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Purpose We aimed to test the effects of providing municipal support and training to primary health care providers compared to both training alone and to care as usual on the proportion of adult patients having their alcohol consumption measured. Methods We undertook a quasi-experimental study reporting on a 5-month implementation period in 58 primary health care centres from municipal areas within Bogotá (Colombia), Mexico City (Mexico), and Lima (Peru). Within the municipal areas, units were randomized to four arms: (1) care as usual (control); (2) training alone; (3) training and municipal support, designed specifically for the study, using a less intensive clinical and training package; and (4) training and municipal support, designed specifically for the study, using a more intense clinical and training package. The primary outcome was the cumulative proportion of consulting adult patients out of the population registered within the centre whose alcohol consumption was measured (coverage). Results The combination of municipal support and training did not result in higher coverage than training alone (incidence rate ratio (IRR) = 1.0, 95% CI = 0.6 to 0.8). Training alone resulted in higher coverage than no training (IRR = 9.8, 95% CI = 4.1 to 24.7). Coverage did not differ by intensity of the clinical and training package (coefficient = 0.8, 95% CI 0.4 to 1.5). Conclusions Training of providers is key to increasing coverage of alcohol measurement amongst primary health care patients. Although municipal support provided no added value, it is too early to conclude this finding, since full implementation was shortened due to COVID-19 restrictions. Trial Registration Clinical Trials.gov ID: NCT03524599; Registered 15 May 2018; https://clinicaltrials.gov/ct2/show/NCT03524599

Background The substitution of healthcare is a way to control rising healthcare costs. The Primary Care Plus (PC+) intervention of the Dutch ‘Blue Care’ pioneer site aims to achieve this feat by facilitating consultations with medical specialists in the primary care setting. One of the specialties involved is dermatology. This study explores referral decisions following dermatology care in PC+ and the influence of predictive patient and consultation characteristics on this decision. Methods This retrospective study used clinical data of patients who received dermatology care in PC+ between January 2015 and March 2017. The referral decision following PC+, (i.e., referral back to the general practitioner (GP) or referral to outpatient hospital care) was the primary outcome. Stepwise logistic regression modelling was used to describe variations in the referral decisions following PC+, with patient age and gender, number of PC+ consultations, patient diagnosis and treatment specialist as the predicting factors. Results A total of 2952 patients visited PC+ for dermatology care. Of those patients with a registered referral, 80.2% (N = 2254) were referred back to the GP, and 19.8% (N = 558) were referred to outpatient hospital care. In the multivariable model, only the treating specialist and patient’s diagnosis independently influenced the referral decisions following PC+. Conclusion The aim of PC+ is to reduce the number of referrals to outpatient hospital care. According to the results, the treating specialist and patient diagnosis influence referral decisions. Therefore, the results of this study can be used to discuss and improve specialist and patient profiles for PC+ to further optimise the effectiveness of the initiative.

Background. Antibiotic prescribing is more prevalent in children. Many factors influence this practice, including the burden of outpatient visits. We aimed to compare antibiotic prescribing for children by low prescribers (LP) and high prescribers (HP) in primary care.Methods. We analyzed pediatric prescriptions in primary care in Istanbul. Among the physicians randomly selected by systematic sampling, those generating >= 1 pediatric prescription/day (n=1218) were defined as LP or HP when they belonged to the lowest (n=305) or highest (n=304) quartile of prescribing, respectively. The antibiotic prescribing characteristics of these groups were compared.Results. We identified that 38.5% of the prescriptions written by physicians included antibiotics, significantly higher in HPs (38.8%) than in LPs (37.2%), (p=0.04). Among antibiotic-containing prescriptions, the mean number of drugs and boxes and the percentage of prescriptions containing injectable drugs/antibiotics were significantly higher in HPs compared to that in LPs. We detected that co-amoxiclav was the most frequently prescribed antibiotic in the LP and HP groups (61.1% and 48.3%, respectively). Stratification of antibiotics by their spectra showed that 11.2% were narrow, 79.8% were broad and 0.5% were ultra-broad-spectrum drugs. LPs were significantly more likely to prescribe broad-spectrum antibiotics (82.5%) than do HPs (78.9%,p

Contains fulltext : 251423.pdf (Publisher’s version ) (Open Access) BACKGROUND: General practice (GP) training in how to communicate with patients with medically unexplained symptoms (MUS) is limited. OBJECTIVE: Development, implementation and evaluation of an evidence-based communication training program for GP residents focused on patients with MUS in primary care. METHODS: We used the intervention mapping (IM) framework to systematically develop the MUS training program. We conducted a needs assessment to formulate change objectives and identified teaching methods for a MUS communication training program. Next, we developed, implemented and evaluated the training program with 46 residents by assessing their self-efficacy and by exploring their experiences with the training. RESULTS: The resulting program is a blended training with an online course and two training days. After attending the training program, GP residents reported significantly higher self-efficacy for communication with patients with MUS at four weeks follow up compared to baseline. Furthermore, GP residents experienced the training program as useful and valued the combination of the online course and training days. CONCLUSION AND PRACTICE IMPLICATIONS: We developed an evidence-based communication training program for the management of patients with MUS in primary care. Future research should examine the effect of the training on GP residents' communication skills in MUS consultations in daily practice.

Background: Globally, about 6% of children are born with a serious birth defect of genetic or partially genetic origin. Carrier screening or testing is one way to identify couples at increased risk of having a child with an autosomal recessive condition. The most common autosomal recessive conditions are thalassaemia, sickle cell disease, cystic fibrosis and Tay-Sachs disease, with higher carrier rates in high-risk populations of specific ancestral backgrounds. Identifying and counselling couples at genetic risk of the conditions before pregnancy enables them to make fully informed reproductive decisions, with some of these choices not being available if testing is only offered in an antenatal setting. This is an update of a previously published review. Objectives: To assess the effectiveness of systematic preconception genetic risk assessment to enable autonomous reproductive choice and to improve reproductive outcomes in women and their partners who are both identified as carriers of thalassaemia, sickle cell disease, cystic fibrosis and Tay-Sachs disease in healthcare settings when compared to usual care. Search methods: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Trials Registers. Date of latest search of the registers: 04 August 2021. In addition, we searched for all relevant trials from 1970 (or the date at which the database was first available if after 1970) to date using electronic databases (MEDLINE, Embase, CINAHL, PsycINFO), clinical trial databases (National Institutes of Health, Clinical Trials Search portal of the World Health Organization, metaRegister of controlled clinical trials), and hand searching of key journals and conference abstract books from 1998 to date (European Journal of Human Genetics, Genetics in Medicine, Journal of Community Genetics). We also searched the reference lists of relevant articles, reviews and guidelines and also contacted subject experts in the field to request any unpublished or other published trials. Date of latest search of all these sources: 25 June 2021. Selection criteria: Any randomised controlled trials (RCTs) or quasi-RCTs (published or unpublished) comparing reproductive outcomes of systematic preconception genetic risk assessment for thalassaemia, sickle cell disease, cystic fibrosis and Tay-Sachs disease when compared to usual care. Data collection and analysis: We identified 37 papers, describing 22 unique trials which were potentially eligible for inclusion in the review. However, after assessment, we found no RCTs of preconception genetic risk assessment for thalassaemia, sickle cell disease, cystic fibrosis and Tay-Sachs disease. Main results: No RCTs of preconception genetic risk assessment for thalassaemia, sickle cell disease, cystic fibrosis and Tay-Sachs disease are included. A trial identified earlier has published its results and has subsequently been listed as excluded in this review. Authors' conclusions: As there are no RCTs of preconception genetic risk assessment for thalassaemia, sickle cell disease, cystic fibrosis, or Tay-Sachs disease included in either the earlier or current versions of this review, we recommend considering potential non-RCTs studies (for example prospective cohorts or before-and-after studies) for future reviews. While RCTs are desirable to inform evidence-based practice and robust recommendations, the ethical, legal and social implications associated with using this trial design to evaluate the implementation of preconception genetic risk assessment involving carrier testing and reproductive autonomy must also be considered. In addition, rather than focusing on single gene-by-gene carrier testing for specific autosomal-recessive conditions as the intervention being evaluated, preconception expanded genetic screening should also be included in future searches as this has received much attention in recent years as a more pragmatic strategy. The research evidence for current international policy recommendations is limited to non-randomised studies.

