional roles. TRIAL REGISTRATION: The POINT project was pre-registered in The Netherlands National Trial Register, with Trial registration number NTR-4389.

Quality of life in primary care patients with moderate medically unexplained physical symptoms.

PURPOSE: Medically Unexplained Physical Symptoms (MUPS) have a large impact on patient's quality of life. Most studies have been limited to chronic MUPS and thus, little is known about moderate MUPS. Improved knowledge concerning determinants influencing quality of life in moderate MUPS patients can be helpful in managing MUPS. This study is aimed at describing the common characteristics seen in moderate MUPS patients and compare them with characteristics seen in chronic MUPS patients and general population. We also identified determinants of the physical and mental components of quality of life in moderate MUPS patients. METHODS: In a cross-sectional study, moderate MUPS patients (n = 160) were compared with chronic MUPS patients (n = 162) and general population (n = 1742) based on demographic characteristics and patient's quality of life. Multivariable linear regression analyses were performed to identify determinants associated with a patient's quality of life, assessed with the RAND-36. RESULTS: Moderate MUPS patients experienced a better quality of life than chronic MUPS patients, but a worse quality of life as compared to the general population. Determinants associated with the physical and mental components of quality of life explain 49.1% and 62.9% of the variance, respectively. CONCLUSION: Quality of life of patients with MUPS varies with MUPS disease stage. Based on their quality of life scores, moderate MUPS patients would be adequately distinguished from chronic MUPS patients. Half of the variance in the physical component and almost two thirds of the mental component would be explained by a number of MUPS-related symptoms and perceptions.

Mismatch between self-perceived and calculated cardiometabolic disease risk among participants in a prevention program for cardiometabolic disease: a cross-sectional study.

BACKGROUND: The rising prevalence of cardiometabolic diseases (CMD) calls for effective prevention programs. Self-assessment of CMD risk, for example through an online risk score (ORS), might induce risk reducing behavior. However, the concept of disease risk is often difficult for people to understand. Therefore, the study objective was to assess the impact of communicating an individualized CMD risk score through an ORS on perceived risk and to identify risk factors and demographic characteristics associated with risk perception among high-risk participants of a prevention program for CMD. METHODS: A cross-sectional analysis of baseline data from a randomized controlled trial conducted in a primary care setting. Seven thousand five hundred forty-seven individuals aged 45-70 years without recorded CMD, hypertension or hypercholesterolemia participated. The main outcome measures were: 1) differences in cognitive and affective risk perception between the intervention group - who used an ORS and received an individualized CMD risk score- and the control group who answered questions about CMD risk, but did not receive an individualized CMD risk score; 2) risk factors and demographic characteristics associated with risk perception. RESULTS: No differences were found in cognitive and affective risk perception between the intervention and control group and risk perception was on average low, even among high-risk participants. A positive family history for diabetes type 2 (ß0.56, CI95% 0.39-0.73) and cardiovascular disease (ß0.28, CI95% 0.13-0.43), BMI ≥25 (ß0.27, CI95% 0.12-0.43), high waist circumference (ß0.25, CI95% 0.02-0.48) and physical inactivity (ß0.30, CI95% 0.16-0.45) were positively associated with cognitive CMD risk perception in high-risk participants. No other risk factors or demographic characteristics were associated with risk perception. CONCLUSIONS: Communicating an individualized CMD risk score did not affect risk perception. A mismatch was found between calculated risk and self-perceived risk in high-risk participants. Family history and BMI seem to affect the level of CMD risk perception more than risk factors such as sex, age and smoking. A dialogue about personal CMD risk between patients and health care professionals might optimize the effect of the provided risk information. TRIAL REGISTRATION: Dutch trial Register number NTR4277, registered 26th Nov 2013.

Use of proton pump inhibitors and risk of iron deficiency: a population-based case-control study.

