Effectiveness of psychosomatic therapy for patients with persistent somatic symptoms: Results from the CORPUS randomised controlled trial in primary care.

OBJECTIVE: To evaluate the effectiveness of psychosomatic therapy versus care as usual in primary care for patients with persistent somatic symptoms (PSS). METHODS: We conducted a pragmatic, two-armed, randomised controlled trial among primary care patients with PSS in the Netherlands that included 39 general practices and 34 psychosomatic therapists. The intervention, psychosomatic therapy, consisted of 6-12 sessions delivered by specialised exercise- and physiotherapists. PRIMARY OUTCOME MEASURE: patient's level of functioning. SECONDARY OUTCOMES: severity of physical and psychosocial symptoms, health-related quality of life, health-related anxiety, illness behaviour and number of GP contacts. RESULTS: Compared to usual care (n = 85), the intervention group (n = 84) showed no improvement in patient's level of functioning (mean difference - 0.50 [95% CI -1.10 to 0.10]; p = .10), and improvement in health-related anxiety (mean difference - 1.93 [95% CI -3.81 to -0.04]; p = .045), over 12 months. At 5-month follow-up, we found improvement in physical functioning, somatisation, and health-related anxiety. The 12-month follow-up revealed no therapy effects. Subgroup analyses showed an overall effect in patient's level of functioning for the group with moderate PSS (mean difference - 0.91 [95% CI -1.78 to -0.03]; p = .042). In the year after the end of therapy, the number of GP contacts did not differ significantly between the two groups. CONCLUSION: We only found effects on some secondary outcome measures, and on our primary outcome measure especially in patients with moderate PSS, the psychosomatic therapy appears promising for further study. TRIAL REGISTRATION: the trial is registered in the Netherlands Trial Registry, https://trialsearch.who.int/Trial2.aspx?TrialID=NTR7356 under ID NTR7356.

Perceived working mechanisms of psychosomatic therapy in patients with persistent somatic symptoms in primary care: a qualitative study.

OBJECTIVES: To explore the perceived working mechanisms of psychosomatic therapy according to patients with persistent somatic symptoms (PSS) and their psychosomatic therapists. DESIGN: Qualitative study using semistructured face-to-face interviews and focus groups. All interviews were audiorecorded, transcribed verbatim and analysed, by two researchers independently, based on the thematic analysis. SETTING: Alongside a randomised controlled trial to establish the (cost-)effectiveness of psychosomatic therapy in patients with PSS in primary care, we conducted a process evaluation with a qualitative study. Patients were recruited in general practice in three regions in the Netherlands. PARTICIPANTS: Interviews were conducted with twenty patients with PSS who received psychosomatic therapy and 25 psychosomatic therapists. In addition, two focus groups were conducted with six and seven psychosomatic therapists, respectively. INTERVENTION: Psychosomatic therapy, delivered by specialised exercise and physical therapists, is a multimodal and tailored treatment based on the biopsychosocial model. OUTCOME MEASURES: Experiences, opinions and views from patients' and therapists' perspective on psychosomatic therapy were identified. RESULTS: A total of 37 interviews with patients, 25 interviews and two focus groups with therapists were analysed. Three main themes emerged from the data of the patients: (1) continuous alternation of psychosocial conversations and body-oriented exercises; (2) awareness of body-mind connection and (3) good relationship with therapist. Four main themes emerged from the data of the therapists (1) building rapport; (2) continuously searching for common ground; (3) making patients aware of the interaction between body and mind; and (4) continuous alternation between exploration and treatment. CONCLUSION: According to patients as well as therapists, the continuous alternation of psychosocial conversations and body-oriented exercises to provide awareness of the interaction between body and mind are the perceived working mechanism of psychosomatic therapy. Therapeutic alliance and finding common ground between patient and therapist are prerequisites for the success of psychosomatic therapy. TRIAL REGISTRATION NUMBER: NL7157 (NTR7356).

Cost-effectiveness of internet-based vestibular rehabilitation with and without physiotherapy support for adults aged 50 and older with a chronic vestibular syndrome in general practice.

