General practitioners' perspectives on relocating care: a Dutch interview study.

BACKGROUND: Healthcare systems around the world are facing significant challenges because higher costs and an increase in demand for care has not been matched by a corresponding growth in the health workforce. Without reform, healthcare systems are unsustainable. Relocating care, such as from hospitals to general practices, is expected to make a key contribution to ensuring healthcare remains sustainable. Relocating care has a significant impact upon general practitioners (GPs). Therefore, we investigated which care, according to GPs, could be relocated and under which conditions. METHOD: GPs were recruited through Nivel's GPs network on eHealth and innovation, located in the Netherlands. One exploratory focus group and 12 in-depth interviews were conducted. Interview transcripts were analyzed using the qualitative research principles of thematic analysis. RESULTS: According to the participants, some diagnostic and follow-up care could be relocated from hospitals to GPs once certain prerequisites are fulfilled. An important condition of relocating care from the hospital to the GP is that GPs have sufficient time to take over these tasks. The types of care that can be relocated from the GP to other settings are those questions where the medical knowledge of the GP can offer nothing extra or where problems in navigating the health system cause patients to either turn to, or stay with, their GP. CONCLUSION: Care should first be relocated from the GP to other settings before attempting to organize the relocation of care from the hospital to the GP. When this, and other conditions are met, some diagnostic and follow-up care can be relocated from the hospital to the GP.

Citizens' perspectives on relocating care: a scoping review.

BACKGROUND: Healthcare systems around the world are facing large challenges. There are increasing demands and costs while at the same time a diminishing health workforce. Without reform, healthcare systems are unsustainable. Relocating care, for example, from hospitals to sites closer to patients' homes, is expected to make a key contribution to keeping healthcare sustainable. Given the significant impact of this initiative on citizens, we conducted a scoping review to provide insight into the factors that influence citizens' attitudes towards relocating care. METHOD: A scoping review was conducted. The search was performed in the following databases: Pubmed, Embase, Cinahl, and Scopus. Articles had to include relocating healthcare and citizens' perspectives on this topic and the articles had to be about a European country with a strong primary care system. After applying the inclusion and exclusion criteria, 70 articles remained. RESULTS: Factors positively influencing citizens' attitudes towards relocating care included: convenience, familiarity, accessibility, patients having more control over their disease, and privacy. Factors influencing negative attitudes included: concerns about the quality of care, familiarity, the lack of physical examination, contact with others, convenience, and privacy. Furthermore, in general, most citizens preferred to relocate care in the studies we found, especially from the hospital to care provided at home. CONCLUSION: Several factors influencing the attitude of citizens towards relocating care were found. These factors are very important when determining citizens' preferences for the location of their healthcare. The majority of studies in this review reported that citizens are in favour of relocating care. In general citizens' perspectives on relocating care are very often missing in articles. It was significant that very few studies on relocation from the hospital to the general practitioner were identified.

Content Validity of a Short Calcium Intake List to Estimate Daily Dietary Calcium Intake of Patients with Osteoporosis.

PURPOSE: Calcium supplements are prescribed for prevention of osteoporotic fractures, but there is controversy whether excess of calcium intake is associated with cardiovascular events. While an accurate estimation of dietary calcium intake is a prerequisite to prescribe the adequate amount of supplementation, the most adequate tools for estimating intake are time-consuming. The aim of this study is to validate a short calcium intake list (SCaIL) that is feasible in daily clinical practice. METHODS: Based on the food groups contributing most to daily dietary calcium intake and portion sizes determined in an earlier study, a three-item, 1-min SCaIL was designed. As a reference method, an extensive dietary history (DH) with specific focus on calcium-rich foods and extra attention for portion sizes was performed. Beforehand, a difference of ≥250 mg calcium between both methods was considered clinically relevant. RESULTS: Sixty-six patients with either primary (n = 40) or secondary (n = 26) osteoporosis were included. On average, the SCaIL showed a small and clinically non-relevant difference in calcium intake with the DH: 24 ± 350 mg/day (1146 ± 440 vs. 1170 ± 485 mg, respectively; p = 0.568). Sensitivity and specificity of the SCaIL, compared to the DH, were 73 and 80%, respectively. However, in 50% of the individuals, a clinically relevant difference of ≥250 mg calcium was observed between both methods, while in 17% this was even ≥500 mg. CONCLUSIONS: The SCaIL is a quick and easy questionnaire to estimate dietary calcium intake at a group level, but is not sufficiently reliable for use in individual patients. Remarkably, the mean dietary calcium intake estimated by the DH of 1170 mg/day indicates that a large proportion of osteoporosis patients might not even need calcium supplementation, although more data are needed to confirm this finding.

The EULAR Outcome Measures Library: development and an example from a systematic review for systemic lupus erythematous instruments.

OBJECTIVES: Patient reported outcomes (PROs) are relevant in rheumatology. Variable accessibility and validity of commonly used PROs are obstacles to homogeneity in evidence synthesis. The objective of this project was to provide a comprehensive library of "validated PROs". METHODS: A launch meeting with rheumatologists, PROs methodological experts, and patients, was held to define the library's aims and scope, and basic requirements. To feed the library we performed systematic reviews on selected diseases and domains. Relevant information on PROs was collected using standardised data collection forms based on the COSMIN checklist. RESULTS: The EULAR Outcomes Measures Library (OML), whose aims are to provide and to advise on PROs on a user-friendly manner albeit based on scientific grounds, has been launched and made accessible to all. PROs currently included cover any domain and, are generic or specifically target to the following diseases: rheumatoid arthritis, osteoarthritis, spondyloarthritis, low back pain, systemic lupus erythematosus, gout, osteoporosis, juvenile idiopathic arthritis, and fibromyalgia. Up to 236 instruments (106 generic and 130 specific) have been identified, evaluated, and included. The systematic review for SLE, which yielded 10 specific instruments, is presented here as an example. The OML website includes, for each PRO, information on the construct being measured and the extent of validation, recommendations for use, and available versions; it also contains a glossary on common validation terms. CONCLUSIONS: The OML is an in progress library led by rheumatologists, related professionals and patients, that will help to better understand and apply PROs in rheumatic and musculoskeletal diseases.

