A Nationwide Flash-Mob Study for Suspected Acute Coronary Syndrome.

PURPOSE: Our primary objective was to evaluate the Marburg Heart Score (MHS), a clinical decision rule, or to develop an adapted clinical decision rule for family physicians (FPs) to safely rule out acute coronary syndrome (ACS) in patients referred to secondary care for suspected ACS. The secondary objective was to evaluate the feasibility of using the flash-mob method, an innovative study design, for large-scale research in family medicine. METHODS: In this 2-week, nationwide, prospective, observational, flash-mob study, FPs collected data on possible ACS predictors and assessed ACS probability (on a scale of 1-10) in patients referred to secondary care for suspected ACS. RESULTS: We collected data for 258 patients in 2 weeks by mobilizing approximately 1 in 5 FPs throughout the country via ambassadors. A final diagnosis was obtained for 243 patients (94.2%), of whom 45 (18.5%) received a diagnosis of ACS. Sex, sex-adjusted age, and ischemic changes on electrocardiography were significantly associated with ACS. The sensitivity of the MHS (cut-off ≤2) was 75.0%, specificity was 44.0%, positive predictive value was 24.3%, and negative predictive value was 88.0%. For the FP assessment (cut-off ≤5), these test characteristics were 86.7%, 41.4%, 25.2%, and 93.2%, respectively. CONCLUSIONS: For patients referred to emergency care, ACS could not be safely ruled out using the MHS or FP clinical assessment. The flash-mob study design may be a feasible alternative research method to investigate relatively simple, clinically relevant research questions in family medicine on a large scale and over a relatively short time frame.

General practitioner use of D-dimer in suspected venous thromboembolism: historical cohort study in one geographical region in the Netherlands.

OBJECTIVES: To investigate how many general practitioner (GP)-referred venous thromboembolic events (VTEs) are diagnosed during 1 year in one geographical region and to investigate the (urgent) referral pathway of VTE diagnoses, including the role of laboratory D-dimer testing. DESIGN: Historical cohort study. SETTING: GP patients of 47 general practices in a demarcated geographical region of 161 503 inhabitants in the Netherlands. PARTICIPANTS: We analysed all 895 primary care patients in whom either the GP determined a D-dimer value or who had a diagnostic work-up for suspected VTE in a non-academic hospital during 2015. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcomes of this study were the total number of VTEs per year and the diagnostic pathways-including the role of GP determined D-dimer testing-of patients urgently referred to secondary care for suspected VTE. Additionally, we explored the use of an age-adjusted D-dimer cut-off. RESULTS: The annual VTE incidence was 0.9 per 1000 inhabitants. GPs annually ordered 5.1 D-dimer tests per 1000 inhabitants. Of 470 urgently GP-referred patients, 31.3% had a VTE. Of those urgently referred based on clinical assessment only (without D-dimer testing), 73.8% (96/130) had a VTE; based on clinical assessment and laboratory D-dimer testing yielded 15.0% (51/340) VTE. Applying age-adjusted D-dimer cut-offs to all patients aged 50 years or older resulted in a reduction of positive D-dimer results from 97.9% to 79.4%, without missing any VTE. CONCLUSIONS: Although D-dimer testing contributes to the diagnostic work-up of VTE, GPs have a high detection rate for VTE in patients who they urgently refer to secondary care based on clinical assessment only.

[Carpal tunnel syndrome: a clinical diagnosis]. / Carpaletunnelsyndroom, een klinische diagnose.

Carpal tunnel syndrome (CTS) is a clinical syndrome diagnosis. There is no universal reference test for diagnosing CTS. In case of a clinical presentation consistent with the typical characteristics of CTS, the diagnosis can be made without additional examinations. In that case, the physician may immediately proceed with a discussion of treatment options with the patient, using the CTS consultation card. Use of clinical provocation tests, questionnaires and hand diagrams is not advised due to their limited diagnostic value. Additional examinations are indicated when a patient does not have all typical characteristics of CTS or when in doubt about the diagnosis. If available, nerve ultrasonography is the test of preference but nerve conduction tests are a good alternative. From the perspective of quality of care, patient-friendliness and efficiency, it is recommended to make arrangements between primary and secondary care about the care process for patients suspected of having CTS.

International definition of a point-of-care test in family practice: a modified e-Delphi procedure.

Background: The use of point-of-care tests (POCTs) in family practice is increasing, and the term POCT is often used in medical literature and clinical practice. Yet, no widely supported definition by several professional fields exists. Objective: To reach consensus on an international definition of a POCT in family practice. Methods: We performed a modified international e-Delphi procedure of four rounds among expert panel members from different professional backgrounds-family practitioners, laboratory specialists, policymakers, researchers and manufacturers. Results: Of 27 panel members from seven different countries, 26 participated in all rounds. Most panel members were active in POCT research or policymaking and 70% worked in family medicine. After choosing important components, structuring of answers and feedback, the following definition was chosen as the best or second best definition by 81% of panel members: a point-of-care test in family practice is a test to support clinical decision making, which is performed by a qualified member of the practice staff nearby the patient and on any part of the patient's body or its derivatives, during or very close to the time of consultation, to help the patient and physician to decide upon the best suited approach, and of which the results should be known at the time of the clinical decision making. Conclusion: The definition emerging from this study can inform family practitioners, laboratory specialists, policymakers and manufacturers on the most widely supported and recognized definition and could act as a clear starting point for the organization and execution of professional point-of-care testing in family practice worldwide.