OBJECTIVES: To evaluate the cost-effectiveness of stand-alone and blended internet-based vestibular rehabilitation (VR) in comparison with usual care (UC) for chronic vestibular syndromes in general practice. DESIGN: Economic evaluation alongside a three-armed, individually randomised controlled trial. SETTING: 59 Dutch general practices. PARTICIPANTS: 322 adults, aged 50 years and older with a chronic vestibular syndrome. INTERVENTIONS: Stand-alone VR consisted of a 6-week, internet-based intervention with weekly online sessions and daily exercises. In blended VR, this intervention was supplemented with face-to-face physiotherapy support. UC group participants received usual general practice care without restrictions. MAIN OUTCOME MEASURES: Societal costs, quality-adjusted life years (QALYs), Vertigo Symptom Scale-Short Form (VSS-SF), clinically relevant response (≥3 points VSS-SF improvement). RESULTS: Mean societal costs in both the stand-alone and blended VR groups were statistically non-significantly higher than in the UC group (mean difference (MD) €504, 95% CI -1082 to 2268; and €916, 95% CI -663 to 2596). Both stand-alone and blended VR groups reported non-significantly more QALYs than the UC group (MD 0.02, 95% CI -0.00 to 0.04; and 0.01, 95% CI -0.01 to 0.03), and significantly better VSS-SF Scores (MD 3.8 points, 95% CI 1.7 to 6.0; and 3.3 points, 95% CI 1.3 to 5.2). For stand-alone VR compared with UC, the probability of cost-effectiveness was 0.95 at a willingness-to-pay ratio of €24 161/QALY, €600/point improvement in VSS-SF and €8000/clinically relevant responder in VSS-SF. For blended VR versus UC, the probability of cost-effectiveness was 0.95 at a willingness-to-pay ratio of €123 335/QALY, €900/point improvement in VSS-SF and €24 000/clinically relevant responder in VSS-SF. CONCLUSION: Stand-alone and blended internet-based VR non-significantly increased QALYs and significantly reduced vestibular symptoms compared with UC, while costs in both groups were non-significantly higher. Stand-alone VR has the highest probability to be cost-effective compared with UC. TRIAL REGISTRATION NUMBER: The Netherlands Trial Register NTR5712.

A brief cognitive behavioural intervention is cost-effective for primary care patients with medically unexplained physical symptoms compared to usual care.

OBJECTIVE: To assess the cost-effectiveness of a brief cognitive behavioural intervention for patients with medically unexplained physical symptoms (MUPS) provided by a mental health nurse practitioner (MHNP) in primary care in comparison with usual care. METHODS: We performed an economic evaluation from a societal perspective alongside a cluster randomised controlled trial with 12 months follow-up. The primary outcome was quality-adjusted life-years (QALYs). Secondary outcomes were the RAND-36 physical component summary score (PCS), somatic symptom severity (Patient Health Questionnaire (PHQ-15), and anxiety and depression symptoms (Hospital Anxiety and Depression Scale (HADS)). Missing data were imputed using multiple imputation. We used non-parametric bootstrapping to estimate statistical uncertainty. The bootstrapped cost-effect pairs were used to estimate cost-effectiveness planes and cost-effectiveness acceptability curves. RESULTS: Mean total costs in the intervention group were significantly lower than in the usual care group (mean difference - 2300€, 95% CI -3257 to -134). The mean difference in QALYs was 0.01 (95% CI -0.01 to 0.04), in PCS 2.46 (95% CI 1.44 to 3.47), in PHQ-15 -0.26 (95% CI -0.81 to 0.28), and in HADS -0.07 (-0.81 to 0.67). At a willingness to pay of 0 € per additional unit of effect, the probability of the intervention being cost-effective was 0.93 for QALYs and 0.92 for PCS, PHQ-15 and HADS scores. CONCLUSION: Our intervention is cost-effective compared to usual care for patients with MUPS. Implementation of the intervention has the potential to result in a significant decline in costs. However, large scale implementation would require increased deployment of MHNPs.