BACKGROUND: Hypochlorhydric states are an important cause of iron deficiency (ID). Nevertheless, the association between therapy with proton pump inhibitors (PPIs) and ID has long been a subject of debate. This case-control study aimed to investigate the risk of ID associated with the use of PPIs using the UK Clinical Practice Research Datalink (CPRD) database. METHODS: Cases were patients aged 19 years or older with first-time diagnosis of ID between 2005 and 2016 (n = 26 806). The dates of first diagnosis of ID in cases defined the index dates. For each case, one control was matched by age, gender and general practice. A PPI "full" user (PFU) was defined as a subject who had received PPIs for a continuous duration of at least 1 year prior to the index date. A PPI "limited" users (PLU) was a subject who intermittently received PPI therapy. A PPI non-user (PNU) was a subject who received no PPI prescriptions prior to the index date. The odds ratio of ID in PFU and PLU compared to PNU was estimated using conditional logistic regression. RESULTS: Among cases, 2960 were PFU, 6607 PLU and 17 239 PNU. Among controls, 1091 were PFU, 5058 PLU and 20 657 PNU. Adjusted odds ratio of ID in PFU and PLU compared to PNU was 3.60 (95%CI, [3.32-3.91]) and 1.51 (95% CI, [1.44-1.58]). Positive dose-response and time-response relationships were observed. CONCLUSIONS: Chronic PPI use increases the risk of ID. Physicians should consider this when balancing the risks and benefits of chronic PPI prescription.

Effects of non-dispensing pharmacists integrated in general practice on medication-related hospitalisations.

AIMS: To evaluate the effect of non-dispensing pharmacists (NDPs) integrated in general practice on medication-related hospitalisations, drug burden index and costs in patients at high risk of medication problems (being 65 years or older and using 5 or more chronic medications). METHODS: This was a multicentre, nonrandomised, controlled intervention study with pre-post comparison (2013 vs June 2014 to May 2015) in 25 general practices in the Netherlands, comparing NDP-led care (intervention) with 2 current pharmaceutical care models (usual care and usual care plus). In the intervention group, 10 specially trained NDPs were employed in general practices to take integral responsibility for the pharmaceutical care. They provided a broad range of medication therapy management services both on patient level (e.g. clinical medication review) and practice level (e.g. quality improvement projects). In the control groups, pharmaceutical care was provided as usual by general practitioners and community pharmacists, or as usual plus, when pharmacists were additionally trained in performing medication reviews. RESULTS: Overall, 822 medication-related hospitalisations were identified among 11 281 high-risk patients during the intervention period. After adjustment for clustering and potential confounders, the rate ratio of medication-related hospitalisations in the intervention group compared to usual care was 0.68 (95% confidence interval: 0.57-0.82) and 1.05 (95% confidence interval: 0.73-1.52) compared to usual care plus. No differences in drug burden index or costs were found. CONCLUSIONS: In general practices with an integrated NDP, the rate of medication-related hospitalisations is lower compared to usual care. No differences with usual care plus were found.

Burden of disease in children with respiratory tract infections in primary care: diary-based cohort study.

BACKGROUND: Respiratory tract infections (RTIs) are a common reason for children to consult in general practice. Antibiotics are often prescribed, in part due to miscommunication between parents and GPs. The duration of specific respiratory symptoms has been widely studied. Less is known about illness-related symptoms and the impact of these symptoms on family life, including parental production loss. Better understanding of the natural course of illness-related symptoms in RTI in children and impact on family life may improve GP-parent communication during RTI consultations. OBJECTIVE: To describe the general impact of RTI on children and parents regarding illness-related symptoms, absenteeism from childcare, school and work, use of health care facilities, and the use of over-the-counter (OTC) medication. METHODS: Prospectively collected diary data from two randomized clinical trials in children with RTI in primary care (n = 149). Duration of symptoms was analysed using survival analysis. RESULTS: Disturbed sleep, decreased intake of food and/or fluid, feeling ill and/or disturbance at play or other daily activities are very common during RTI episodes, with disturbed sleep lasting longest. Fifty-two percent of the children were absent for one or more days from childcare or school, and 28% of mothers and 20% of fathers reported absence from work the first week after GP consultation. Re-consultation occurred in 48% of the children. OTC medication was given frequently, particularly paracetamol and nasal sprays. CONCLUSION: Appreciation of, and communication about the general burden of disease on children and their parents, may improve understanding between GPs and parents consulting with their child.

