How to use polarity thinkingTM to manage tensions between accountability and learner agency when using a multipurpose portfolio?

Portfolios are often implemented to target multiple purposes, e.g. assessment, accountability and/or self-regulated learning. However, in educational practice, it appears to be difficult to combine different purposes in one portfolio, as interdependencies between the purposes can cause tensions. This paper explored directions to manage tensions that are inextricably linked to multipurpose portfolio use. We used a systems thinking methodology, that was based on the polarity thinkingTM framework. This framework provides a step-by-step approach to chart a polarity map® that can help to balance the tensions present in specific settings. We followed the steps of the framework to chart a polarity map for multipurpose portfolio use. Based on literature and our prior research, we selected one overarching polarity: accountability and learner agency. This polarity seems responsible for multiple tensions related to multipurpose portfolio use. We formulated values (potential benefits) and fears (tensions that can arise) of the two poles of this polarity. Then, we organised a session with stakeholders who work with the portfolio of the Dutch General Practice speciality programme. Together we formulated action steps and early warnings that can help to balance accountability and learner agency during multipurpose portfolio use. In addition to previous recommendations concerning portfolio use, we advocate that it is important to create a shared frame of reference between all involved with the multipurpose portfolio. During this process, the acknowledgement and discussion of tensions related to multipurpose portfolio use are vital.

It Is Smart to Set Treatment Goals, But Are Set Treatment Goals SMART? A Qualitative Assessment of Goals Described in the Assessment of the Burden of COPD Tool.

The Assessment of the Burden of COPD (ABC) tool facilitates shared decision-making and goal setting to develop a personalized care plan. In a previous trial (RCT), the ABC tool was found to have a significant effect on patients' Health-related Quality of Life (HRQoL). In this exploratory study we used data from the intervention group of the RCT to investigate if patients with health-related goals had an improved HRQoL compared to those without goals, and if the quality and types of goals differed for those who have a clinically meaningful improvement in HRQoL. We hypothesized that the quality and the type of the goal described in the ABC tool, relates to an improved HRQoL. We assessed the quality of the goals according to the Specificity, Measurability, Achievability, Relevance and Timeliness (SMART) criteria, and coded and counted each type of goal. We found that having a goal or not, did not differ significantly for those who had a clinically meaningful improved HRQoL versus those who had not, nor was the quality or type of goal significantly different. The most common types of goals were exercise more, smoke less, and improve weight. Based on the results, we speculate that when a clinically meaningful improvement in HRQoL is achieved, it is not related to a single component (i.e. goal setting as part of shared decision-making) but that the different components of the ABC tool (visualization of burden, shared decision making, utilization of tailored evidence based interventions, and regular monitoring of progress) may have a synergistic effect on disease cognition and/or behavior change. Noteworthy, the sample size was small while the calculated effect size was moderate, making it unlikely to find a significant effect.

Learning from complex elderly care: a qualitative study on motivating residents in family medicine.

BACKGROUND: More and more patients need complex care, especially the elderly. For various reasons, this is becoming increasingly difficult. The onus is essentially on family physicians to provide this care and family medicine residency programs should therefore prepare their residents for this task. We know from self-determination theory (SDT) that motivation plays a key role in learning and that in order to boost motivation, fulfillment of 3 basic psychological needs - for autonomy, competence, and relatedness - is crucial. As residents often lack motivation, residency programs face the important challenge to motivate them to learn about and engage in complex elderly care. How to do so, however, is not yet sufficiently understood. METHODS: We conducted a qualitative multi-institutional case study across four universities in Belgium and the Netherlands. In the period between June, 2015, and May, 2019, we triangulated information from semi-structured interviews, document analysis, and observations of educational moments. Guided by SDT concepts, the analysis was performed iteratively by a multidisciplinary team, using ATLAS.ti, version 8. In this process, we gained more insights into residents' motivation to learn complex elderly care. RESULTS: We scrutinized 1,369 document pages and 4 films, observed 34 educational moments, and held 41 semi-structured interviews. Although we found all the 3 basic psychological needs postulated by SDT, each seemed to have its own challenges. First, a tension between the need to guide residents and to encourage their independent learning complicated fulfillment of the need for autonomy. Second, the unpredictability of complex care led to reduced feelings of competence. Yet, guidelines and models could help residents to capture and apprehend its complexity. And third, family medicine practice, patients, and educational practice, by either satisfying or thwarting the need for relatedness, were identified as key mediators of motivation. By setting the right example and encouraging residents to discuss authentic dilemmas and switch their health care approach from cure to care, educators can boost their motivation. CONCLUSION: Our study has demonstrated that the degree of perceived autonomy, guidance by the education program, use of authentic dilemmas, as well as involvement of group facilitators can aid the process of motivation. TRIAL REGISTRATION: NVMO, ERB number 482.