Psychosomatic therapy for patients frequently attending primary care with medically unexplained symptoms, the CORPUS trial: study protocol for a randomised controlled trial.

BACKGROUND: Medically unexplained symptoms (MUS) are highly prevalent and pose a burden both on patients and on health care. In a pilot study psychosomatic therapy delivered by specialised therapists for patients with MUS showed promising results with regard to patient's acceptability, feasibility and effects on symptoms. The aim of this study is to establish whether psychosomatic therapy by specialised psychosomatic exercise therapists is cost- effective in decreasing symptoms and improving functioning in patients who frequently consult their general practitioner (GP) with MUS. METHODS: A randomised effectiveness trial with an economic evaluation in primary care with 158 patients aged 18 years and older who are frequently consulting their GP with MUS. Patients will be assigned to psychosomatic therapy in addition to usual care or usual care only. Psychosomatic therapy is a multi-component and tailored intervention, aiming to empower patients by applying psycho-education, relaxation techniques, mindfulness, cognitive approaches and/or graded activity. Patients assigned to the psychosomatic therapy receive 6 to 12 sessions of psychosomatic therapy, of 30-45 min each, delivered by a specialised exercise or physical therapist. Primary outcome measure is patient-specific functioning and disability, measured with the Patient-Specific Functional Scale (PSFS). Secondary outcome measures are symptom severity, consultation frequency and referrals to secondary care, patient satisfaction, quality of life and costs. Assessments will be carried out at baseline, and after 4 and 12 months. An economic evaluation alongside the trial will be conducted from a societal perspective, with quality-adjusted life years (QALYs) as outcome measure. Furthermore, a mixed-methods process evaluation will be conducted. DISCUSSION: We expect that psychosomatic therapy in primary care for patients who frequently attend the GP for MUS will improve symptoms and daily functioning and disability, while reducing consultation frequency and referrals to secondary care. We expect that the psychosomatic therapy provides value for money for patients with MUS. TRIAL REGISTRATION: Netherlands Trial Register, ID: NL7157 (NTR7356). Registered 13 July 2018.

Supported self-help to prevent relapse or recurrence of depression: Who benefits most?

BACKGROUND: This study aimed to identify subgroups for whom supported self-help preventive cognitive therapy (S-PCT) is more (cost)effective than treatment as usual (TAU) in preventing relapse and recurrence of major depression. METHODS: We conducted a randomized controlled trial in which 248 remitted, recurrently depressed participants were randomized to S-PCT (n = 124) or TAU (n = 124). Clinical outcome was relapse or recurrence of major depressive disorder (SCID-I). We tested the moderating effects on relapse or recurrence of age, gender, education level, residual depressive symptoms, number of previous episodes, age of onset, antidepressant medication, somatization, and self-efficacy with logistic regression analyses adjusted for baseline values of depressive symptoms. We examined moderating effects on costs using linear regression analyses adjusted for baseline costs. A stratified cost-effectiveness analysis was performed to tease out differences in cost-effectiveness between subgroups. RESULTS: We found no moderating effect on relapse or recurrence for any of the potential moderators. For costs, the number of previous depressive episodes was identified as a moderator. At a willingness-to-pay of 16,000€, the probability that S-PCT was cost-effective compared to TAU was 95% for participants with 2-3 episodes and 11% for participants with ≥4 episodes. LIMITATIONS: Participants and counselors were not blinded. The study was primarily designed to assess the (cost)effectiveness of S-PCT and not to conduct moderation analyses. CONCLUSIONS: S-PCT was effective in preventing relapse or recurrence of depressive disorders in a broad range of participants, but is more likely to be cost-effective in participants with 2-3 episodes than ≥4 episodes. This indicates that S-PCT can best be offered to participants with fewer previous depressive episodes.

Cost-effectiveness of interventions for medically unexplained symptoms: A systematic review.