Randomised controlled trial protocol (GRIP study): examining the effect of involvement of a general practitioner and home care oncology nurse after a cancer diagnosis on patient reported outcomes and healthcare utilization.

BACKGROUND: Due to the ageing population and improving diagnostics and treatments, the number of cancer patients and cancer survivors is increasing. Policymakers, patients and professionals advocate a transfer of (part of) cancer care from the hospital environment to the primary care setting, as this could stimulate personalized and integrated care, increase cost-effectiveness and would better meet the patients' needs and expectations. The effects of structured active follow-up from primary care after cancer diagnosis have not been studied yet. Therefore the GRIP study aims to assess the effects of structured follow-up after a cancer diagnosis, by a primary care team including a general practitioner (GP) and a home care oncology nurse (HON), on satisfaction and healthcare utilization of patients treated with curative intent. METHODS: We will conduct a multicentre, two-arm randomised controlled trial in The Netherlands. We plan to include 150 patients who will be treated with curative intent for either breast, lung, colorectal, gynaecologic cancer, or melanoma. Further inclusion criteria are: age 18 years and older, able to answer questionnaires in Dutch, GP agrees to participate and the possibility to include the patient before the start of treatment. All patients receive care as usual. The intervention arm will receive additional structured follow-up consisting of a GP consultation before onset of treatment to empower the patient for shared decision making with the specialist and a minimum of three contacts with the HON during and after treatment. Primary outcomes are: patient satisfaction with care at the level of specialist, GP and nurse and healthcare utilization. Secondary outcomes include: quality of life, employment status, patient empowerment, shared decision making, mental health and satisfaction with given information. Repeated questionnaires, filled in by the participants, will be assessed within the 1-year study period. DISCUSSION: This randomised controlled trial will evaluate the effects of structured follow-up after a cancer diagnosis by a primary care team including a GP and HON, for patients undergoing treatment with curative intent. Results from the present study may provide the evidence needed to optimally rearrange responsibilities in cancer care delivery and consequently improve cancer care and patient related outcomes. TRIAL REGISTRATION: Trial number: NTR5909 .

A "time out consultation" in primary care for elderly patients with cancer: Better treatment decisions by structural involvement of the general practitioner.

Treatment decisions in elderly patients with cancer are complex. Not only the type and stage of the tumor, but also comorbidity, medical background and personal contextual factors need to be taken into account. The individual treatment perspective, life expectancy and quality of life are important determinants of the final treatment decision for the elderly cancer patient. Because of their longstanding relation with the elderly and their holistic approach we think that general practitioners should be involved, and we suggest that every elderly patient with cancer should have a 'time out consultation' with the general practitioner to prepare for the final treatment choice.

Relative risk of irritable bowel syndrome following acute gastroenteritis and associated risk factors.

SUMMARY: A prospective cohort study using electronic medical records was undertaken to estimate the relative risk (RR) of irritable bowel syndrome (IBS) following acute gastroenteritis (GE) in primary-care patients in The Netherlands and explore risk factors. Patients aged 18-70 years who consulted for GE symptoms from 1998 to 2009, met inclusion/exclusion criteria and had at least 1 year of follow-up data were included. Patients with non-GE consultations, matched by age, gender, consulting practice and time of visit, served as the reference group. At 1 year, 1·2% of GE patients (N = 2428) had been diagnosed with IBS compared to 0·3% of the reference group (N = 2354). GE patients had increased risk of IBS [RR 4·85, 95% confidence interval (CI) 2·02-11·63]. For GE patients, concomitant cramps and history of psycho-social consultations were significantly associated with increased risk. GE patients had increased risk of IBS up to 5 years post-exposure (RR 5·40, 95% CI 2·60-11·24), suggesting there may be other contributing factors.

[Towards culturally sensitive care for elderly immigrants! Design and development of a community based intervention programme in the Netherlands]. / Op weg naar cultuursensitieve zorg voor oudere migranten! Opzet en werkwijze van het Stem van de Oudere Migrant project.