To increase usage of evidence-based smoking cessation interventions (EBSCIs) among smokers, an online decision aid (DA) was developed. The aims of this study were (1) to conduct a usability evaluation, (2) to conduct a program evaluation and evaluate decisional conflict after using the DA and (3) to determine the possible change in the intention to use EBSCIs before and directly after reviewing the DA. A cross-sectional study was carried out in September 2020 by recruiting smokers via the Internet (n = 497). Chi-squared tests and t-tests were conducted to test the differences between smokers who differed in the perceived usability of the DA on the program evaluation and in decisional conflict. The possible changes in intention to use EBSCIs during a cessation attempt before and after reviewing the DA were tested using t-tests, McNemar’s test and χ2 analysis. The participants evaluated the usability of the DA as moderate (MU, n = 393, 79.1%) or good (GU, n = 104, 20.9%). GU smokers rated higher on all the elements of the program evaluation and experienced less decisional conflict, but also displayed a higher intention to quit. After reviewing the DA, the participants on average had a significantly higher intention to use more EBSCIs, in particular in the form of eHealth. Recommendations to make the DA more usable could include tailoring, using video-based information and including value clarification methods. Furthermore, a hybrid variant in which smokers can use the DA independently and with the guidance of a primary care professional could aid both groups in choosing a fitting EBSCI option.

Background Combined lifestyle interventions (CLIs) are designed to help people who are overweight or obese maintain a healthy new lifestyle. The CooL intervention is a CLI in the Netherlands, in which lifestyle coaches counsel adults and children (and/or their parents) who are obese or at high risk of obesity to achieve a sustained healthier lifestyle. The intervention consists of coaching on lifestyle in group and individual sessions, addressing the topics of physical activity, dietary behaviours, sleep, stress management and behavioural change. The aim of this study was to evaluate the implementation process of the Coaching on Lifestyle (CooL) intervention and its facilitating and impeding factors. Methods Mixed methods were used in this action-oriented study. Both quantitative (number of referrals, attendance lists of participants and questionnaires) and qualitative (group and individual interviews, observations, minutes and open questions) data were collected among participants, lifestyle coaches, project group members and other stakeholders. The Consolidated Framework for Implementation Research was used to analyse the data. Results CooL was evaluated by stakeholders and participants as an accessible and useful programme, because of its design and content and the lifestyle coaches’ approach. However, stakeholders indicated that the lifestyle coaches need to become more familiar in the health care network and public sectors in the Netherlands. Lifestyle coaching is a novel profession and the added value of the lifestyle coach is not always acknowledged by all health care providers. Lifestyle coaches play a crucial role in ensuring the impact of CooL by actively networking, using clear communication materials and creating stakeholders’ support and understanding. Conclusion The implementation process needs to be strengthened in terms of creating support for and providing clear information about lifestyle coaching. The CooL intervention was implemented in multiple regions, thanks to the efforts of many stakeholders. Lifestyle coaches should engage in networking activities and entrepreneurship to boost the implementation process. It takes considerable time for a lifestyle coach to become fully incorporated in primary care. Trial registration NTR6208; date registered: 13–01-2017; retrospectively registered; Netherlands Trial Register.

Background Primary Care Plus (PC+) is an intervention where patients consult specialists in a primary care setting outside the hospital. Two facilities have been founded in the city of Maastricht, the Netherlands. Main aim is to achieve substitution of hospital care with primary care and hence reduce costs. The objective of this study is to evaluate referral patterns per specialty, specialist and diagnosis group, as input for deliberations to optimise substitution. Methods Prospectively collected referral data after PC+ consultations between November 2014 and March 2016 was analysed for eight participating specialties. Primary outcomes were differences in referral patterns per specialty, specialist and diagnosis group. Absolute counts and percentages were recorded for categorical variables, means and standard deviations for continuous variables. Statistical analyses were performed using IBM SPSS Statistics 23 (SPSS Inc., Chicago, IL). Results In total 4536 patients were seen in PC+; 3132 (69.0%) were referred back to the general practitioner (GP), whereas 1275 (28.1%) were referred to secondary care. Referral information of 130 (2.9%) patients was unknown. Large differences in referral numbers to secondary care after PC+ consultation were found between specialties (from 8.6% (gynaecology) to 43.8% (orthopaedic surgery)), specialists (14.5 to 65.2%) and diagnosis groups (11.1 to 93.4%). Conclusions Wide variation in referral numbers to secondary care between specialties, specialists and diagnosis groups exists after PC+ consultations. This data indicates that deliberation and further research is needed in order to optimize substitution initiatives like PC+.

Disease labels and causal explanations for certain symptoms or conditions have been found to have both positive and negative outcomes. For example, a diagnosis of polycystic ovary syndrome could conceivably motivate a person to engage in weight management, which is the recommended first line treatment. Furthermore, doctors may feel more comfortable discussing weight when linked to a medical condition. However, such a diagnosis may elicit feelings of increased anxiety, perceived severity and reduced sense of control. Mixed findings are also evident for impacts of genetic explanations on psychosocial outcomes and behaviours. Using hypothetical scenarios presented in an online survey, participants were asked to imagine that they were visiting their general practitioner due to experiencing weight gain, irregular periods, and more pimples than usual. Participants were randomised to receive different diagnostic labels (‘polycystic ovary syndrome', ‘weight’ or no label/description) and causal explanations (genetic or environmental) for their symptoms. Primary outcomes assessed included intention to eat a healthier diet and perceived personal control of weight (average score on scale 1–7 across 3 items). Secondary outcomes included weight stigma, blameworthiness, worry, perceived severity, self-esteem, belief diet will reduce risks and menu item choice. Participants were 545 females aged 18–45 years (mean = 33 years), living in Australia, recruited through a national online recruitment panel. The sample was overweight on average (BMI = 26.5). Participants reporting a PCOS diagnosis were excluded from analyses. We found no main effects of the label or explanation on intention to eat healthier or perceived personal control of weight. For secondary outcomes, those given the genetic explanation reported higher weight stigma (range 1–7; MD = 0.27, 95%CI: 0.011,0.522), greater worry (range 1–7; MD = 0.27, 95%CI: 0.037,0.496), lower self-esteem (range 10–40; MD = 1.26, 95%CI: 0.28 to 2.24) and perceived their weight as more severe (range 1–7; MD = 0.28; 95%CI: 0.05,0.52) than those given the environmental explanation, averaged over disease label given. These findings further highlight the deleterious effects of genetic explanations on psychosocial outcomes and reinforce the need for caution when communicating the aetiology of weight-related health issues.

We developed a 3.5-h training for general practitioners (GPs) in delivering brief stop-smoking advice according to different methods (ABC, 5As). In a pragmatic, cluster randomised controlled trial our training proved effective in increasing GP-delivered rates of such advice (from 13% to 33%). In this follow-up analysis we examined the effect of the training and compared ABC versus 5As on patient-reported quit attempts and point prevalence abstinence at weeks 4, 12 and 26 following GP consultation. Follow-up data were collected in 1937 smoking patients – independently of the receipt of GP advice – recruited before or after the training of 69 GPs. At week 26, ∼70% of the patients were lost to follow-up. All 1937 patients were included in an intention-to-treat analysis; missing outcome data were imputed. Quit attempts and abstinence rates did not differ significantly from pre- to post-training or between patients from the ABC versus the 5As group. However, ancillary analyses showed that patients who received GP advice compared to those who did not had two times higher odds of reporting a quit attempt at all follow-ups and abstinence at week 26. We reported that our training increases GP-delivered rates of stop-smoking advice, and the present analysis confirms that advice is associated with increased quit attempts and abstinence rates in patients. However, our training did not further improve these rates, which might be related to patients’ loss to follow-up or to contextual factors, e.g. access to free evidence-based cessation treatment, which can hamper the transfer of GPs’ advice into patients’ behaviour change., GP-delivered brief stop-smoking advice increases smoking patients’ quit attempts and abstinence rates. 3.5 h GP training in providing such advice according to the ABC versus 5As method increases advice rates. https://bit.ly/2SM3on4

Background: To expedite the use of evidence-based smoking cessation interventions (EBSCIs) in primary care and to thereby increase the number of successful quit attempts, a referral aid was developed. This aid aims to optimize the referral to and use of EBSCIs in primary care and to increase adherence to Dutch guidelines for smoking cessation. Methods: Practice nurses (PNs) will be randomly allocated to an experimental condition or control condition, and will then recruit smoking patients who show a willingness to quit smoking within six months. PNs allocated to the experimental condition will provide smoking cessation guidance in accordance with the referral aid. Patients from both conditions will receive questionnaires at baseline and after six months. Cessation effectiveness will be tested via multilevel logistic regression analyses. Multiple imputations as well as intention to treat analysis will be performed. Intervention appreciation and level of informed decision-making will be compared using analysis of (co)variance. Predictors for appreciation and informed decision-making will be assessed using multiple linear regression analysis and/or structural equation modeling. Finally, a cost-effectiveness study will be conducted. Discussion: This paper describes the study design for the development and evaluation of an information and decision tool to support PNs in their guidance of smoking patients and their referral to EBSCIs. The study aims to provide insight into the (cost) effectiveness of an intervention aimed at expediting the use of EBSCIs in primary care.