Point-of-care testing in primary care patients with acute cardiopulmonary symptoms: a systematic review.

Background: Point-of-care tests (POCT) can assist general practitioners (GPs) in diagnosing and treating patients with acute cardiopulmonary symptoms, but it is currently unknown if POCT impact relevant clinical outcomes in these patients. Objective: To assess whether using POCT in primary care patients with acute cardiopulmonary symptoms leads to more accurate diagnosis and impacts clinical management. Methods: We performed a systematic review in four bibliographic databases. Articles published before February 2016 were screened by two reviewers. Studies evaluating the effect of GP use of POCT on clinical diagnostic accuracy and/or effect on treatment and referral rate in patients with cardiopulmonary symptoms were included. Results: Our search yielded nine papers describing data from seven studies, on the clinical diagnostic accuracy of POCT in a total of 2277 primary care patients with acute cardiopulmonary symptoms. Four papers showed data on GP use of D-dimer POCT in pulmonary embolism (two studies); two studies on Troponin T in acute coronary syndrome; one on heart-type fatty acid-binding protein (H-FABP) in acute coronary syndrome; one on B-type natriuretic peptide (BNP) in heart failure; one on 3-in-1 POCT (Troponin T, BNP, D-dimer) in acute coronary syndrome, heart failure and/or pulmonary embolism. Only one study assessed the effect of GP use of POCT on treatment initiation and one on actual referral rates. Conclusion: There is currently limited and inconclusive evidence that actual GP use of POCT in primary care patients with acute cardiopulmonary symptoms leads to more accurate diagnosis and affects clinical management. However, some studies show promising results, especially when a POCT is combined with a clinical decision rule.

General practitioners' experiences with out-of-hours cardiorespiratory consultations: a qualitative study.

OBJECTIVES: To explore general practitioners' (GPs') experiences with and views on the diagnosis and management of patients with cardiorespiratory symptoms during GP out-of-hours care. We also aimed to identify ways of (diagnostic) support during these consultations. DESIGN: Qualitative study; face-to-face semistructured interviews. SETTING: GP out-of-hours care in the Netherlands. PARTICIPANTS: 15 GPs in the province of Limburg, the Netherlands. RESULTS: Overall, GPs find cardiorespiratory consultations challenging and difficult. Tension and uncertainty as well as defensive behaviour were the key themes that characterised GPs' experiences. We identified several subthemes underlying the key themes: setting, potentially severe consequences, absence of a pre-existing relationship and little knowledge of the patient's background, difficulties differentiating between possible causes of symptoms, changed public opinion and patient population, and previous experiences. GPs approach cardiorespiratory consultations differently and their threshold for referring patients and performing diagnostic tests is lower. We identified differing views on the use of additional diagnostic tests at GP out-of-hours services. CONCLUSIONS: This study sheds further light on how GPs experience cardiorespiratory consultations during out-of-hours care and how this leads to a high number of cardiorespiratory referrals. GPs relate cardiorespiratory consultation during out-of-hours care with tension and uncertainty leading to defensive behaviour, which can be translated into a different approach towards cardiorespiratory consultations and a lower threshold for referring patients and performing diagnostic tests. Opinions on the possible added value of additional diagnostics in reducing the number of referrals should be further investigated, as we identified differing views on the use of additional diagnostic tests at GP out-of-hours services.

Access to diagnostic tests during GP out-of-hours care: A cross-sectional study of all GP out-of-hours services in the Netherlands.

BACKGROUND: In general practice, excluding serious conditions is one of the cornerstones of the consultation. Diagnostic tests are widely used to assist the decision-making process in these cases. Little is known about general practitioners' (GPs) access to diagnostic tests at GP out-of-hours services. OBJECTIVES: To determine GPs' access to diagnostic tests-imaging, function tests, laboratory tests, and point-of-care tests (POCT)-during GP out-of-hours care and to assess whether access to diagnostic facilities differs between services located adjacent to or separate from an accident and emergency (A&E) department. METHODS: Cross-sectional survey of all 117 GP out-of-hours services in the Netherlands in 2014. RESULTS: One-hundred-seventeen GP out-of-hours services participated in the survey; response rate 100%. Access to diagnostic tests during GP out-of-hours care varied across services, although generally there was limited access. Electrocardiography was available in 26% (30/117) of all services, conventional radiography in 19% (22/117), laboratory tests between 37% (43/117) and 65% (76/117). All services had glucose POCT and urine dipstick tests available while none utilized troponin POCT. We observed no relevant differences in access to diagnostic tests between services adjacent to or separate from an A&E department. CONCLUSION: GPs in the Netherlands had limited and varying access to diagnostic tests during GP out-of-hours care in 2014. Out-of-hours services adjacent to A&E departments do not offer wider access to diagnostic tests. Further research on the accessibility of diagnostic tests in other European countries with similar and different GP out-of-hours care systems could shed further light on the effects of accessibility to diagnostic tests. [Box: see text].