BACKGROUND: In Western countries, health and social welfare facilities are not easily accessible for elderly immigrants and their needs are sub optimally addressed. A transition is needed towards culturally sensitive services to make cure and care accessible for elderly immigrants. We developed an intervention programme in which ethnic community health workers (CHWs) act as liaisons between immigrant elderly and local health care and social welfare services. METHODS: In a quasi experimental design, the effectiveness of introduction of CHWs, will be evaluated in three (semi) urban residential areas in the Netherlands within three different migrant groups and compared with a control group. The primary outcome is use of health care and social welfare facilities by the elderly. Secondary outcomes are quality of life and functional impairments. Implementation of the intervention programme will be examined with focus groups and data registration of CHW activities. In this paper design and methodological issues are discussed. DISCUSSION: This study can contribute to the improvement of care for elderly immigrants by developing culturally sensitive care whereby the elderly immigrants themselves actively participate. To enable a successful transition, proper identification and recruitment of CHWs is required. Once proven effective, the CHW function can be further integrated into the existing local health care and welfare system.

Gastroprotective strategies in chronic NSAID users: a cost-effectiveness analysis comparing single-tablet formulations with individual components.

OBJECTIVES: To evaluate the cost-effectiveness of competing gastroprotective strategies, including single-tablet formulations, in the prevention of gastrointestinal (GI) complications in patients with chronic arthritis taking nonsteroidal anti-inflammatory drugs (NSAIDs). METHODS: We performed a cost-utility analysis to compare eight gastroprotective strategies including NSAIDs, cyclooxygenase-2 inhibitors, proton pump inhibitors (PPIs), histamine-2 receptor antagonists, misoprostol, and single-tablet formulations. We derived estimates for outcomes and costs from medical literature. The primary outcome was incremental cost per quality-adjusted life-year gained. We performed sensitivity analyses to assess the effect of GI complications, compliance rates, and drug costs. RESULTS: For average-risk patients, NSAID + PPI cotherapy was most cost-effective. The NSAID/PPI single-tablet formulation became cost-effective only when its price decreased from €0.78 to €0.56 per tablet, or when PPI compliance fell below 51% in the NSAID + PPI strategy. All other strategies were more costly and less effective. The model was highly sensitive to the GI complication risk, costs of PPI and NSAID/PPI single-tablet formulation, and compliance to PPI. In patients with a threefold higher risk of GI complications, both NSAID + PPI cotherapy and single-tablet formulation were cost-effective. CONCLUSIONS: NSAID + PPI cotherapy is the most cost-effective strategy in all patients with chronic arthritis irrespective of their risk for GI complications. For patients with increased GI risk, the NSAID/PPI single-tablet formulation is also cost-effective.

[Proactive and structured care for the elderly in primary care]. / Proactieve en gestructureerde zorg voor kwetsbare oudere patiënten in de eerstelijn: Achtergrond, opzet en uitvoering van een screenings- en zorgprogramma.

BACKGROUND: Currently, primary care for the older, vulnerable patient is reactive, fragmented and does not meet patients needs. Given the expected increase of home-dwelling frail elderly people a transition is needed to proactive and integrated care. METHODS: In the described study, we explore two innovative interventions in primary care. First we describe a newly developed screening and monitoring program for frail elderly patients based on routine care information in general practice. Second, we describe a multidisciplinary intervention program by trained nurses for frail elderly patients in general practice. The effectiveness of the interventions is examined in a three-armed, cluster randomized trial, taking place in 58 primary care practices in Utrecht, the Bilt and Maarsenbroek. RESULTS: Three thousand eight patients are included. Primary outcome measure is the impact of the interventions on the daily activities, measured with the Katz questionnaire. Secondary outcomes measures are the quality of life, mortality, recording in a care or nursing home, visit to an emergency room or outpatient unit, recording in the hospital and volunteer caregivers tax.

The cost-effectiveness of an indicated blended care intervention in primary care compared to usual care in patients with moderate persistent somatic symptoms.