A TASMAN Expedition: Development of a Questionnaire to Assess Specific Self-Management Abilities.

Introduction: Self-management (SM) is a core component of well-being and perceived health for patients with chronic obstructive pulmonary disease (COPD). Most theories on SM share that self-efficacy, illness-perception and coping are determinants of SM behavior. Optimal support to improve SM should be tailored to the individual patient's level of these determinants as SM abilities vary between patients. To tailor SM support, it is therefore necessary to assess the scores on these determinants. Unfortunately, no such instrument exists for clinical use. Therefore, the first goal of this study was to verify presumed correlations between SM and the determinants thereof. The second goal was to develop an instrument to assess the SM abilities. Methods: In this cross-sectional, observational study, COPD patients completed the General Self-Efficacy Scale (GSES), Brief Illness Perception Questionnaire (B-IPQ) and the Utrecht Proactive Coping Competence measure (UPCC) as well as the Self-Management Ability Scale (SMAS-30). Correlations between the questionnaires were assessed and a principal component analysis (PCA) was performed to identify the best-fitting items in the three independent variables related to SM. These items were used to create an instrument to assess SM abilities. Results: Hundred COPD patients (58 males, 41 females, 1 unknown) were included. The correlation between SM and self-efficacy, illness perception on concerns and proactive coping was moderate and significant (r=0.318, p<0.01; r=-.230, p<0.05; r=.426, p<0.01, respectively). PCA identified six UPCC items and nine GSES items that met the predefined criteria. These items were supplemented with the B-IPQ concerns item to establish the new instrument to assess SM abilities.

[Nausea; article for education and training purposes]. / Misselijkheid.

Nausea is a common presenting symptom in medical care with a broad differential diagnosis. In this teaching article we provide practical information on many aspects of nausea including pathophysiology and differential diagnosis, history and physical examination, and diagnostic tests and treatment. This was done by means of answering several questions from the daily practice of general practitioners, specialists in internal medicine and surgeons. In a patient with nausea a provisional diagnosis can be made based on medical history, careful history-taking and age. Diagnostic testing is only performed on clinical suspicion and depends on the provisional diagnosis and presence of alarm symptoms. Tailored medical treatment of nausea is based on the provisional diagnosis and on the mechanism of action of the intended antiemetic agent.

European Society of ColoProctology: guideline for haemorrhoidal disease.

AIM: The goal of this European Society of ColoProctology project was to establish a multidisciplinary, international guideline for haemorrhoidal disease (HD) and to provide guidance on the most effective (surgical) treatment for patients with HD. METHODS: The development process consisted of six phases. In phase one we defined the scope of the guideline. The patient population included patients with all stages of haemorrhoids. The target group for the guideline was all practitioners treating patients with haemorrhoids and, in addition, healthcare workers and patients who desired information regarding the treatment management of HD. The guideline needed to address both the diagnosis of and the therapeutic modalities for HD. Phase two consisted of the compilation of the guideline development group (GDG). All clinical members needed to have affinity with the diagnosis and treatment of haemorrhoids. Further, attention was paid to the geographical distribution of the clinicians. Each GDG member identified at least one patient in their country who could read English to comment on the draft guideline. In phase three review questions were formulated, using a reversed process, starting with possible recommendations based on the GDG's knowledge. In phase four a literature search was performed in MEDLINE (Ovid), PubMed, Embase (Ovid) and the Cochrane Database of Systematic Reviews. The search was focused on existing systematic reviews addressing each review question, supplemented by other studies published after the time frame covered by the systematic reviews. In phase five data of the included papers were extracted by the surgical resident (RT) and checked by the methodologist (JK) and the GDG. If needed, meta-analysis of the systematic reviews was updated by the surgical resident and the methodologist using Review Manager. During phase six the GDG members decided what recommendations could be made based on the evidence found in the literature using GRADE. RESULTS: There were six sections: (i) symptoms, diagnosis and classification; (ii) basic treatment; (iii) outpatient procedures; (iv) surgical interventions; (v) special situations; (vi) other surgical techniques. Thirty-four recommendations were formulated. CONCLUSION: This international, multidisciplinary guideline provides an up to date and evidence based summary of the current knowledge of the management of HD and may serve as a useful guide for patients and clinicians.