BACKGROUND: In primary and secondary care medically unexplained symptoms (MUS) or functional somatic syndromes (FSS) constitute a major burden for patients and society with high healthcare costs and societal costs. Objectives were to provide an overview of the evidence regarding the cost-effectiveness of interventions for MUS or FSS, and to assess the quality of these studies. METHODS: We searched the databases PubMed, PsycINFO, the National Health Service Economic Evaluation Database (NHS-EED) and the CEA registry to conduct a systematic review. Articles with full economic evaluations on interventions focusing on adult patients with undifferentiated MUS or fibromyalgia (FM), irritable bowel syndrome (IBS) and chronic fatigue syndrome (CFS), with no restrictions on comparators, published until 15 June 2018, were included. We excluded preventive interventions. Two reviewers independently extracted study characteristics and cost-effectiveness data and used the Consensus on Health Economic Criteria Checklist to appraise the methodological quality. RESULTS: A total of 39 studies out of 1,613 articles met the inclusion criteria. Twenty-two studies reported costs per quality-adjusted life year (QALY) gained and cost-utility analyses (CUAs). In 13 CUAs the intervention conditions dominated the control conditions or had an incremental cost-effectiveness ratio below the willingness-to-pay threshold of € 50,000 per QALY, meaning that the interventions were (on average) cost-effective in comparison with the control condition. Group interventions focusing on MUS (n = 3) or FM (n = 4) might be more cost-effective than individual interventions. The included studies were heterogeneous with regard to the included patients, interventions, study design, and outcomes. CONCLUSION: This review provides an overview of 39 included studies of interventions for patients with MUS and FSS and the methodological quality of these studies. Considering the limited comparability due to the heterogeneity of the studies, group interventions might be more cost-effective than individual interventions. REGISTRATION: Study methods were documented in an international prospective register of systematic reviews (PROSPERO) protocol, registration number: CRD42017060424.

Evaluation of a Pain Assessment Procedure in Long-Term Care Residents With Pain and Dementia.

BACKGROUND: The management of pain in long-term care (LTC) residents with dementia is complex. A prospective exploratory study was conducted to describe the course of pain and pain management strategies following a guideline-based pain assessment procedure in LTC residents with pain and dementia. MEASURES: Pain observations with the Mobilization Observation Behaviour Intensity Dementia (MOBID-2) Pain Scale, a review of the electronic patient file and pharmacy files and physical examination of LTC residents with pain and dementia. INTERVENTION: Communication of the assessment results to the attending physician including guideline-based treatment recommendations. OUTCOMES: After three months, complete follow-up data were obtained for 64 residents. Pain intensity was significantly reduced (P < 0.001). The proportion of residents with persistent pain was 58% and the total number of analgesic prescriptions did not change significantly. CONCLUSIONS: There is room for improvement regarding pain management in LTC residents with pain and dementia, and performance feedback seems a promising strategy to explore further.

The CIPRUS study, a nurse-led psychological treatment for patients with undifferentiated somatoform disorder in primary care: study protocol for a randomised controlled trial.

BACKGROUND: Up to a third of patients presenting medically unexplained physical symptoms in primary care may have a somatoform disorder, of which undifferentiated somatoform disorder (USD) is the most common type. Psychological interventions can reduce symptoms associated with USD and improve functioning. Previous research has either been conducted in secondary care or interventions have been provided by general practitioners (GPs) or psychologists in primary care. As efficiency and cost-effectiveness are imperative in primary care, it is important to investigate whether nurse-led interventions are effective as well. The aim of this study is to examine the effectiveness and cost-effectiveness of a short cognitive behavioural therapy (CBT)-based treatment for patients with USD provided by mental health nurse practitioners (MHNPs), compared to usual care. METHODS: In a cluster randomised controlled trial, 212 adult patients with USD will be assigned to the intervention or care as usual. The intervention group will be offered a short, individual CBT-based treatment by the MHNP in addition to usual GP care. The main goal of the intervention is that patients become less impaired by their physical symptoms and cope with symptoms in a more effective way. In six sessions patients will receive problem-solving treatment. The primary outcome is improvement in physical functioning, measured by the physical component summary score of the RAND-36. Secondary outcomes include health-related quality of life measured by the separate subscales of the RAND-36, somatization (PHQ-15) and symptoms of depression and anxiety (HADS). Problem-solving skills, health anxiety, illness perceptions, coping, mastery and working alliance will be assessed as potential mediators. Assessments will be done at 0, 2, 4, 8 and 12 months. An economic evaluation will be conducted from a societal perspective with quality of life as the primary outcome measure assessed by the EQ-5D-5L. Health care, patient and lost productivity costs will be assessed with the Tic-P. DISCUSSION: We expect that the intervention will improve physical functioning and is cost-effective compared to usual care. If so, more patients might successfully be treated in general practice, decreasing the number of referrals to specialist care. TRIAL REGISTRATION: Dutch Trial Registry, identifier: NTR4686 , Registered on 14 July 2014.