INTRODUCTION: Appropriate treatment for people with an increased risk for developing chronic Persistent Somatic Symptoms (PSS) is of great importance at an early stage to improve quality of life and prevent high costs for society. OBJECTIVE: To evaluate the cost-effectiveness of an integrated blended care intervention compared to usual care for QALYs, subjective symptom impact and physical and mental health status in patients with moderate PSS. METHODS: This economic evaluation was conducted alongside a 12-month prospective, multicenter cluster randomized controlled trial in Dutch primary care. 80 participants received the intervention and 80 participants received usual care. Seemingly unrelated regression analyzes were performed to estimate cost and effect differences. Missing data were imputed using multiple imputation. Bootstrapping techniques were used to estimate uncertainty. RESULTS: We found no significant difference in total societal costs. Intervention, primary and secondary healthcare and absenteeism costs were higher for the intervention group. The ICER for QALYs demonstrated the intervention was on average less costly and less effective compared to usual care. For the subjective symptom impact and physical health, the ICER indicated that the intervention group was on average less costly and more effective. For mental health, the intervention was on average more costly and less effective. CONCLUSION: We didn't find an integrated blended primary care intervention to be cost-effective compared to usual care. However, when looking on relevant, but specific outcome measures (subjective symptom impact and physical health) for this population, average costs are found to be lower and the effectiveness found to be higher.

Cost-effectiveness of targeted screening for hepatitis C in The Netherlands.

On account of the serious complications of hepatitis C virus (HCV) infection and the improved treatment possibilities, the need to improve HCV awareness and case-finding is increasingly recognized. To optimize a future national campaign with this objective, three pilot campaigns were executed in three regions in The Netherlands. One campaign was aimed at the general population, a second (similar) campaign was extended with a support programme for primary care and a third campaign was specifically aimed at hard-drug users. Data from the pilot campaigns were used to build a mathematical model to estimate the incremental cost-effectiveness ratio of the different campaigns. The campaign aimed at the general public without support for primary care did not improve case-finding and was therefore not cost-effective. The similar campaign accompanied by additional support for primary care and the campaign aimed at hard-drug users emerged as cost-effective interventions for identification of HCV carriers.

Psychometric evaluation of the Decision Support Tool for Functional Independence in community-dwelling older people.

Background: The aging population is increasingly faced with daily life limitations, threatening their Functional Independence (FI). These limitations extend different life domains and require a broad range of community-care professionals to be addressed. The Decision Support Tool for Functional Independence (DST-FI) facilitates community-care professionals in providing uncontradictory recommendations regarding the maintenance of FI in community-dwelling older people. The current study aims to determine the validity and reliability of the DST-FI. Methods: Sixty community-care professionals completed a twofold assessment. To assess construct validity, participants were asked to assign predefined recommendations to fifty cases of older people to maintain their level of FI. Hypotheses were tested regarding the expected recommendations per case. Content validity was assessed by questions on relevance, comprehensiveness, and comprehensibility of the current set of recommendations. Twelve participants repeated the assessment after two weeks to enable both within- and between rater reliability properties, expressed by an Intraclass Correlation Coefficient. Results: Seven out of eight predefined hypotheses confirmed expectations, indicating high construct validity. As the recommendations were indicated 'relevant' and 'complete', content validity was high as well. Agreement between raters was poor to moderate while agreement within raters was moderate to excellent, resulting in moderate overall reliability. CONCLUSION: The DST-FI suggests high validity and moderate reliability properties when used in a population of community-dwelling older people. The tool could facilitate community-care professionals in their task to preserve FI in older people. Future research should focus on psychometric properties like feasibility, acceptability, and developing and piloting strategies for implementation in community-care.

Effects of structured involvement of the primary care team versus standard care after a cancer diagnosis on patient satisfaction and healthcare use: the GRIP randomised controlled trial.