Aim To explore the perceived barriers and facilitators in the management of the patients having diabetes with comorbidities by primary care physicians. Methods A qualitative In-Depth Interview study was conducted among the primary care physicians at seventeen urban primary health care centres at Bhubaneswar city of Odisha, India. The digitally recorded interviews were transcribed verbatim and translated into English. The data were analysed using thematic analysis. Results Barriers related to physicians, patients and health system were identified. Physicians felt lack of necessary knowledge and skills, communication skills and overburdening due to multiple responsibilities to be major barriers to quality care. Patients’ attitude and beliefs along with socio-economic status played an important role in treatment adherence and in the management of their disease conditions. Poor infrastructure, irregular medicine supply, and shortage of skilled allied health professionals were also found to be barriers to optimal care delivery, as was the lack of electronic medical records and personal treatment records. Conclusion Comprehensive guidelines with on the job training for capacity building of the physicians and creation of multidisciplinary teams at primary care level for a more holistic approach towards management of diabetes with comorbidities could be the way forward to optimal delivery of care.

Background Less attractive specialties in medicine are struggling to recruit and retain physicians. When properly organized and delivered, continuing medical education (CME) activities that include short courses, coaching in the workplace, and communities of practice might offer a solution to this problem. This position paper discusses how educationalists can create CME activities based on the self-determination theory that increase physicians’ intrinsic motivation to work in these specialties. Main content The authors propose a set of guidelines for the design of CME activities that offer physicians meaningful training experiences within the limits of the available resources and support. First, to increase physicians’ sense of professional relatedness, educationalists must conduct a learner needs assessment, evaluate CME’s long-term outcomes in work-based settings, create social learning networks, and involve stakeholders in every step of the CME design and implementation process. Moreover, providing accessible, practical training formats and giving informative performance feedback that authentically connects to learners' working life situation increases physicians’ competence and autonomy, so that they can confidently and independently manage the situations in their practice contexts. For each guideline, application methods and instruments are proposed, making use of relevant literature and connecting to the self-determination theory. Conclusions By reducing feelings of professional isolation and reinforcing feelings of competence and autonomy in physicians, CME activities show promise as a strategy to recruit and retain physicians in less attractive specialties.

Background: Prescription behavior in low back pain (LBP) differs between physical therapists with a biomedical versus a biopsychosocial belief, despite the presence of clinical guidelines. Objective: To examine (1) the beliefs of physical therapy students and their adherence to clinical LBP guidelines in Belgium and the Netherlands; (2) whether the beliefs and attitudes of physical therapy students change during education; (3) whether beliefs are related to guideline adherence; (4) whether beliefs and attitudes differ with or without a personal history of LBP. Methods: A cross-sectional design included students in the 2nd and 4th year of physical therapy education in 6 Belgian and 2 Dutch institutions. To quantify beliefs, the Pain Attitudes and Beliefs Scale, the Health Care Providers' Pain and Impairment Relationship Scale, and a clinical case vignette were used. Results: In total, 1624 students participated. (1) Only 47% of physical therapy students provide clinical guidelines' consistent recommendations for activity and 16% for work. (2) 2nd year students score higher on the biomedical subscales and lower on the psychosocial subscale. 4th year students make more guideline consistent recommendations about work and activity. (3) Students with a more biopsychosocial belief give more guideline adherent recommendations. (4) Personal experience with LBP is not associated with different beliefs or attitudes. Conclusions: A positive shift occurs from a merely biomedical model towards a more biopsychosocial model from the 2nd to the 4th year of physical therapy education. However, guideline adherence concerning activity and work recommendations remains low. (C) 2020 Associacao Brasileira de Pesquisa e Pos-Graduacao em Fisioterapia. Published by Elsevier Editora Ltda. All rights reserved.

This paper outlines the protocol for a quasiexperimental study1 to test the implementation of primary healthcare (PHC)-based measurement, advice and treatment for heavy drinking and comorbid depression at the municipal level in three Latin American countries, Colombia, Mexico and Peru (Scale-up of Prevention and Management of Alcohol Use Disorders and Comorbid Depression in Latin America (SCALA) study). Heavy drinking is a cause of considerable disability, morbidity and mortality.2 Heavy drinking is a causal factor for some communicable diseases (including TB and HIV/AIDS), for many non-communicable diseases (NCDs, including cancers, cardiovascular diseases and gastrointestinal diseases) and for many mental and behavioural disorders, including depression, dementias and suicide.3 4 In PHC settings, two-fifths of people with heavy drinking have depression, with risks of incident depression higher for heavier as opposed to lighter drinkers.5 In addition to its role in the aetiology of depression, heavy drinking is associated with worsening the depression course, including suicide risk, impaired social functioning and impaired …

The use of evidence-based smoking cessation interventions (SCIs) can significantly increase the number of successful smoking cessation attempts. To obtain an overview of the knowledge and viewpoints on the effectiveness and use of SCIs, a three-round online Delphi study was conducted among researchers and primary care professionals (PCPs). The four objectives of this study are to gain an overview of (i) the criteria important for recommending SCIs, (ii) the perceptions of both groups on the effectiveness of SCIs, (iii) the factors to consider when counseling different (high-risk) groups of smokers and (iv) the perceptions of both groups on the use of e-cigarettes as an SCI. We found a high level of agreement within groups on which smoker characteristics should be considered when recommending an SCI to smokers. We also found that PCPs display a lower degree of consensus on the effectiveness of SCIs. Both groups see a value in the use of special protocols for different (high-risk) groups of patients, but the two groups did not reach consensus on the use of e-cigarettes as a means to quit. Making an inventory of PCPs’ needs regarding SCIs and their usage may provide insight into how to facilitate a better uptake in the primary care setting.

Background Currently there is no published data on the inclusion of breastfeeding education within the UK medical school curriculum. This study aims to address this knowledge gap and explore students’ perceptions of their readiness to support breastfeeding. Methods An online survey was used to collect data from 32 UK undergraduate medical schools and their students. All students in their final two years of study at the 30 universities offering a 5- or 6-year medicine course, were eligible. Results Curriculum data was obtained from 26 (81%) institutions. Compulsory breastfeeding education was provided by 85% (N = 22) institutions with 81% (n = 21) providing lecture-based teaching and 19% (n = 5) offering formal clinical education. Overall, 411 students from 22 institutions participated. A moderate ability to identify the benefits of breastfeeding was observed; however, self-rated confidence in practical skills was poor. Assisting with latching was the least confident skill, with confidence in only 3% (14/411) students. Most students (93%) viewed doctors as playing an important role in breastfeeding, with those interested in either women’s health, paediatrics or general practice perceiving the role of doctors as more important. Overall, 93% (381/411) students requested further breastfeeding education. Conclusions This study suggests UK medical schools are not adequately preparing students to support breastfeeding patients. Further studies should explore the competency of doctors to meet the needs of lactating women, and design optimal training for UK medical students.

Objective/Background: The Dutch College of General Practitioners' guideline on peripheral arterial disease (PAD) provides clear recommendations on the management of PAD. An ankle brachial index (ABI) measurement, prescription of antiplatelet drugs and statins, and supervised exercise therapy (SET) for intermittent claudication (IC) are advised. The aims of this study were to determine the adherence of general practitioners (GPs) to their own guideline on PAD and to evaluate the reliability of primary care ABI measurements. Methods: This was a cross-sectional study. All patients suspected of having symptomatic PAD who were referred by GPs to a large hospital in 2015 were evaluated regarding three of the guideline criteria: (i) ABI measurement; (ii) prescription of secondary prevention; (iii) initiation of SET. ABI values obtained in primary care and the hospital's vascular laboratory were compared using correlation coefficients and regression analysis. An abnormal ABI was defined as a value =.9). Results: Of 308 potential patients with new onset PAD, 58% (n = 178) had undergone ABI measurement prior to referral. A modest correlation between ABI values obtained in primary care and the vascular laboratory was found (r = .63, p < .001). Furthermore, a moderate reliability was calculated (intraclass correlation coefficient 0.60, 95% confidence interval 0.49-0.69, p < .001). Of the new patients with an abnormal ABI, 59% used antiplatelet drugs and 55% used statins. A referral for SET was initiated by a GP in 10% of new PAD patients with IC symptoms. Conclusions: Adherence by Dutch GPs to their own society's PAD guideline has room for improvement. The reliability of ABI measurements is suboptimal, whereas rates of prescription of secondary prevention and initiation of SET as primary treatment for IC need upgrading. (C) 2018 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

The effectiveness of influenza vaccination in the elderly has long been a topic of debate, fueled by the absence of direct evidence from randomized trials on its effect on mortality and the methodological limitations of observational studies pointing this direction. It is argued that new placebo-controlled trials should be undertaken to resolve this uncertainty. However, such trials may be ethically questionable. To bring this discussion forward, we provide a comprehensive overview of the ethical challenges of an influenza vaccine efficacy trial designed to evaluate mortality in the elderly. An important condition in the justification of a trial is the existence of genuine uncertainty in regard to the answer to a research question. Therefore an extensive analysis of the existing levels of knowledge is needed to support the conclusion that an effect of vaccination on mortality is uncertain. Even if a so called "clinical equipoise" status applies, denying a control group vaccination would be problematic because vaccination is considered "competent care" and withholding vaccination could substantially increase patients' risk for influenza and its complications. Given the high burden of disease and already proven benefits of vaccination, such a trial is unlikely to meet the Declaration of Helsinki stating that the importance of a trial must outweigh the risk patients are exposed to. While a placebo-controlled trial in vaccine refusers may be considered, such a trial is unlikely to meet substantial methodological barriers regarding trial size and generalizability. We conclude that a new trial is unlikely to provide for a direct answer, let alone change current policy. At the same time, given the lack of consensus on the ethical acceptability of a placebo-controlled trial on the effect of influenza vaccination on mortality in the elderly, we invite researchers considering such trials to address the ethical challenges discussed in this manuscript. (C) 2018 Elsevier Ltd. All rights reserved.