Guided and unguided internet-based vestibular rehabilitation versus usual care for dizzy adults of 50†years and older: a protocol for a three-armed randomised trial.

INTRODUCTION: Dizziness is a common symptom in general practice with a high prevalence among older adults. The most common cause of dizziness in general practice is peripheral vestibular disease. Vestibular rehabilitation (VR) is a safe and effective treatment for peripheral vestibular disease that entails specific exercises to maximise the central nervous system compensation for the effects of vestibular pathology. An internet-based VR intervention has recently been shown to be safe and effective. Online interventions are low cost and easily accessible, but prone to attrition and non-adherence. A combination of online and face-to-face therapy, known as blended care, may balance these advantages and disadvantages. METHODS AND ANALYSIS: A single-blind, three-arm, randomised controlled trial among patients aged 50 years and over presenting with dizziness of vestibular origin in general practice will be performed. In this study, we will compare the clinical and cost-effectiveness of stand-alone internet-based VR and internet-based VR with physiotherapeutic support ('blended care') with usual care during 6 months of follow-up. We will use a translated Dutch version of a British online VR intervention. Randomisation will be stratified by dizziness severity. The primary outcome measure is the Vertigo Symptoms Scale-Short Form. Intention-to-treat analysis will be performed, adjusting for confounders. The economic evaluation will be conducted from a societal perspective. We will perform an additional analysis on the data to identify predictors of successful treatment in the same population to develop a clinical decision rule for general practitioners. ETHICS AND DISSEMINATION: The ethical committee of the VU University Medical Center approved ethics and dissemination of the study protocol. The insights and results of this study will be widely disseminated through international peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER: Pre-results, NTR5712.

Impairment reduction in older dizzy people in primary care: study protocol for a cluster randomised controlled trial.

BACKGROUND: The management of dizziness in older patients is primarily diagnosis-oriented. However, in 40% of older patients with dizziness, GPs are not able to identify an underlying cause, and a number of common underlying causes of dizziness cannot (or hardly) be treated. In this study we will investigate the effectiveness of a prognosis-oriented approach in the management of dizziness in older patients. This prognosis-oriented approach comprises identification of patients at risk for chronic dizziness with persistent impairment by identifying risk factors for an unfavourable course of dizziness. Patients at risk for chronic dizziness with persistent impairment will be offered treatment addressing the identified modifiable risk factors. METHODS/DESIGN: This study will be performed in primary care. An intervention study and a validation study will be conducted in a three-arm cluster randomised design. In the intervention study we will investigate a risk factor guided multi-component intervention. The risk factor guided intervention includes: (1) medication adjustment in case of three or more prescribed fall-risk-increasing drugs, (2) stepped care in case of anxiety disorder and/or depression, and (3) exercise therapy in case of impaired functional mobility. The primary outcome measure is dizziness-related impairment, which will be assessed with the Dizziness Handicap Inventory. Secondary outcome measures are quality of life, anxiety disorder and depression, use of fall-risk-increasing drugs, dizziness frequency, fall frequency, and healthcare utilization. DISCUSSION: This study is, to date, the first study that will investigate the effectiveness of a prognosis-oriented approach for reducing dizziness-related impairment in older people in primary care. Offering treatment that addresses identified modifiable risk factors to patients at high risk for chronic dizziness is unique. The pragmatic design of this study will enable evaluation of the outcomes in real-life routine practice conditions. An effective intervention will not only reduce dizziness-related impairment, but may also decrease healthcare utilization and healthcare costs. The previously developed risk score that will be validated alongside the intervention study will enable GPs to identify patients at high risk for chronic dizziness with persistent impairment. TRIAL REGISTRATION: Netherlands Trial Register (identifier: NTR4346), registration date 15 December 2013.