Interprofessional Pulmocheck care pathway: An innovative approach to managing pediatric asthma care in the Netherlands.

OBJECTIVES: Under-diagnosis and suboptimal asthma control in children persists. An innovative care pathway was developed by a hospital department of pediatrics with the aim to detect pulmonary problems in children and provide appropriate treatment possibilities through systematic feedback towards the referring primary care physician. Primary care physicians can use this pathway to refer children with asthma-like symptoms for a one-day assessment. Goals are to measure the usage of the pathway by primary care general practitioners (GPs), the outcomes in terms of new diagnoses of asthma, the reduction in regular referrals, generated recommendations/therapy and the adequacy of asthma follow-up. METHODS: We collected all feedback letters sent to the GP concerning children who underwent the Pulmocheck in 2010, 2011 and 2012. Furthermore, all GPs, who had referred a child to the Pulmocheck in this period and that subsequently was diagnosed with asthma and was further managed in primary care, were sent a follow-up questionnaire in 2014. RESULTS: There were 121 referrals from 51 GPs in 3 years to this pathway. In 59.5% of these referrals a new diagnosis of asthma was established. In 90.9% one or more changes in clinical management were advised. The response rate to the follow-up questionnaires was 65.7% of which 4.8% of the children with new established asthma were reviewed four times or more in the follow-up period, 17.4% two times, 65.2% once, and in 8.7% were not followed. CONCLUSIONS: The specialty pediatric asthma care pathway revealed a high number of children with newly diagnosed asthma, but was also helpful to exclude this diagnosis. However, the referral rate of GPs to this pathway was low, but in the children, that were referred several changes in the clinical management were advised and the frequency of monitoring of the children with diagnosed asthma was not in accordance with the asthma guidelines.

Rome III vs Rome IV criteria for irritable bowel syndrome: A comparison of clinical characteristics in a large cohort study.

BACKGROUND: The Rome criteria for irritable bowel syndrome (IBS) have been revised and are expected to apply only to the subset of Rome III IBS subjects with abdominal pain as predominant symptom, occurring at least once a week. The aim of this study was to determine the percentage of Rome III IBS subjects that fulfills Rome IV criteria and to evaluate differences between Rome IV-positive and Rome IV-negative subjects. METHODS: Four hundred and four Rome III IBS subjects completed a 14-day end-of-day symptom diary, the Gastrointestinal Symptom Rating Scale (GSRS), Hospital Anxiety and Depression Scale, and RAND 36-item Short-Form Health Survey (SF-36). Diary-based surrogate Rome IV criteria were defined as occurrence of abdominal pain at least 1 day each week with a severity of ≥2 (mild; definition 1) or ≥3 (considerable; definition 2). KEY RESULTS: Using surrogate Rome IV criteria, 353 (87.4%, definition 1) and 249 (61.6%, definition 2) subjects were defined as Rome IV positive. These patients were more often female, younger, and recruited from secondary/tertiary care compared with Rome IV-negative subjects. They also presented with higher abdominal pain scores and gastrointestinal (GI) symptom severity on both end-of-day diary and GSRS, higher psychological symptom scores, and lower quality of life compared with Rome IV-negative subjects. CONCLUSIONS AND INFERENCES: The Rome IV IBS population likely reflects a subgroup of Rome III IBS patients with more severe GI symptomatology, psychological comorbidities, and lower quality of life. This implies that results from Rome III IBS studies may not be directly comparable to those from Rome IV IBS populations.

Association between exhaled inflammatory markers and asthma control in children.