Background: Paying attention to their patients’ work and recognizing work-related problems is challenging for many general practitioners (GPs). Objectives: To assess the effect of training designed to improve the care for patients with work-related problems in general practice. Methods: A cluster randomized controlled trial among 32 Dutch GPs. GPs in the intervention group received five-hour training. GPs in the control group were not trained. Included patients (age 18–63, working ≥12 h per week) completed baseline questionnaires and follow-up questionnaires planned after one year. Primary outcome at patient level was patients’ expectations about their ability to work, measured using the return-to-work self-efficacy scale (RTW-SE). Primary outcomes on GP level were their use of ICPC-code Z05 (‘work-related problem’) per 1000 working-age patients and percentage of the electronic medical files of working-age patients in which information about occupation had been recorded. Results: A total of 640 patients completed the baseline questionnaire and 281 the follow-up questionnaire. We found no statistically significant differences in patients’ RTW-SE scores: intervention 4.6 (95%CI: 4.2–5.0); control 4.5 (95%CI: 4.1–4.9). Twenty-nine GPs provided data about the GP-level outcomes, which showed no statistically significant differences: use of ICPC code Z05 11.6 (95%CI: 4.7–18.6) versus 6.0 (95%CI: –1.2 to 13.2) per 1000 working-age patients; recording of occupation 28.8% (95%CI: 25.8–31.7) versus 28.6% (95%CI: 25.6–31.6). Conclusion: Training GPs did not improve patients’ work-related self-efficacy or GPs’ registration of work-related problems and occupation.

Background Imbalance in distribution of Health Care Workers (HCWs) in a country is a global challenge. Almost all of the rural and underdeveloped areas are struggling with the shortage of HCWs, especially physicians. Therefore, this study aimed to identify factors governing the retention of physicians in rural and underdeveloped areas. Methods International databases including Scopus, PubMed, Web of Science, Proquest, and Embase were searched using Mesh terms in order to find peer-reviewed journal articles addressing physicians’ retention factors in rural and underdeveloped areas. The records were screened, and any duplicate results were removed. The quality of the studies was assessed according to the Critical Appraisal Skills Program developed for different types of studies. Then, through content analysis, the related factors were identified from finally selected papers, coded, and categorized. Results The initial search resulted in 2312 relevant articles. On the basis of specific selection criteria, 35 full-text articles were finally reviewed.. The major affecting factors in physicians’ retention in rural and underdeveloped regions were classified into the following six categories: 1) financial; 2) career and professional; 3) working conditions; 4) personal; 5) cultural; and 6) living conditions factors. Conclusion There is a complex interplay of factors governing physicians’ retention in rural and underdeveloped areas. If health organizations are concerned with physicians’ retention in deprived areas, they should take into account these main factors. Moreover, they should develop policies and strategies to attract and retain physicians in rural and underdeveloped areas.

BackgroundPrimary care guidelines for the management of persistent, often ‘medically unexplained’, physical symptoms encourage GPs to discuss with patients how these symptoms relate to negative emotions. However, many GPs experience difficulties in reaching a shared understanding with patients.AimTo explore how patients with persistent symptoms describe their negative emotions in relation to their physical symptoms in primary care consultations, in order to help GPs recognise the patient’s starting points in such discussions.Design and settingA qualitative analysis of 47 audiorecorded extended primary care consultations with 15 patients with persistent physical symptoms.MethodThe types of relationships patients described between their physical symptoms and their negative emotions were categorised using content analysis. In a secondary analysis, the study explored whether patients made transitions between the types of relations they described through the course of the consultations.ResultsAll patients talked spontaneously about their negative emotions. Three main categories of relations between these emotions and physical symptoms were identified: separated (negation of a link between the two); connected (symptom and emotion are distinct entities that are connected); and inseparable (symptom and emotion are combined within a single entity). Some patients showed a transition between categories of relations during the intervention.ConclusionPatients describe different types of relations between physical symptoms and negative emotions in consultations. Physical symptoms can be attributed to emotions when patients introduce this link themselves, but this link tends to be denied when introduced by the GP. Awareness of the ways patients discuss these relations could help GPs to better understand the patient’s view and, in this way, collaboratively move towards constructive explanations and symptom management strategies.

Background In oncology, Health Care Professionals often experience conducting Advance Care Planning (ACP) conversations as difficult and are hesitant to start them. A structured approach could help to overcome this. In the ACTION trial, a Phase III multi-center cluster-randomized clinical trial in six European countries (Belgium, Denmark, Italy, the Netherlands, Slovenia, United Kingdom), patients with advanced lung or colorectal cancer are invited to have one or two structured ACP conversations with a trained facilitator. It is unclear how trained facilitators experience conducting structured ACP conversations. This study aims to understand how facilitators experience delivering the ACTION Respecting Choices (RC) ACP conversation. Methods A qualitative study involving focus groups with RC facilitators. Focus group interviews were recorded, transcribed, anonymized, translated into English, and thematically analysed, supported by NVivo 11. The international research team was involved in data analysis from initial coding and discussion towards final themes. Results Seven focus groups were conducted, involving 28 of in total 39 trained facilitators, with different professional backgrounds from all participating countries. Alongside some cultural differences, six themes were identified. These reflect that most facilitators welcomed the opportunity to participate in the ACTION trial, seeing it as a means of learning new skills in an important area. The RC script was seen as supportive to ask questions, including those perceived as difficult to ask, but was also experienced as a barrier to a spontaneous conversation. Facilitators noticed that most patients were positive about their ACTION RC ACP conversation, which had prompted them to become aware of their wishes and to share these with others. The facilitators observed that it took patients substantial effort to have these conversations. In response, facilitators took responsibility for enabling patients to experience a conversation from which they could benefit. Facilitators emphasized the need for training, support and advanced communication skills to be able to work with the script. Conclusions Facilitators experienced benefits and challenges in conducting scripted ACP conversations. They mentioned the importance of being skilled and experienced in carrying out ACP conversations in order to be able to explore the patients’ preferences while staying attuned to patients’ needs. Trial registration International Standard Randomised Controlled Trial Number registry 63110516 (ISRCTN63110516) per 10/3/2014.

Background Assessing the cost effectiveness of training aimed at increasing general practitioners’ (GP) work awareness and patients’ work-related self-efficacy and quality of life. Methods A cluster randomized controlled trial in twenty-six GP practices in the southeast of the Netherlands with 32 participating GPs. GPs working in an intervention group practice received training and GPs working in a control group practice delivered usual care. The training intervention consisted of lectures and workshops aimed at increasing GPs’ work awareness and more proactive counseling for patients with work-related problems (WRP). Subjects were working age patients with paid work for at least 12 h per week, who visited one of the participating GPs during the study period. As outcome measures we used the Return to Work Self Efficacy scale to assess patients’ work-related self-efficacy and the Euroquol to assess quality of life. We also measured health care costs and productivity costs. With a 4-item questionnaire we asked patients to assess their GPs’ work awareness. Data were collected at baseline, after 6 and 12 months. Results Data of 280 patients could be analyzed. The patient related outcomes did not improve after GP training. The change in GP work awareness and the overall mean cost difference (of €770) in favor of the intervention group were not significant. Conclusions The training intervention presented in this paper was not cost-effective. Training which is further personalized and targeted at high risk groups with respect to WRP, is more likely to be cost effective. Electronic supplementary material The online version of this article (10.1186/s12875-019-0924-9) contains supplementary material, which is available to authorized users.