Associations of financial strain and income with depressive and anxiety disorders.

BACKGROUND: Previous research has shown socioeconomic inequality in prevalence and onset of depressive disorders. It is not yet clear whether perceived financial strain is associated with depressive and/or anxiety disorders in addition to an objective indicator, such as income. This study examines whether financial strain is associated with the prevalence and onset/recurrence of depressive and/or anxiety disorders, above income. METHODS: Data are from the Netherlands Study of Depression and Anxiety. Associations between financial strain, income and presence of depressive and/or anxiety disorder at baseline were assessed among 2937 participants (18-65 years). Impact of financial strain and income on 4-year onset/recurrence of depressive and/or anxiety disorders were examined among 1250 participants without a depressive or anxiety disorder at baseline. Depressive and anxiety disorders were determined with the Composite-International-Diagnostic-Interview. Financial strain and income were assessed in an interview. RESULTS: Participants with mild or severe financial strain had higher odds of being depressed (OR=1.68, 95% CI 1.35 to 2.09; OR=3.88, 95% CI 2.58 to 5.81) or remitted (OR=1.56, 95% CI 1.24 to 1.96; OR=1.99, 95% CI 1.27 to 3.11) at baseline compared with healthy controls, after adjusting for income. Mild or severe financial strain was not associated with onset/recurrence of depressive and/or anxiety disorders during follow-up (OR=1.08, 95% CI 0.83 to 1.42; OR=1.05, 95% CI 0.64 to 1.73). CONCLUSIONS: Financial strain was associated with having a depressive and/or anxiety disorder, above the effect of income. Healthcare and social services should be alert to this association, even for higher income households. However, financial strain and income were not related with 4-year onset/recurrence of depressive and/or anxiety disorders.

Evaluation of systematic assessment of asthma-like symptoms and tobacco smoke exposure in early childhood by well-child professionals: a randomised trial.

OBJECTIVES: This study aimed to evaluate the effectiveness of systematic assessment of asthma-like symptoms and environmental tobacco smoke (ETS) exposure during regular preventive well-child visits between age 1 and 4 years by well-child professionals. METHODS: Sixteen well-child centres in Rotterdam, the Netherlands, were randomised into 8 centres where the brief assessment form regarding asthma-like symptoms and ETS exposure was used and 8 centres that applied usual care. 3596 and 4179 children (born between April 2002 and January 2006) and their parents visited the intervention and control centres, respectively. At child's age 6 years, physician-diagnosed asthma ever, wheezing, fractional exhaled nitric oxide (FeNO), airway resistance (Rint), health-related quality of life (HRQOL) and ETS exposure at home ever were measured. Linear mixed models were applied. RESULTS: No differences in asthma, wheezing, FeNO, Rint or HRQOL measurements between intervention and control group were found using multilevel regression in an intention-to-treat analysis (p>0.05). Children of whom the parents were interviewed by using the brief assessment form at the intervention well-child centres had a decreased risk on ETS exposure at home ever, compared to children who visited the control well-child centres, in an explorative per-protocol analysis (aOR = 0.71, 95% CI:0.59-0.87). CONCLUSIONS: Systematic assessment and counselling of asthma-like symptoms and ETS exposure in early childhood by well-child care professionals using a brief assessment form was not effective in reducing the prevalence of physician-diagnosed asthma ever and wheezing, and did not improve FeNO, Rint or HRQOL at age 6 years. Our results hold some promise for interviewing parents and using information leaflets at well-child centres to reduce ETS exposure at home in preschool children. TRIAL REGISTRATION: Controlled-Trials.com ISRCTN15790308.