The relationship between exhaled inflammatory markers and asthma control in children is unclear. To explore the association between inflammatory markers in exhaled breath (fractional nitric oxide (FeNO), volatile organic compounds (VOCs), cytokines/chemokines) and asthma control. To assess whether exhaled inflammatory markers are able to discriminate between children with persistently controlled/uncontrolled asthma. 96 asthmatic children were followed-up in a one-year observational study. Every 2 months, the following parameters were assessed: asthma control, FeNO, lung function (forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC), exhaled VOCs, and cytokines/chemokines in exhaled breath condensate (EBC). Random Forest was used to analyse the relationship between exhaled inflammatory markers and asthma control. For each model, patients were randomly selected for a training set and validation set. To assess the accuracy of the classification models, receiver operating characteristic-curves (ROC-curves) were generated. No significant association was found between the exhaled inflammatory markers (FeNO, markers in EBC, VOCs) and asthma control (area under the ROC-curve 49%). However, 15 exhaled VOCs could discriminate between subgroups of children with persistently controlled and uncontrolled asthma during all clinical visits (area under the ROC-curve 86%). Adding FeNO and markers in EBC to this model, did not lead to a more accurate classification (area under the ROC-curve 87%). There was no association between exhaled inflammatory markers and asthma control in children. However, children with persistently controlled or uncontrolled asthma during the 12 month study period could be discriminated by a set of VOCs.

Effectiveness of video- versus text-based computer-tailored smoking cessation interventions among smokers after one year.

BACKGROUND: In western countries, smoking prevalence rates are high among smokers unmotivated to quit and those with a lower socioeconomic status (LSES). Multiple computer tailoring and the use of audio-visual aids may improve such interventions and increase cessation in LSES smokers. This study assessed the 12-month effectiveness of a video- and text-based computer-tailored intervention. METHODS: A randomized controlled trial in the Netherlands was used in which smokers were allocated to the video-based condition (VC) (N=670), the text-based condition (TC) (N=708) or the control condition (CC) (brief generic text advice) (N=721). After 12months, self-reported prolonged abstinence was assessed and biochemically verified in respondents indicating to have quit smoking. Three analysis strategies were used to assess the effects: (1) multiple imputation (MI); (2) intention-to-treat (ITT); (3) complete case analysis (CC). RESULTS: VC was more effective in prolonged abstinence compared to CC (odds ratio (OR)=1.90, p=.005) and the text-based condition (OR=1.71, p=.01). VC was furthermore more effective than TC. No differences were found for SES and motivational levels. Results were similar when using ITT and CC. For our secondary outcome seven-day point prevalence abstinence; however, neither VC (OR=1.17, p=.34) or TC (OR=0.91, p=.52) outperformed the CC. CONCLUSION: The video-based computer-tailored intervention was effective in obtaining substantial long-term abstinence compared to the text-based version and a brief generic text advice.

Irritable bowel syndrome: an integrated explanatory model for clinical practice.

BACKGROUND: Although irritable bowel syndrome (IBS) is a symptom-based diagnosis, clinicians' management of and communication about the disorder is often hampered by an unclear conceptual understanding of the nature of the problem. We aimed to elucidate an integrated explanatory model (EM) for IBS from the existing literature for pragmatic use in the clinical setting. METHODS: Systematic and exploratory literature searches were performed in PubMed to identify publications on IBS and EMs. KEY RESULTS: The searches did not identify a single, integrated EM for IBS. However, three main hypotheses were elucidated that could provide components with which to develop an IBS EM: (i) altered peripheral regulation of gut function (including sensory and secretory mechanisms); (ii) altered brain-gut signaling (including visceral hypersensitivity); and (iii) psychological distress. Genetic polymorphisms and epigenetic changes may, to some degree, underlie the etiology and pathophysiology of IBS and could increase the susceptibility to developing the disorder. The three model components also fit into one integrated explanation for abdominal symptoms and changes in stool habit. Additionally, IBS may share a common pathophysiological mechanism with other associated functional syndromes. CONCLUSIONS & INFERENCES: It was possible to elucidate an integrated, three-component EM as a basis for clinicians to conceptualize the nature of IBS, with the potential to contribute to better diagnosis and management, and dialog with sufferers.

How to encourage smokers to participate in web-based computer-tailored smoking cessation programs: a comparison of different recruitment strategies.