Objective: To develop and provide validity and feasibility evidence for the QUality of Information Transfer (QUIT) tool. Background: Prompt escalation of care in the setting of patient deterioration can prevent further harm. Escalation and information transfer skills are not currently measured in surgery. Methods: This study comprised 3 phases: the development (phase 1), validation (phase 2), and feasibility analysis (phase 3) of the QUIT tool. Phase 1 involved identification of core skills needed for successful escalation of care through literature review and 33 semistructured interviews with stakeholders. Phase 2 involved the generation of validity evidence for the tool using a simulated setting. Thirty surgeons assessed a deteriorating postoperative patient in a simulated ward and escalated their care to a senior colleague. The face and content validity were assessed using a survey. Construct and concurrent validity of the tool were determined by comparing performance scores using the QUIT tool with those measured using the Situation-Background-Assessment-Recommendation (SBAR) tool. Phase 3 was conducted using direct observation of escalation scenarios on surgical wards in 2 hospitals. Results: A 7-category assessment tool was developed from phase 1 consisting of 24 items. Twenty-one of 24 items had excellent content validity (content validity index >0.8). All 7 categories and 18 of 24 (P < 0.05) items demonstrated construct validity. The correlation between the QUIT and SBAR tools used was strong indicating concurrent validity (r = 0.694, P < 0.001). Real-time scoring of escalation referrals was feasible and indicated that doctors currently have better information transfer skills than nurses when faced with a deteriorating patient. Conclusions: A validated tool to assess information transfer for deteriorating surgical patients was developed and tested using simulation and real-time clinical scenarios. It may improve the quality and safety of patient care on the surgical ward.

Aim: This article synthesises the results of a large international study on primary care (PC), the QUALICOPC study. Background: Since the Alma Ata Declaration, strengthening PC has been high on the policy agenda. PC is associated with positive health outcomes, but it is unclear how care processes and structures relate to patient experiences. Methods: Survey data were collected during 2011–2013 from approximately 7000 PC physicians and 70 000 patients in 34, mainly European, countries. The data on the patients are linked to data on the PC physicians within each country and analysed using multilevel modelling. Findings: Patients had more positive experiences when their PC physician provided a broader range of services. However, a broader range of services is also associated with higher rates of hospitalisations for uncontrolled diabetes, but rates of avoidable diabetes-related hospitalisations were lower in countries where patients had a continuous relationship with PC physicians. Additionally, patients with a long-term relationship with their PC physician were less likely to attend the emergency department. Capitation payment was associated with more positive patient experiences. Mono- and multidisciplinary co-location was related to improved processes in PC, but the experiences of patients visiting multidisciplinary practices were less positive. A stronger national PC structure and higher overall health care expenditures are related to more favourable patient experiences for continuity and comprehensiveness. The study also revealed inequities: patients with a migration background reported less positive experiences. People with lower incomes more often postponed PC visits for financial reasons. Comprehensive and accessible care processes are related to less postponement of care. Conclusions: The study revealed room for improvement related to patient-reported experiences and highlighted the importance of core PC characteristics including a continuous doctor–patient relationship as well as a broad range of services offered by PC physicians.

Background : Research suggests that palliative home care should be integrated early into standard care for end-stage COPD patients. Patients also express the wish to be cared for and to die at home. However, a practice model for early integration of palliative home care (PHC) into standard care for end-stage COPD has not been fully developed. Aim : To develop an intervention for early integration of PHC into standard care for end-stage COPD patients. Methods : We conducted a Phase 0-I study according to the Medical Research Council Framework for the development of complex interventions. Phase 0 aimed to identify the inclusion criteria and key components of the intervention by way of an explorative literature search of interventions, expert consultations, and seven focus groups with general practitioners and community nurses on perceived barriers to and facilitators of early integrated PHC for COPD. In Phase 1, the intervention, its inclusion criteria and its components were developed and further refined by an expert panel and two expert opinions. Results : Phase 0 resulted in identification of inclusion criteria and components from existing interventions, and barriers to and facilitators of early integration of PHC for end-stage COPD. Based on these findings, a nurse-led intervention was developed in Phase I consisting of training for PHC nurses in symptom recognition and physical therapy exercises for end-stage COPD, regular visits by PHC nurses at the patients' homes, two information leaflets on selfmanagement, a semi-structured protocol and follow-up plan to record the outcomes of the home visits, and integration of care by enabling collaboration and communication between home and hospital-based professional caregivers. Conclusion : This Phase 0-I trial succeeded in developing a complex intervention for early integration of PHC for end-stage COPD. The use of three methods in Phase 0 gave reliable data on which to base inclusion criteria and components of the intervention. The preliminary effectiveness, feasibility and acceptability of the intervention will be subsequently tested in a Phase II study.

Background Within the EU-funded project PRIMA-eDS (Polypharmacy in chronic diseases: Reduction of Inappropriate Medication and Adverse drug events in older populations by electronic Decision Support) an electronic decision support tool (the “PRIMA-eDS-tool”) was developed for general practitioners (GPs) to reduce inappropriate medication in their older polypharmacy patients. After entering patient data relevant to prescribing in an electronic case report form the physician received a comprehensive medication review (CMR) on his/her screen displaying recommendations regarding missing indications, necessary laboratory tests, evidence-base of current medication, dose adjustments for renal malfunction, potentially harmful drug-drug interactions, contra-indications, and possible adverse drug events. We set out to explore the usage of the PRIMA-eDS tool and the adoption of the recommendations provided by the CMR to optimise the tool and prepare it for its future implementation. Methods In a qualitative study carried out in North Rhine-Westphalia, Germany, 21 GPs using the PRIMA-eDS tool within the PRIMA-eDS study were interviewed. Interviews encompassed the GPs’ attitudes regarding use of the electronic case report form and the CMR, their response to the recommendations, and the implementation of the tool into daily practice routine. The collected data were analysed applying thematic qualitative text analysis. Results GPs found the patient data entry into the electronic case report form to be inconvenient and time-consuming. The CMR was conducted often outside practice hours and without the patient present. GPs found that the PRIMA-eDS CMR provided relevant information for and had several positive effects on the caring process. However, they encountered several barriers when wanting to change medication. Conclusions It is unlikely that the PRIMA-eDS CMR will be used in the future as it is now as patient data entry is too time-consuming. Several barriers towards deprescribing medications were found which are common in deprescribing studies. Given the positive attitude towards the CMR, a new way of entering patient data into the PRIMA-eDS tool to create the CMR needs to be developed. Electronic supplementary material The online version of this article (10.1186/s12875-018-0789-3) contains supplementary material, which is available to authorized users.

BACKGROUND: In an attempt to deal with the pressures on the healthcare system and to guarantee sustainability, changes are needed. This study is focused on a cardiology Primary Care Plus intervention in which cardiologists provide consultations with patients in a primary care setting in order to prevent unnecessary referrals to the hospital. This study explores which patients with non-acute and low-complexity cardiology-related health complaints should be excluded from Primary Care Plus and referred directly to specialist care in the hospital.METHODS: This is a retrospective observational study based on quantitative data. Data collected between January 1 and December 31, 2015 were extracted from the electronic medical record system. Logistic regression analyses were used to select patient groups that should be excluded from referral to Primary Care Plus.RESULTS: In total, 1525 patients were included in the analyses. Results showed that male patients, older patients, those with the referral indication 'Stable Angina Pectoris' or 'Dyspnoea' and patients whose reason for referral was 'To confirm disease' or 'Screening of unclear pathology' had a significantly higher probability of being referred to hospital care after Primary Care Plus.CONCLUSIONS: To achieve efficiency one should exclude patient groups with a significantly higher probability of being referred to hospital care after Primary Care Plus.TRIAL REGISTRATION NUMBER: NTR6629 (Data registered: 25-08-2017) (registered retrospectively).

Objective: Consistent evidence on the effects of specialist services in the primary care setting is lacking. Therefore, this study evaluated the effects of an in-house internist at a GP practice on the number of referrals to specialist care in the hospital setting. Additionally, the involved GPs and internist were asked to share their experiences with the intervention.Design: A retrospective interrupted times series study.Setting: Two multidisciplinary general practitioner (GP) practices.Intervention: An internist provided in-house patient consultations in two GP practices and participated in the multidisciplinary meetings.Subjects: The referral data extracted from the electronic medical record system of the GP practices, including all referral letters from the GPs to specialist care in the hospital setting.Main outcome measures: The number of referrals to internal medicine in the hospital setting. This study used an autoregressive integrated moving average model to estimate the effect of the intervention taking account of a time trend and autocorrelation among the observations, comparing the pre-intervention period with the intervention period.Results: It was found that the referrals to internal medicine did not statistically significant decrease during the intervention period.Conclusions: This small explorative study did not find any clues to support that an in-house internist at a primary care setting results in a decrease of referrals to internal medicine in the hospital setting.Key points:An in-house internist at a primary care setting did not result in a significant decrease of referrals to specialist care in the hospital setting. The GPs and internist experience a learning-effect, i.e. an increase of knowledge about internal medicine issues.