Childhood nonspecific abdominal pain in family practice: incidence, associated factors, and management.

PURPOSE: Nonspecific abdominal pain (NSAP) is a common complaint in childhood. In specialist care, childhood NSAP is considered to be a complex and time-consuming problem, and parents are hard to reassure. Little is known about NSAP in family practice, but the impression is that family physicians consider it to be a benign syndrome needing little more than reassurance. This discrepancy calls for a better understanding of NSAP in family practice. METHODS: Data were obtained from the Second Dutch National Survey of General Practice (2001). Using registration data of 91 family practices, we identified children aged 4 to 17 years with NSAP. We calculated the incidence, and we studied factors associated with childhood NSAP, referrals, and prescriptions. RESULTS: The incidence of NSAP was 25.0 (95% confidence interval [CI], 23.7-26.3) per 1,000 person years. Most children (92.7%) with newly diagnosed NSAP (N = 1,480) consulted their doctor for this condition once or twice. Factors independently associated with NSAP were female sex (odds ratio [OR] = 1.4; 95% CI, 1.3-1.5), nongastrointestinal-nonspecific somatic symptoms (OR = 1.3; 95% CI, 1.1-1.5), and health care use (OR = 1.04; 95% CI, 1.03-1.05). When NSAP was diagnosed at the first visit, 3% of the patients were referred to specialist care, and 1% received additional testing. Family physicians prescribed medication in 21.3% of the visits for NSAP. CONCLUSIONS: Childhood NSAP is a common problem in family practice. Most patients visit their doctor once or twice for this problem. Family physicians use little additional testing and make few referrals in their management of childhood NSAP. Despite the lack of evidence for effectiveness, family physicians commonly prescribe medication for NSAP.

Low hospital admission rates for respiratory diseases in children.

BACKGROUND: Population-based data on hospital admissions for children aged 0-17 years concerning all respiratory diseases are scarce. This study examined hospital admissions in relation to the preceding consultations in general practice in this age group. METHODS: Data on children aged 0-17 years with respiratory diseases included in the Second Dutch National Survey of General Practice (DNSGP-2) were linked to all hospital admissions in the Dutch National Medical Registration. Admission rates for respiratory diseases were calculated. Data were analysed using multivariate logistic regression. RESULTS: Of all 79,272 children within the DNSGP-2, 1.8% were admitted to hospital for any respiratory diagnosis. The highest admission rates per 1000 children were for chronic disease of tonsils and adenoids (12.9); pneumonia and influenza (0.97); and asthma (0.92). Children aged 0-4 years and boys were admitted more frequently. Of children with asthma, 2.3% were admitted for respiratory diseases. For asthma, admission rates varied by urbanisation level: 0.47/1000 children/year in cities with ≤ 30,000 inhabitants, 1.12 for cities with ≥ 50,000 inhabitants, and 1.73 for the three largest cities (p = 0.002). Multivariate logistic regression showed that within two weeks after a GP consultation, younger age (OR 0.81, 95% CI 0.76-0.88) and more severe respiratory diseases (5.55, 95% CI 2.99-8.11) predicted hospital admission. CONCLUSIONS: Children in the general population with respiratory diseases (especially asthma) had very low hospital admission rates. In urban regions children were more frequently admitted due to respiratory morbidity. For effectiveness studies in a primary care setting, hospital admission rates should not be used as quality end-point.

Management of childhood urinary tract infections: an economic modeling study.