The reach, retention and costs of four strategies aimed to recruit smokers for participation in a computer-tailored smoking cessation intervention was explored. The study was part of a randomized controlled trial whereby 832 respondents were randomized to three conditions. Smokers were invited by general practitioners (GPs), newspapers, Internet and other strategies (i.e. mailing organizations) to take part. ANOVA's/Chi-square tests explored sample differences. Logistic regression analyses investigated differences between the samples regarding retention and smoking behaviour. Smokers recruited via GPs (N = 144) had a lower educational level and suffered more from chronic obstructive pulmonary disease compared with respondents recruited via Internet (N = 307) (χ(2) = 11.554, df = 3, P = 0.009). Less motivated respondents recruited by GPs were more likely to return to study compared with the less motivated respondents recruited by 'other recruitment' strategies (χ(2) = 6.416, df = 3, P = 0.093). Highly addicted respondents recruited from newspapers (N = 213) were less likely to make a quit attempt compared with highly addicted respondents recruited by GPs (OR = 0.334, P = 0.035). Females from newspapers were less likely to remain abstinent compared with the GP sample (OR = 0.337, P = 0.005). Recruitment via GPs showed highest costs. Recruitment strategy influenced the type of smokers. Group differences were associated with different patterns of quitting.

Patient adherence to prescribed medication instructions for dyspepsia: the DIAMOND-study.

BACKGROUND: Insight into patient adherence is needed to enable an effect evaluation of medication for dyspepsia. OBJECTIVES: Adherence was explored by investigating two adherence outcome measures (completeness and intake fidelity) using data from the DIAMOND-study. METHODS: The DIAMOND-study is a pragmatic RCT comparing a 'step-up' with a 'step-down' treatment strategy. In step 1 participants (n =653) were instructed to use five pills/day for maximally 30 days: an antacid 4dd plus a placebo 1dd ('step-up') or a proton pump inhibitor 1dd plus a placebo 4dd ('step-down'). If the complaints persisted, step 2 was started (H(2)-receptor antagonist 2dd), and subsequently step 3 (five pills/day, placebo and verum vice versa from step 1). Completeness was assessed by pill counts, intake fidelity by patient questionnaires measuring the degree to which patients adhered to specific instructions concerning timing, frequency, dose and way of intake. RESULTS: In step 1, patients used on average 3.9 pills/day (78% of the prescribed doses), in step 2, 1.7 pills/day (85%) and in step 3, 3.6 pills/day (72%). For the four times daily pills, half of the patients used less than 80% of the prescribed pills per day. This was one third of the patients for the twice daily pills and one quarter for the once daily pills. There were no completeness differences between active or placebo medication and no differences between the study arms. As regards intake fidelity, 70% of the patients made one or more errors in the medication intake. CONCLUSION: There is room for improvement in adherence rates for dyspepsia medication.

COPD screening in general practice using a telephone questionnaire.

Chronic obstructive pulmonary disease (COPD) is a growing health problem, and an underestimated and underdiagnosed disease in primary care. The aim of this survey was to study the feasibility of detecting undiagnosed COPD patients in the general practice population with the aid of a telephone questionnaire. The study was held in 2 general practices in the Netherlands. During 2 weeks, all patients registered with these 2 practices and aged between 40 and 75 years were contacted through a call center. Persons known with a previous history or diagnosis of COPD or asthma or comorbidity were excluded from the telephone list. The telephone interview used the Respiratory Health Screening Questionnaire (DB Price, 2006). Based on the score on this instrument, respondents were classified as having a low, moderate or high risk of having COPD. Smoking behaviour and BMI were also recorded. Patients with medium and high risk for COPD were invited for spirometry, performed by 2 experienced registered nurses. The results of the telephone interview and spirometric findings were assessed by the attending GP, who established the final diagnosis. The call center reached 1032 persons, 813 of whom answered the questions. The percentage of smokers was 49.2%, with an average number of pack-years of 17.9 (SD = 17); mean BMI was 26.1. Spirometry and analysis by the GP showed that 15.7% of the medium-risk group had previously undiagnosed COPD, versus 39.6% of the high-risk group. The number of undiagnosed COPD patients in the general practice population is considerable. Case finding can focus on moderate- and high-risk groups after telephone risk assessment.

Soluble or insoluble fibre in irritable bowel syndrome in primary care? Randomised placebo controlled trial.