BACKGROUND: The growing number of cancer survivors and treatment possibilities call for more personalised and integrated cancer care. Primary care seems well positioned to support this. We aimed to assess the effects of structured follow-up of a primary care team after a cancer diagnosis. METHODS: We performed a multicentre randomised controlled trial enrolling patients curatively treated for breast, lung, colorectal, gynaecologic cancer or melanoma. In addition to usual cancer care in the control group, patients randomized to intervention were offered a "Time Out consultation" (TOC) with the general practitioner (GP) after diagnosis, and subsequent follow-up during and after treatment by a home care oncology nurse (HON). Primary outcomes were patient satisfaction with care (questionnaire: EORTC-INPATSAT-32) and healthcare utilisation. Intention-to-treat linear mixed regression analyses were used for satisfaction with care and other continuous outcome variables. The difference in healthcare utilisation for categorical data was calculated with a Pearson Chi-Square or a Fisher exact test and count data (none versus any) with a log-binomial regression. RESULTS: We included 154 patients (control n = 77, intervention n = 77) who were mostly female (75%), mainly diagnosed with breast cancer (51%), and had a mean age of 61 (SD ± 11.9) years. 81% of the intervention patients had a TOC and 68% had HON contact. Satisfaction with care was high (8 out of 10) in both study groups. At 3 months after treatment, GP satisfaction was significantly lower in the intervention group on 3 of 6 subscales, i.e., quality (- 14.2 (95%CI -27.0;-1.3)), availability (- 15,9 (- 29.1;-2.6)) and information provision (- 15.2 (- 29.1;-1.4)). Patients in the intervention group visited the GP practice and the emergency department more often ((RR 1.3 (1.0;1.7) and 1.70 (1.0;2.8)), respectively). CONCLUSIONS: In conclusion, the GRIP intervention, which was designed to involve the primary care team during and after cancer treatment, increased the number of primary healthcare contacts. However, it did not improve patient satisfaction with care and it increased emergency department visits. As the high uptake of the intervention suggests a need of patients, future research should focus on optimizing the design and implementation of the intervention. TRIAL REGISTRATION: GRIP is retrospectively (21/06/2016) registered in the 'Netherlands Trial Register' (NTR5909).

Exploring Associations between Oral Health and Frailty in Community-Dwelling Older People.

BACKGROUND: In frail older people with natural teeth factors like polypharmacy, reduced salivary flow, a decrease of oral self-care, general healthcare issues, and a decrease in dental care utilization contribute to an increased risk for oral complications. On the other hand, oral morbidity may have a negative impact on frailty. OBJECTIVE: This study explored associations between oral health and two frailty measures in community-dwelling older people. DESIGN: A cross-sectional study. SETTING: The study was carried out in a Primary Healthcare Center (PHC) in The Netherlands. PARTICIPANTS: Of the 5,816 persons registered in the PHC, 1,814 persons were eligible for participation at the start of the study. MEASUREMENTS: Two frailty measures were used: 1. Being at risk for frailty, using Electronical Medical Record (EMR) data, and: 2. Survey-based frailty using 'The Groningen Frailty Indicator' (GFI). For oral health measures, dental-record data (dental care utilization, dental status, and oral health information) and self-reported oral problems were recorded. Univariate regression analyses were applied to determine the association between oral health and frailty, followed by age- and sex-adjusted multivariate logistic regressions. RESULTS: In total 1,202 community-dwelling older people were included in the study, 45% were male and the mean age was 73 years (SD=8). Of all participants, 53% was at risk for frailty (638/1,202), and 19% was frail based on the GFI (222/1,202). A dental emergency visit (Odds Ratio (OR)= 2.0, 95% Confidence Interval (CI)=1.33;3.02 and OR=1.58, 95% CI=1.00;2.49), experiencing oral problems (OR=2.07, 95% CI=1.52;2.81 and OR=2.87, 95% CI= 2.07;3.99), and making dietary adaptations (OR=2.66, 95% CI=1.31;5.41 and OR=5.49, 95% CI= 3.01;10.01) were associated with being at risk for frailty and survey-based frailty respectively. CONCLUSIONS: A dental emergency visit and self-reported oral health problems are associated with frailty irrespective of the approach to its measurement. Healthcare professionals should be aware of the associations of oral health and frailty in daily practice.

Disease burden of post-infectious irritable bowel syndrome in The Netherlands.