UNLABELLED: Childhood urinary tract infections (UTIs) can lead to renal scarring and ultimately to terminal renal failure, which has a high impact on quality of life, survival, and health-care costs. Variation in the treatment of UTIs between practices is high. OBJECTIVE: To assess the cost-effectiveness of a maximum care model for UTIs in children, implying more testing and antibiotic treatment, compared with current practice in primary care in The Netherlands. METHODS: We performed a probabilistic modeling study using Markov models. Figures used in the model were derived from a systematic review of the research literature. Multidimensional Monte Carlo simulation was used for the probabilistic analyses. RESULTS: Maximum care gained 0.00102 (males) and 0.00219 (girls) QALYs (quality-adjusted life-years) and saved 42.70 euro (boys) and 77.81 euro (girls) in 30 years compared with current care, and was thus dominant. Net monetary benefit of maximum care ranged from 20 euro to 200 euro for a willingness to pay for a QALY ranging from 0 euro to 80,000 euro, respectively. Maximum care was also dominant over improved current care, although less dominant than to current care. CONCLUSIONS: This study suggested that maximum care for childhood UTI was dominant in the long run to current care, meaning that it delivered more quality of life at lower costs. Nevertheless, making firm conclusions is not possible, given the limitations of the input data.

Decreasing incidence of adenotonsillar problems in Dutch general practice: real or artefact?

BACKGROUND: The incidence of hypertrophy and recurrent infections of the tonsils/adenoids appears to be decreasing in the Netherlands. It is uncertain whether this is a 'real' decrease in the incidence of disease or an 'artefact'. AIM: To investigate possible causes of the decreasing incidence of adenotonsillar problems among Dutch children. DESIGN OF STUDY: Observational. SETTING: A nationally representative general practice database. METHOD: Incidence rates were calculated over 2002-2005 among children aged 0-14 years. Multilevel Poisson regression analyses were used to examine the following possible causes of changing incidence rates: change in recording (more substitution codes), change in the demand for care (fewer visits to the GP), and change in the supply of care (fewer antibiotic prescriptions and referrals). Indications for a 'real' change in the incidence of disease were examined by calculating incidence rates of other clinical manifestations of microbial pathogens that may cause adenotonsillar problems. RESULTS: The incidence rate decreased significantly (P = 0.017) from 3.0 to 1.3 per 1000 children per year. Correcting for demand for and supply of care led to a smaller decline in yearly incidence, from 2.9 to 1.7 per 1000 children per year (P = 0.105). No clearly similar trend was found in other clinical manifestations of viruses and bacteria that may cause adenotonsillar problems. CONCLUSION: Part of the declining trend can be explained by a change in the demand for and supply of care, but no apparent causal clue emerged for the residual declining trend in the incidence of disease.

What is the role of virus vaccination in patients with asthma?

It is estimated that viruses play a role in 30% to 80% of asthma exacerbations. Thus, virus vaccination in patients with asthma could play an important role in preventing asthma exacerbations and other complications. Influenza is the only agent for which a routine vaccine is currently available. This article discusses whether influenza vaccination in patients with asthma, based on the available evidence, is justified. Cost-effectiveness of (influenza) vaccination for patients with asthma is questionable. For the other major viruses involved, the present state of affairs is described. Although progress is being made, a vaccine may be available in the near future only for respiratory syncytial virus (RSV). Meanwhile, clinicians and patients should aim for an optimal treatment with the currently available asthma medication.

Parents' awareness of and knowledge about young children's urinary tract infections.

OBJECTIVE: To provide insight into parents' awareness of and knowledge about urinary tract infections (UTIs) in young children. METHODS: Twenty interviews with parents who had a child recently diagnosed with a UTI were audiotaped, transcribed verbatim, and qualitatively analysed. RESULTS: Most parents knew the typical symptoms related to UTI. But, according to the parents, neither they nor all general practitioners (GPs) thought of a UTI in case of atypical symptoms. The awareness that UTI can be a serious illness usually came to parents later, partly because health care workers often did not explicitly mention this. According to the parents, health care workers should be more aware of UTIs in children. Parents felt that health education or mass screening might not be desirable because it would increase anxiety or would be perceived as not relevant. CONCLUSION: Parents could not consistently recognise UTI in their children and were most times unaware of the possible consequences of a UTI. Nevertheless, parents were sceptical about health education and mass screening. PRACTICE IMPLICATIONS: There seems little scope for health education addressed at parents or screening for UTI in young children. Instead, physicians and nurses should be alert for the possibility of UTIs in young children, and more information should be given once a UTI is diagnosed.