OBJECTIVE: To determine the effectiveness of increasing the dietary content of soluble fibre (psyllium) or insoluble fibre (bran) in patients with irritable bowel syndrome. DESIGN: Randomised controlled trial. SETTING: General practice. PARTICIPANTS: 275 patients aged 18-65 years with irritable bowel syndrome. INTERVENTIONS: 12 weeks of treatment with 10 g psyllium (n=85), 10 g bran (n=97), or 10 g placebo (rice flour) (n=93). MAIN OUTCOME MEASURES: The primary end point was adequate symptom relief during at least two weeks in the previous month, analysed after one, two, and three months of treatment to assess both short term and sustained effectiveness. Secondary end points included irritable bowel syndrome symptom severity score, severity of abdominal pain, and irritable bowel syndrome quality of life scale. RESULTS: The proportion of responders was significantly greater in the psyllium group than in the placebo group during the first month (57% v 35%; relative risk 1.60, 95% confidence interval 1.13 to 2.26) and the second month of treatment (59% v 41%; 1.44, 1.02 to 2.06). Bran was more effective than placebo during the third month of treatment only (57% v 32%; 1.70, 1.12 to 2.57), but this was not statistically significant in the worst case analysis (1.45, 0.97 to 2.16). After three months of treatment, symptom severity in the psyllium group was reduced by 90 points, compared with 49 points in the placebo group (P=0.03) and 58 points in the bran group (P=0.61 versus placebo). No differences were found with respect to quality of life. Fifty four (64%) of the patients allocated to psyllium, 54 (56%) in the bran group, and 56 (60%) in the placebo group completed the three month treatment period. Early dropout was most common in the bran group; the main reason was that the symptoms of irritable bowel syndrome worsened. CONCLUSIONS: Psyllium offers benefits in patients with irritable bowel syndrome in primary care. TRIAL REGISTRATION: Clinical trials NCT00189033.

Influence of gastric mucosal status on success of stepwise acid suppressive therapy for dyspepsia.

BACKGROUND: The most effective initial treatment strategy of dyspepsia is still under debate. Individual biological characteristics, such as condition of gastric mucosa, might contribute to selection of the most appropriate acid suppression treatment strategy. AIM: To assess whether pre-treatment testing of gastric mucosal status is relevant for treatment success in an RCT comparing step-up and step-down therapies in newly diagnosed dyspepsia patients. METHODS: Baseline serum samples were collected to assess gastric mucosal status using serum levels of pepsinogens-I&II, gastrin-17, and Helicobacter pylori IgA/IgG-antibodies. The 6-month treatment success was compared between step-up and step-down for patients with serum diagnoses: normal; gastritis; corpus atrophy or antrum atrophy. RESULTS: In all, 519 patients (M/F: 249/270, age: 47 (18-85) years, 29%H. pylori+) were randomized to step-up (n = 293) or step-down (n = 226). Normal mucosa, gastritis and corpus atrophy were diagnosed serologically in 70%, 28% and 2% of the patients, evenly distributed between the strategies (P = 0.65). Treatment success was achieved in respectively, 69%, 70% and 70% for the serum diagnosis groups, and did not differ between the strategies. CONCLUSIONS: Dyspepsia treatment success could not be predicted by gastric mucosal status. Therefore, serum diagnosis of gastric mucosal status is no useful tool for patient allocation to acid suppressive treatment strategies.

Which patient-related factors determine self-perceived patient adherence to prescribed dyspepsia medication?

Patient adherence to medical treatment for dyspepsia is disappointing, whereas adherence is crucial for a proper evaluation of treatment. This prospective study used elements of the Integrated Change Model and Weiner's Attribution Theory to describe patients' important cognitions and their interrelationships regarding self-perceived adherence to short-term medical treatment for dyspepsia. Patient questionnaires measured the predictors before treatment and self-perceived adherence after treatment. Approximately one-quarter of the patients indicated that they were non-adherent (n = 347). Univariate and multiple linear regression analyses revealed several significant predictors that explained 44% of the variance in self-perceived adherence. Patients with a low educational level, patients who claimed to regularly forget their medication in general, patients with a low self-efficacy or a low intention were less likely to be adherent. These results may indicate targets for interventions designed to improve adherence to medical treatment for dyspepsia. For instance, asking about expected difficulties in taking acid suppressants (e.g. forgetfulness or medication use at weekends) and making action plans to overcome these difficulties (e.g. using reminders) may result in improved adherence rates. Such an approach may reach a substantial number of patients since one in five patients in our study experienced some difficulties in taking medication.