The nature of cancer control is changing, with an increasing emphasis, fuelled by public and political demand, on prevention, early diagnosis, and patient experience during and after treatment. At the same time, primary care is increasingly promoted, by governments and health funders worldwide, as the preferred setting for most health care for reasons of increasing need, to stabilise health-care costs, and to accommodate patient preference for care close to home. It is timely, then, to consider how this expanding role for primary care can work for cancer control, which has long been dominated by highly technical interventions centred on treatment, and in which the contribution of primary care has been largely perceived as marginal. In this Commission, expert opinion from primary care and public health professionals with academic and clinical cancer expertise-from epidemiologists, psychologists, policy makers, and cancer specialists-has contributed to a detailed consideration of the evidence for cancer control provided in primary care and community care settings. Ranging from primary prevention to end-of-life care, the scope for new models of care is explored, and the actions needed to effect change are outlined. The strengths of primary care-its continuous, coordinated, and comprehensive care for individuals and families-are particularly evident in prevention and diagnosis, in shared follow-up and survivorship care, and in end-of-life care. A strong theme of integration of care runs throughout, and its elements (clinical, vertical, and functional) and the tools needed for integrated working are described in detail. All of this change, as it evolves, will need to be underpinned by new research and by continuing and shared multiprofessional development.

BackgroundPhysical therapists' recommendations to patients to avoid daily physical activity can be influenced by the therapists' kinesiophobic beliefs. Little is known about the amount of influence of a physical therapist's kinesiophobic beliefs on a patient's actual lifting capacity during a lifting test.ObjectiveThe objective of this study was to determine the influence of physical therapists' kinesiophobic beliefs on lifting capacity in healthy people.DesignA blinded, cluster-randomized cross-sectional study was performed.MethodsThe participants (n=256; 105 male, 151 female) were physical therapist students who performed a lifting capacity test. Examiners (n=24) were selected from second-year physical therapist students. Participants in group A (n=124) were tested in the presence of an examiner with high scores on the Tampa Scale of Kinesiophobia for health care providers (TSK-HC), and those in group B (n=132) were tested in the presence of an examiner with low scores on the TSK-HC. Mixed-model analyses were performed on lifting capacity to test for possible (interacting) effects.ResultsMean lifting capacity was 32.1 kg (SD=13.6) in group A and 39.6 kg (SD=16.4) in group B. Mixed-model analyses revealed that after controlling for sex, body weight, self-efficacy, and the interaction between the examiners' and participants' kinesiophobic beliefs, the influence of examiners' kinesiophobic beliefs significantly reduced lifting capacity by 14.4 kg in participants with kinesiophobic beliefs and 8.0 kg in those without kinesiophobic beliefs.LimitationsGeneralizability to physical therapists and patients with pain should be studied.ConclusionsPhysical therapists' kinesiophobic beliefs negatively influence lifting capacity of healthy adults. During everyday clinical practice, physical therapists should be aware of the influence of their kinesiophobic beliefs on patients' functional ability.

Objectives To evaluate and compare Chlamydia trachomatis (CT) diagnostic test practices of different sexually transmitted infection (STI) care providers in 16-29 year olds from one defined geographic Dutch region (280 000 inhabitants). Both number and proportion of positive CT tests (ie, test positivity) were assessed, and factors associated with these outcomes.Methods Data on laboratory testing and diagnosis of urogenital, anorectal and oropharyngeal CT between 2006 and 2010 were retrieved from general practitioners (GPs), gynaecologists, an STI clinic and a population-based chlamydia screening programme. Multivariable regression analyses explored associations between age, sex, test year, socio-economic status (SES) and STI care provider and the outcomes being the number of tests and test positivity.Results Overall, 22 831 tests were performed (1868 positive; 8.2%). Extragenital (ie, anorectal and oropharyngeal) tests accounted for 4% of all tests (7.5% positive) and were almost exclusively (99%) performed by the STI clinic. STI clinics tested most men (37.2% of all tested men), whereas GPs tested most women (29.9% of all tested women). GPs and STI clinics accounted for 73.3% (1326/1808) of urogenital CT diagnoses. In women, the number of tests increased with age, whereas test positivity decreased for all STI care providers. Lower SES was associated with higher test positivity in GP and gynaecology patients.Conclusions STI clinics performed most CT tests in men, whereas GPs performed most CT tests in women. GPs and STI clinics accounted for the majority of positives. Extragenital CT testing is rarely performed outside the STI clinic and needs to be promoted, especially in men who have sex with men.

ObjectiveHealth care for the physical health of patients with severe mental illness (SMI) needs to be improved. Therefore, we aimed to develop policy recommendations to improve this physical health care in the Netherlands based on consensus (general agreement) between the major stakeholders.MethodA modified Delphi was used to explore barriers and subsequently establish policy recommendations with all key stakeholders. Consensus was sought between patients with SMI, their family carers, general practitioners, and mental healthcare professionals - all experts in the everyday practice of health care.ResultsConsensus was reached on policy recommendations regarding (i) improvements in collaboration between healthcare professionals, (ii) the need for professional education on the specific medical risks of patients with SMI, and (iii) the distinguished responsibilities of general practitioners on the one hand and mental healthcare professionals on the other hand in taking care of patients' physical health.ConclusionThis article provides a range of policy recommendations that could lead to considerable improvements in the physical health of SMI patients.

The history of opiate treatment in the United Kingdom (UK) since the early 1980s is a rich source of learning about the benefits and pitfalls of drug treatment policy. We present five possible lessons to be learnt about how factors outside the clinic, including government, charities and researchers can influence treatment and outcomes. First, do not let a crisis go to waste. The philosophical shift from abstinence to harm reduction in the 1980s, in response to an HIV outbreak in injecting users, facilitated expansion in addiction services and made a harm reduction approach more acceptable. Second, studies of drug-related deaths can lead to advances in care. By elucidating the pattern of mortality, and designing interventions to address the causes, researchers have improved patient safety in certain contexts, though significant investment in Scotland has not arrested rising mortality. Third, collection of longitudinal data and its use to inform clinical guidelines, as pursued from the mid-1990s, can form an enduring evidence base and shape policy, sometimes in unintended ways. Fourth, beware of the presentation of harm reduction and recovery as in conflict. At the least, this reduces patient choice, and at worst, it has caused some services to be redesigned in a manner that jeopardises patient safety. Fifth, the relationship between the third and state sectors must be carefully nurtured. In the UK, early collaboration has been replaced by competition, driven by changes in funding, to the detriment of service provision.

Consumo de alcohol; Presión sanguínea; Atención primaria; Recomendaciones Consum d'alcohol; Pressió sanguínea; Atenció primària; Recomanacions Alcohol use; Blood pressure; Primary healthcare; Recommendations Background: Hazardous and harmful alcohol use and high blood pressure are central risk factors related to premature non-communicable disease (NCD) mortality worldwide. A reduction in the prevalence of both risk factors has been suggested as a route to reach the global NCD targets. This study aims to highlight that screening and interventions for hypertension and hazardous and harmful alcohol use in primary healthcare can contribute substantially to achieving the NCD targets. Methods: A consensus conference based on systematic reviews, meta-analyses, clinical guidelines, experimental studies, and statistical modelling which had been presented and discussed in five preparatory meetings, was undertaken. Specifically, we modelled changes in blood pressure distributions and potential lives saved for the five largest European countries if screening and appropriate intervention rates in primary healthcare settings were increased. Recommendations to handle alcohol-induced hypertension in primary healthcare settings were derived at the conference, and their degree of evidence was graded. Results: Screening and appropriate interventions for hazardous alcohol use and use disorders could lower blood pressure levels, but there is a lack in implementing these measures in European primary healthcare. Recommendations included (1) an increase in screening for hypertension (evidence grade: high), (2) an increase in screening and brief advice on hazardous and harmful drinking for people with newly detected hypertension by physicians, nurses, and other healthcare professionals (evidence grade: high), (3) the conduct of clinical management of less severe alcohol use disorders for incident people with hypertension in primary healthcare (evidence grade: moderate), and (4) screening for alcohol use in hypertension that is not well controlled (evidence grade: moderate). The first three measures were estimated to result in a decreased hypertension prevalence and hundreds of saved lives annually in the examined countries. Conclusions: The implementation of the outlined recommendations could contribute to reducing the burden associated with hypertension and hazardous and harmful alcohol use and thus to achievement of the NCD targets. Implementation should be conducted in controlled settings with evaluation, including, but not limited to, economic evaluation. The workshop entitled “Screening and intervention for harmful alcohol use as a tool to improve the management of hypertension in primary care”, held on November 12, 2015, in Barcelona, Spain, was financially supported by Lundbeck (in providing travel allowances for some participants). An agenda of the workshop can be found in Additional file 1: Appendix 1.