Making the invisible visible: bioelectrical impedance analysis demonstrates unfavourable body composition in rheumatoid arthritis patients in clinical practice.

OBJECTIVES: To examine differences between the assessment of body composition by body mass index (BMI) and bioelectrical impedance analysis (BIA) in patients with rheumatoid arthritis (RA). METHOD: The body composition of RA patients was assessed during their visit to the outpatient department of a Dutch academic hospital using BMI, fat-free mass index (FFMI), and fat mass index (FMI). FFMI and FMI were determined by single-frequency BIA. RESULTS: Sixty-five consecutive RA patients (83% women, mean age 58 years, median disease duration 7 years) with moderately active disease [mean Disease Activity Score using 28 joint counts (DAS28) = 3.40; mean Rheumatoid Arthritis Disease Activity Index (RADAI) score = 3.49] and moderate disability [mean Health Assessment Questionnaire (HAQ) score = 0.87] were included. Based on BMI, 2% of our study population were underweight, 45% had a healthy body composition, and 54% were overweight or obese. Based on BIA, 18% of the patients showed a low FFMI and 74% had a high or very high FMI. Low FFMI was found in 44% of the women with a normal BMI, and high FMI was found in 40% of the women and 75% of the men with a normal BMI. CONCLUSIONS: A high frequency of unfavourable body composition, predominantly reduced FFMI and elevated FMI, was found in a cohort of RA patients with moderately active disease, turning BMI into an unreliable method for assessment of body composition in RA. BIA, however, might be the preferred method to assess FFMI and FMI in RA patients in clinical practice, as it is easy to use and relatively inexpensive.

Discordant perspectives of rheumatologists and patients on COBRA combination therapy in rheumatoid arthritis.

OBJECTIVE: The COBRA therapy (combination therapy in early rheumatoid arthritis) has proven to be an effective treatment for early RA, but is rarely prescribed. A survey showed reluctance of Dutch reumatologists to apply COBRA therapy in early RA. The present qualitative study was carried out to further explore the reservation of Dutch rheumatologists towards prescribing COBRA therapy and include patients' view on (components of) COBRA therapy. METHODS: Two focus group discussions were undertaken for rheumatologists (n(1) = 8, n(2) = 7) and two for patients (n(1) = 4, n(2) = 8). In addition, in-depth interviews were conducted with 11 rheumatologists and 1 patient. These were taped and transcribed. Two independent researchers identified themes and these were discussed with three other researchers. RESULTS: Rheumatologists were positive concerning effectiveness of COBRA therapy, but highly concerned about their patients' possible negative reaction to the large amount of pills to be prescribed. In addition, rheumatologists perceived lack of time explaining and prescribing COBRA therapy and felt uncomfortable prescribing high doses of prednisolone. Patients were positive about an aggressive combination therapy such as COBRA, and they had no qualms taking many pills if this could improve their prognosis. Patients associated prednisolone with negative side-effects, but were also aware of the benefits and the need of prednisolone in rough times. A decrease in the amount of pills after intensive treatment was highly appreciated. CONCLUSION: Rheumatologists and patients differed in opinion about the use of COBRA therapy. Rheumatologists were particularly concerned about their patients' reaction towards them prescribing such an aggressive and complex therapy, whereas patients, while aware of the side-effects, were most interested in suppressing illness symptoms and reducing future damage regardless of the amount of pills.

Tight control and intensified COBRA combination treatment in early rheumatoid arthritis: 90% remission in a pilot trial.

OBJECTIVE: To investigate the efficacy and feasibility of an intensive combination treatment in early rheumatoid arthritis (RA) combined with monitoring both disease activity and cartilage degradation. METHODS: In a pilot trial, 21 patients with active early RA (mean DAS28 5.3; mean disease duration 3 months) were treated with COBRA treatment comprising sulfasalazine, methotrexate and high-dose step-down prednisolone, intensified by adding hydroxychloroquine and continued low-dose prednisolone. In addition, based on measurements of disease activity or a marker of cartilage degradation (CTX-II), treatment adjustments were possible with methotrexate intensification after 8 or 21 weeks; and with infliximab after 21 weeks. RESULTS: Nineteen of 21 patients (90%) were in remission (DAS28 <2.6) after 40 weeks (8 weeks, 57%; 21 weeks, 76%). American College of Rheumatology (ACR) criteria, ACR20, 50, 70 and 90 improvements rates were 100%, 95%, 71% and 43% respectively. CTX-II excretion decreased by mean (SD) 347(292) ng/mmol creatinine, but only 50% of patients reduced their CTX-II excretion below the cut-off point. The two monitoring groups showed no significant difference in remission according to DAS score or CTX-II excretion, despite a trend towards more intensive treatment in the CTX-II group. Treatment intensification was feasible according to protocol. CONCLUSIONS: This small pilot study suggests that intensified and tightly controlled COBRA treatment is uniquely effective in early RA. TRIAL REGISTRATION NUMBER: ISRCTN96372677.