[Diagnostic tests in GP out-of-hours services in the Netherlands]. / Aanvullende diagnostiek op Nederlandse huisartsenpost.

OBJECTIVE: To determine GPs' access to diagnostic tests (medical imaging, laboratory tests, and point-of-care tests) during GP out-of-hours care in the Netherlands and to assess whether access differs between services located adjacent to or separate from an Accident and Emergency (A&E) department. DESIGN: Cross-sectional survey. METHOD: In 2014 we invited all GP out-of-hours services in the Netherlands to participate in a survey on GPs' access to diagnostic tests in Dutch GP out-of-hours services. RESULTS: 117 GP out-of-hours services participated in the survey; response rate 100%. Although access to diagnostic tests during GP out-of-hours care varied across services, overall there was limited access. Electrocardiography was available in 26% (30/117) of all services, and conventional radiography in 19% (22/117). Access to various types of laboratory tests ranged between 37% (43/117) and 65% (76/117). All services had glucose point-of-care tests and urine dipstick tests available. We observed no relevant differences in access to in-house diagnostic tests between services adjacent to or separate from an A&E department. More than half (56%) of out-of-hours services expressed plans to expand their diagnostic facilities. CONCLUSION: GPs in the Netherlands have limited and varying access to diagnostic tests in GP out-of-hours services. GPs working in out-of-hours services adjacent to A&E departments do not have wider access to diagnostic tests than GPs working at a separate location. With current developments towards joint organisation structures of GP out-of-hours services and A&E departments in the Netherlands, the organisation of diagnostic facilities within out-of-hours care may be subject of debate.

[Point-of-care testing in family practices: present use and need for tests in the future]. / Sneltesten in de huisartspraktijk: huidig gebruik en behoefte aan testen in de toekomst.

OBJECTIVE: To provide insight into the current use, future needs, and attitudes towards point-of-care testing among Dutch family practitioners. DESIGN: Cross-sectional online survey. METHOD: We performed a survey among 2129 Dutch family practitioners. We asked respondents to report on the current and desired use of point-of-care tests, frequency of use, their opinions on aspects of point-of-care tests and consequences of point-of-care tests on their practice, acceptable waiting times for test results to come in, the desire for point-of-care tests at out-of-hours services, and conditions for which a point-of-care test could assist in diagnosis. RESULTS: 639 family practitioners completed the survey (response rate: 30%). The most common point-of-care tests currently used by family physicians were: blood glucose (96%), urine leucocytes or nitrite (96%), urine pregnancy (94%), haemoglobin (58%), and CRP (48%). The most commonly desired point-of-care tests were: D-dimer (70%), troponin (65%), BNP (62%), chlamydia (60%), and INR (54%). Family practitioners expected point-of-care tests to have a positive effect on patient satisfaction (93%), diagnostic certainty (89%), antibiotics use (84%), and substitution to primary care (78%). They considered the proven effect on clinical management (46%) and the tests' reliability (35%) to be important aspects of point-of-care tests. Respondents wanted point-of-care tests to help them diagnose acute conditions, such as acute thromboembolic disorders (D-dimers), cardiac disorders (troponin, BNP), and infections (CRP, chlamydia). CONCLUSION: The current use of point-of-care testing in family practice is restricted to a limited number of tests. In the future, Dutch family practitioners wish to use more point-of-care tests, especially in acute conditions in which a diagnostic decision needs to be made immediately.

Incidence of oral anticoagulant-associated intracerebral hemorrhage in the Netherlands.

BACKGROUND AND PURPOSE: The aim of this study was to estimate the annual adult incidence and risk of intracerebral hemorrhage (ICH) and oral anticoagulant-associated ICH (OAC-ICH) in the Netherlands. METHODS: We retrospectively selected all consecutive adult patients with a nontraumatic ICH seen in 1 of 3 hospitals in the region South-Limburg, the Netherlands, from 2007 to 2009. Crude incidences were age-adjusted to Dutch and European population. RESULTS: We identified 652 ICH cases, of which 168 (25.8%) were OAC associated. The adult Dutch age-adjusted annual incidence of ICH and OAC-ICH was 34.8 (95% confidence interval, 32.0-37.8) and 8.7 (95% confidence interval, 7.3-10.3) per 100 000 person-years, respectively. The absolute risk of OAC-ICH was estimated at 0.46% per patient-year of OAC treatment. CONCLUSIONS: The annual incidences of ICH and OAC-ICH are relatively high in the Netherlands when compared with international literature.