Randomized patients in IBS research had different disease characteristics compared to eligible and recruited patients.

OBJECTIVE: The recruitment process may generate a selected patient sample, which may threaten the generalizability of trial results. This risk is particularly high in case disease and patient characteristics demonstrate a wide variation, such as in irritable bowel syndrome (IBS). We compared IBS patients who were selected, approached, and randomized to participate in a clinical trial assessing the efficacy of dietary fiber therapy in IBS. STUDY DESIGN AND SETTING: Retrospective survey in primary care patients diagnosed with IBS by their general practitioner in the past 2 years selected and invited for participation in a trial. Characteristics were compared between randomized patients (n=193) nonrandomized eligible patients (n=371), and patients not eligible for participating in the trial (n=724). RESULTS: Of the 2,100 IBS patients, 1,288 (61%) returned the questionnaire. Randomized patients had a higher intensity of IBS abdominal pain as compared to the other groups, a higher consultation rate and a longer IBS disease history. Noneligible patients had less active IBS symptoms. CONCLUSIONS: Patients randomized do differ from those nonrandomized in IBS disease characteristics. These observations may have implications for the applicability of our research outcome.

Measuring the severity of upper gastrointestinal complaints: does GP assessment correspond with patients' self-assessment?

BACKGROUND: Questionnaires are frequently used to measure the severity of gastrointestinal (GI) complaints. These questionnaires can either be filled out by the physicians or by the patients, but it is not clear whether these scores correspond. This study aimed to investigate the interrater agreement between physician-reported severity and patient-reported severity concerning the patients' upper GI complaints. METHODS: In a prospective observational study, the severity of eight GI complaints was registered by both patients and GPs independently on a seven-point scale (n = 316) before and after treatment with esomeprazole. Weighted kappa values for the agreement on the severity and simple kappa values for the agreement on the absence or presence of symptoms were calculated. RESULTS: The weighted kappa values ranged from 0.14 to 0.68 indicating poor to moderate agreement. The agreement on the presence or absence of symptoms was similar. Several systematic differences in scoring were found: the GPs tended to underestimate the severity of belching, nausea, early satiety, vomiting and upper and lower abdominal pain. Furthermore, the treatment effect for belching and lower abdominal pain was more often overestimated, while the treatment effect for nausea was more often underestimated by the GP. CONCLUSION: The agreement between GP and patient is low. The differences in scoring should be kept in mind when comparing physician-reported outcomes with patient-reported outcomes.

Prognostic factors and clinical outcome in acute lower respiratory tract infections: a prospective study in general practice.

BACKGROUND: Unrealistic expectations about illness duration are likely to result in reconsultations and associated unnecessary antibiotic prescriptions. An evidence-based account of clinical outcomes in patients with lower respiratory tract infection (LRTI) may help avoid unnecessary antibiotic prescriptions and reconsultations. OBJECTIVES: We aimed to identify clinical factors that may predict a prolonged clinical course or poor outcome for patients with LRTI and to provide an evidence-based account of duration of an LRTI and the impact of the illness on daily activities in patients consulting in general practice. METHODS: A prospective cohort study of 247 adult patients with a clinical diagnosis of LRTI presenting to 25 GPs in The Netherlands was carried out. Multivariable Cox regression analysis was used to identify baseline clinical and infection parameters that predicted the time taken for symptoms to resolve. A Kaplan-Meier curve was used to analyse time-to-symptom resolution. Clinical cure was recorded by the GPs at 28 days after the initial consultation and by the patients at 27 days. RESULTS: Co-morbidity of asthma was a statistically significant predictor of delayed symptom resolution, whereas the presence of fever, perspiring and the prescription of an antibiotic weakly predicted enhanced symptom resolution. The GPs considered 89% of the patients clinically cured at 28 days, but 43% of these nevertheless reported ongoing symptoms. Patient-reported cure was much lower (51%), and usual daily activities were limited in 73% of the patients at baseline, and 19% at final follow-up. CONCLUSIONS: The course of LRTI was generally uncomplicated, but the morbidity of this illness was considerable with a longer duration than generally reported, especially for patients with co-existent asthma. These results underline once again the importance of providing GPs with an evidence-based account of outcomes to share with patients in order to set realistic expectations and of enhancing their communication skills within the consultation.