Purpose of Review The aim of this study is to summarise the current literature on both the impact and the implementation of primary health care-based screening and advice programmes to reduce heavy drinking, as an evidence-based component of managing alcohol use disorder in primary health care. Recent Findings Systematic reviews of reviews find conclusive evidence for the impact of primary health care delivered screening and brief advice programmes in reducing heavy drinking. The content, length of advice and which profession delivers the advice seems less important than the actual encounter between provider and patient. Despite the global burden of disease due to heavy drinking and the evidence that this can be reduced by screening and brief advice programmes delivered in primary health care, such programmes remain poorly implemented. Were such programmes widely implemented, there would be substantial health and productivity gains. Systematic reviews and international studies indicate that improved implementation requires tailoring of training and programme content to match the needs of providers, training and ongoing support and embedding of programmes within local community support, championed by local leaders. Summary The next stage of implementation and scale-up of evidence-based screening and brief advice programmes should take place embedded within supportive local community action, with appropriate research to demonstrate impact.

Background:Strategies for the involvement of primary care in the management of patients with presumed or diagnosed dementia are heterogeneous across Europe. We wanted to explore attitudes of primary care physicians (PCPs) when managing dementia: (i) the most popular cognitive tests, (ii) who had the right to initiate or continue cholinesterase inhibitor or memantine treatment, and (iii) the relationship between the permissiveness of these rules/guidelines and PCP's approach in the dementia investigations and assessment.Methods:Key informant survey. Setting: Primary care practices across 25 European countries. Subjects: Four hundred forty-five PCPs responded to a self-administered questionnaire. Two-step cluster analysis was performed using characteristics of the informants and the responses to the survey. Main outcome measures: Two by two contingency tables with odds ratios and 95% confidence intervals were used to assess the association between categorical variables. A multinomial logistic regression model was used to assess the association of multiple variables (age class, gender, and perceived prescription rules) with the PCPs’ attitude of “trying to establish a diagnosis of dementia on their own.”Results:Discrepancies between rules/guidelines and attitudes to dementia management was found in many countries. There was a strong association between the authorization to prescribe dementia drugs and pursuing dementia diagnostic work-up (odds ratio, 3.45; 95% CI 2.28–5.23).Conclusions:Differing regulations about who does what in dementia management seemed to affect PCP's engagement in dementia investigations and assessment. PCPs who were allowed to prescribe dementia drugs also claimed higher engagement in dementia work-up than PCPs who were not allowed to prescribe.

Smoking cessation is the only effective intervention to slow down the accelerated decline in lung function in smokers with chronic obstructive pulmonary disease. Nevertheless, physicians often do not routinely provide evidence-based smoking cessation treatment to their patients. To understand underlying reasons, we explored how physicians engage in smoking cessation treatment in their chronic obstructive pulmonary disease patients. In total, 21 focus group discussions were held with general practitioners and pulmonologists in seven different countries in Europe and Asia. We generated three themes, whereby some of the issues concerned smokers in general: first, ‘physicians’ frustration with chronic obstructive pulmonary disease patients who smoke’. These frustrations interfered with the provision of evidence-based treatment and could result in this group of patients being treated unequally. Second: ‘physicians’ limited knowledge of, and negative beliefs about, smoking cessation treatment’. This hindered treating smokers effectively. Third: ‘healthcare organisational factors that influence the use of smoking cessation treatments’. Money and time issues, as well as the failure to regard smoking as a disease, influenced how physicians engaged in smoking cessation treatment. Our results indicate that there is a number of barriers to the provision of effective smoking cessation treatment in patients with chronic obstructive pulmonary disease and smokers in general. Introducing an informative smoking cessation programme, including communication skills and ethical issues, in the vocational and postgraduate medical training may help to address these barriers. This is important in order to increase engagement with smoking cessation treatment and to improve quality of chronic obstructive pulmonary disease care., Chronic lung disease: Changing attitudes to help patients stop smoking Doctors should be given careful, ethically-informed guidance during medical training to help them to support patients to quit smoking. The most important part of treatment for patients with chronic obstructive pulmonary disease (COPD) is help to stop smoking. However, there is evidence to suggest that doctors don’t always motivate COPD patients to quit. Eva Anne Marije van Eerd at Maastrict University, The Netherlands, together with an international team of scientists, conducted focus group interviews with doctors in seven different countries to assess barriers to smoking cessation. They found that doctors’ frustration with and negative attitudes towards patients who continued to smoke contributed to poor cessation management and treatment inequalities in some cases. Many doctors also cited a lack of experience with smoking cessation techniques alongside time and money issues as barriers to effective treatment.

Background:With the advent of smartphone devices, an increasing number of mHealth applications that target melanoma identification have been developed, but none addresses the general context of melanoma and nonmelanoma skin cancer identification.Introduction:In this study a smartphone application using fractal and classical image analysis for the risk assessment of skin lesions is systematically evaluated to determine its sensitivity and specificity in the diagnosis of melanoma and nonmelanoma skin cancer along with actinic keratosis and Bowen's disease.Materials and Methods:In the Department of Dermatology, Catharina Hospital Eindhoven, The Netherlands, 341 melanocytic and nonmelanocytic lesions were imaged using SkinVision app; 239 underwent histopathological examination, while the rest of 102 lesions were clinically diagnosed as clearly benign and not removed. The algorithm has been calibrated using the images of the first 233 lesions. The calibrated version of the algorithm was used in a subset of 108 lesions, and the obtained results were compared with the medical findings.Results:On the 108 cases used for evaluation the algorithm scored 80% sensitivity and 78% specificity in detecting (pre)malignant conditions.Discussion:Although less accurate than the dermatologist's clinical eye, the app may offer support to other professionals who are less familiar with differentiating between benign and malignant lesions.Conclusion:An mHealth application for the risk assessment of skin lesions was evaluated. It adds value to diagnosis tools of its type by taking into consideration pigmented and nonpigmented lesions all together and detecting signs of malignancy with high sensitivity.

Summary Objective To review studies on the perceptions, diagnosis and management of irritable bowel syndrome (IBS) in primary care. Methods Systematic searches of PubMed and Embase. Results Of 746 initial search hits, 29 studies were included. Relatively few primary care physicians were aware of (2–36%; nine studies) or used (0–21%; six studies) formal diagnostic criteria for IBS. Nevertheless, most could recognise the key IBS symptoms of abdominal pain, bloating and disturbed defaecation. A minority of primary care physicians [7–32%; one study (six European countries)] preferred to refer patients to a specialist before making an IBS diagnosis, and few patients [4–23%; three studies (two European, one US)] were referred to a gastroenterologist by their primary care physician. Most PCPs were unsure about IBS causes and treatment effectiveness, leading to varied therapeutic approaches and broad but frequent use of diagnostic tests. Diagnostic tests, including colon investigations, were more common in older patients (>45 years) than in younger patients [

Guidelines discourage chronic benzodiazepines and related Z drugs (BZD/Zs) for sleep problems. However, prevalence among nursing home residents remains high. Discontinuing these drugs is widely recommended but seems difficult to implement. The aim of our study was to evaluate the overall feasibility in the nursing home, in terms of willingness towards discontinuation and success rate at 8 months, together with the impact on withdrawal symptoms, change in sleep quality, quality of life and medication use. In a convenience sample of five nursing homes (823 residents), we included cognitively competent residents with chronic BZD/Z use for insomnia. We investigated sleep quality [with Pittsburgh Sleep Quality Index (PSQI)], quality of life (EQ-5D) and withdrawal symptoms [Benzodiazepine Withdrawal Symptom Questionnaire (BWSQ)]. Success rate was analysed with survival analysis. Of the 135 eligible residents, both general physician (GP) and resident were willing to initiate discontinuation in 38 residents. Reasons for refusing to initiate discontinuation among GPs was the unmotivated patient and among residents the reluctance towards change. At 8 months, 66.0 % were successful discontinuers, with the subjective PSQI component evolving favourably (p = 0.013) and a decreasing number of midnight awakenings (p = 0.041). In the relapse group (n = 13), the quality of life decreased (p = 0.012), with mainly an increase of problems with activities and pain/discomfort. In both groups, the withdrawal symptoms, functionality and medication use did not change. Discontinuation of chronic BZD/Z use is feasible in the nursing home setting without noticeable withdrawal symptoms, without a switch in medication use, without detrimental effect on quality of life and with a positive effect on the self-perceived sleep quality.

OBJECTIVE To assess whether after the introduction of diabetes performance measures decreases in undertreatment correspond with increases in overtreatment for blood pressure (BP) and glycemic control in different patient age groups. RESEARCH DESIGN AND METHODS We conducted a cohort study using data from the Groningen Initiative to Analyse Type 2 Diabetes Treatment (GIANTT) database. General practices were included when data were available from 1 year before to at least 1 year after the introduction of diabetes performance measures. Included patients had a confirmed diagnosis of type 2 diabetes. Potential overtreatment was defined as prescribing maximum treatment or a treatment intensification to patients with a sustained low-risk factor level. Potential undertreatment was defined as a lack of treatment intensification in patients with a sustained high-risk factor level. Percentages of over- and undertreated patients at baseline were compared with those in subsequent years, and stratified analyses were performed for different patient age groups. RESULTS For BP, undertreatment significantly decreased from 61 to 57% in the first year after the introduction of performance measures. In patients >75 years of age, undertreatment decreased from 65 to ∼61%. Overtreatment was relatively stable (∼16%). For glycemic control, undertreatment significantly increased from 49 to 53%, and overtreatment remained relatively stable (∼7%). CONCLUSIONS The improvement of BP undertreatment after introduction of the performance measures did not correspond with an increase in overtreatment. The performance measures appeared to have little impact on improving glucose-regulating treatment. The trends did not differ among patient age groups.