Post-infectious irritable bowel syndrome (PI-IBS) has been established as a sequel of infectious intestinal disease (IID). The aim of this study was to estimate the burden of PI-IBS caused by the pathogens Campylobacter, Salmonella and Shigella, and to compare this with other outcomes associated with these pathogens. The attributable risk of PI-IBS due to bacterial pathogens was calculated and linked to national data on gastroenteritis incidence and measures for severity and duration of illness in order to estimate the burden of PI-IBS. One year post-infection, IBS developed in 9% of patients with bacterial IID. The burden of PI-IBS adds over 2300 disability adjusted life years to the total annual disease burden for the selected pathogens. PI-IBS is a frequent sequel of IID, resulting in a considerable disease burden compared to other outcomes. If this relationship is not considered, this will result in an underestimation of the disease burden of IID.

Pharmacological dependency in chronic treatment of gastroesophageal reflux disease: a randomized controlled clinical trial.

BACKGROUND: Despite evidence of the overuse of acid suppressive medication for gastroesophageal reflux disease (GERD), a transfer to noncontinuous therapy after long-term treatment proves difficult. AIM: To quantify the effect of blinded dosage reduction after long-term therapy on symptom control and quality of life while assessing pharmacological and placebo needs. METHODS: Primary care patients with a history of GERD and long-term treatment were randomized to daily placebo with pantoprazole rescue (n = 141) or daily pantoprazole with placebo rescue (n = 62) upon relief after 4 weeks pantoprazole 20 mg. The number of rescue tablets, symptom control and generic quality of life were analyzed. RESULTS: Measured from the daily placebo arm, 19% of the patients terminated treatment, 33% managed with 2-6 tablets/week, 38% needed a daily dosage and 10% needed more than a daily dosage in the long run. At these final dosages, symptom control and quality of life were dosage-independent and, furthermore, equal to values of patients on fixed daily pantoprazole. A temporal decrease in well-being was seen in 24% of the patients. CONCLUSION: A significant placebo response is apparent in long-term users of acid suppressive medication and pharmacological dependency is overestimated. Despite their history of long-term treatment, the majority of GERD patients can be switched from daily to on-demand treatment without impairing symptom control and quality of life.

Time to diagnosis of symptomatic gastric and oesophageal cancer in the Netherlands: Where is the room for improvement?

BACKGROUND: An efficient diagnostic pathway and early stage diagnosis for cancer patients is widely pursued. This study aims to chart the duration of the diagnostic pathway for patients with symptomatic oesophageal and gastric cancer, to identify factors associated with long duration and to assess the association of duration with tumour stage at diagnosis. METHODS: This was a retrospective cohort study, using electronic health records of six routine primary care databases covering about 640,000 patients, partly linked to the Netherlands Cancer Registry. Symptomatic patients with oesophageal and gastric cancer (2010-2015) that presented in primary care were included. Duration of four diagnostic intervals was determined: patient interval; first symptoms to primary care consultation, primary care interval; consultation to referral, secondary care interval; referral to diagnosis, and the diagnostic interval; consultation to diagnosis. Characteristics associated with 'long duration' (≥P75 duration) were assessed using log-binomial regression. Median durations were stratified for tumour stages. RESULTS: Among 312 symptomatic patients with upper gastrointestinal cancer, median durations were: patient interval: 29 days (interquartile interval 15-73), primary care interval: 12 days (interquartile interval 1-43), secondary care interval: 13 days (interquartile interval 6-29) and diagnostic interval: 31 days (11-74). Patient interval duration was comparable for patients with and without alarm symptoms. Absence of cancer-specific alarm symptoms was associated with 'long duration' of primary care interval and secondary care interval: relative risk 5.0 (95% confidence interval 2.7-9.1) and 2.1 (95% confidence interval 1.3-3.7), respectively. Median diagnostic interval duration for local stage disease was 51 days (interquartile interval 13-135) versus 27 days (interquartile interval 11-71) for advanced stage (p = 0.07). CONCLUSION: In the diagnostic pathway of upper gastrointestinal cancers, the longest interval is the patient interval. Reducing time to diagnosis may be achieved by improving patients' awareness of alarm symptoms and by diagnostic strategies which better identify cancer patients despite low suspicion.