Rationale, aims and objectiveSubstituting outpatient hospital care with primary care is seen as a solution to decrease unnecessary referrals to outpatient hospital care and decrease rising healthcare costs. This systematic review aimed to evaluate the effects on quality of care, health and costs outcomes of substituting outpatient hospital care with primary care-based interventions, which are performed by medical specialists in face-to-face consultations in a primary care setting.MethodThe systematic review was performed using the PICO framework. Original papers in which the premise of the intervention was to substitute outpatient hospital care with primary care through the involvement of a medical specialist in a primary care setting were eligible.ResultsA total of 14 papers were included. A substitution intervention in general practitioner (GP) practices was described in 11 papers, three described a joint consultation intervention in which GPs see patients together with a medical specialist. This study showed that substitution initiatives result mostly in favourable outcomes compared to outpatient hospital care. The initiatives resulted mostly in shorter waiting lists, shorter clinic waiting times and higher patient satisfaction. Costs for treating one extra patient seemed to be higher in the intervention settings. This was mainly caused by inefficient planning of consultation hours and lower patient numbers.ConclusionsDespite the fact that internationally a lot has been written about the importance of performing substitution interventions in which preventing unnecessary referrals to outpatient hospital care was the aim, only 14 papers were included. Future systematic reviews should focus on the effects on the Triple Aim of substitution initiatives in which other healthcare professions than medical specialists are involved along with new technologies, such as e-consults. Additionally, to gain more insight into the effects of substitution initiatives operating in a dynamic healthcare context, it is important to keep evaluating the interventions in a longitudinal study design.

Background: Fever in children is common and mostly caused by self-limiting infections. However, the number of (re)consultations in primary care is high, driven by lack of knowledge and fear among parents. These drivers have only been studied in parents when consulting with their sick child. Aim: To study knowledge, attitudes, and practice in childhood fever in parents within the general population. Design and setting: Internet-based survey of a sample of 1000 parents from the general population of the Netherlands. Method: A 26-item cross-sectional survey was conducted of parents with one or more children aged < 5 years. Results: Of 625 responders (average age 34.9 years), 63.4% and 43.7% indicated ever visiting their GP or GP’s out-of-hours centre with a febrile child, respectively: 88.3% knew the definition of fever (>38°C), 55.2% correctly stated that antibiotics are effective in treating bacterial infections and not viral infections, and 72.0% knew that not every child with a fever needs treatment with antibiotics or paracetamol. When asked to prioritise aspects of a GP’s consultation, 53.6% considered physical examination as most important. Obtaining a prescription for antibiotics or antipyretics was considered least important. Conclusion: Knowledge, attitudes, and practices concerning childhood fever varied among parents with young children. Parents generally expect thorough physical examination and information, but not a prescription for medication (antibiotics or antipyretics) when consulting with a feverish child. GPs must be aware of these expectations as these provide opportunities to enhance consultations in general and prescription strategies in particular.

Item does not contain fulltext BACKGROUND/OBJECTIVE: To examine the content of Dutch practice nurses' (PNs') advices about weight, nutrition and physical activity to overweight and obese patients. SUBJECTS/METHODS: A 100 videotaped real-life PN consultations (The Netherlands, 2010/2011) with overweight or obese patients were selected. An observational checklist was developed to assess frequency and content. Personalization of advices was scored, as also the guidelines on which PNs based their advices. Content analysis was used to identify different categories of advices. RESULTS: About one quarter of advices concerned weight, over two-thirds nutrition and one-third physical activity. Lose weight, eat less fat and be more physically active in general were the main categories for each type of advice. Despite high clarity of advices, lower scores were found for specificity and personalization. Very few nutrition advices were provided in combination with physical activity advices. CONCLUSIONS: Weight advices often related to the patient's complaint. PNs seldom set a concrete weight goal. Although benefits of physical activity were discussed, often no practical advices were provided about how to achieve this. Integrated lifestyle advice was not common: advices about nutrition and physical activity were fragmented throughout the consultation. Obesity prevention needs more emphasis in PNs' educational programs.

Background Although fever in children is often self-limiting, antibiotics are frequently prescribed for febrile illnesses. GPs may consider treating serious infections by prescribing antibiotics. Aim To examine whether alarm signs and/or symptoms for serious infections are related to antibiotic prescription in febrile children in primary care. Design and setting Observational cohort study involving five GP out-of-hours services. Method Clinical information was registered and manually recoded. Children (

Objective To assess whether quality indicators for treatment of cardiovascular and renal risk factors are associated with short-term outcomes in patients with diabetes.Design A prospective cohort study using linear regression adjusting for confounders.Setting The GIANTT database (Groningen Initiative to Analyse Type 2 Diabetes Treatment) containing data from primary care medical records from The Netherlands.Participants 15 453 patients with type 2 diabetes mellitus diagnosed before 1 January 2008. Mean age 66.5 years, 47.5% men.Exposure Quality indicators assessing current treatment (CT) status or treatment intensification (TI) for patients with diabetes with elevated cardiovascular or renal risk factors.Main outcome measures Low-density lipoprotein cholesterol (LDL-C), systolic blood pressure (SBP), and albumin: creatinine ratio (ACR) before and after assessment of treatment quality.Results Use of lipid-lowering drugs was associated with better LDL-C levels (-0.41 mmol/litre; 95% CI -0.48 to -0.34). Use of blood pressure-lowering drugs and use of renin-angiotensin system inhibitors in patients with elevated risk factor levels was not associated with better SBP and ACR outcomes, respectively. TI was also associated with better LDL-C (-0.82 mmol/litre; CI -0.93 to -0.71) in patients with elevated LDL-C levels, and with better SBP (-1.26 mm Hg; CI -2.28 to -0.24) in patients with two elevated SBP levels. Intensification of albuminuria-lowering treatment showed a tendency towards better ACR (-2.47 mmol/mg; CI -5.32 to 0.39) in patients with elevated ACR levels.Conclusions Quality indicators of TI were predictive of better short-term cardiovascular and renal outcomes, whereas indicators assessing CT status showed association only with better LDL-C outcome.

Background: Performance measures are used for assessing quality of care. Higher performance shown by these measures is expected to reflect better care, but little is known whether they predict better patient outcomes.Objective: To assess the predictive value of performance measures of glucose management on glycemic control, and evaluate the impact of patient characteristics on this association.Research Design: Cohort study (2007-2009).Subjects: A total of 15,454 type 2 diabetes patients (mean age, 66.5 y; 48% male) from the GIANTT cohort.Measures: We included performance measures assessing frequency of HbA1c monitoring, glucose-lowering treatment status, and treatment intensification. Associations between performance and glycemic control were tested using multivariate linear regression adjusted for confounding, reporting estimated differences in HbA1c with 95% confidence intervals (CI). Impact of patient characteristics was examined through interactions.Results: Annual HbA1c monitoring was associated with better glycemic control when compared with no such monitoring (HbA1c -0.29%; 95% CI -0.37, -0.22). This association lost significance in patients with lower baseline HbA1c, older age, and without macrovascular comorbidity. Treatment status was associated with better glycemic control only in patients with elevated baseline HbA1c. Treatment intensification after elevated HbA1c levels was associated with better glycemic control compared with no intensification (HbA1c -0.21; 95% CI -0.26, -0.16).Conclusions: Performance measures of annual HbA1c monitoring and of treatment intensification did predict better patient outcomes, whereas the measure of treatment status did not. Predictive value of annual monitoring and of treatment status varied across patient characteristics, and it should be used with caution when patient characteristics cannot be taken into account.

Background Substitution is the shift of care from specialized health care to less expensive and more accessible primary health care. It seems promising for restraining rising mental health care costs. The goal of this study was to investigate a potential for substitution of patients with psychological or social problems, but without severe psychiatric disorders, from Dutch specialized mental health care to primary care, especially family practices. Methods We extracted anonymized data from two national databases representing primary and specialized care in 2012. We calculated the number of patients with and without psychiatric disorder per 1,000 citizens in three major settings: family practices, primary care psychologists, and specialized care. Family physicians recorded psychopathology using the International Classification of Primary Care, while psychologists and specialists used the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Results Considerable numbers of patients without a diagnosed DSM-IV psychiatric disorder were treated by primary care psychologists (32.8%) or in specialized care (20.8%). Over half of the patients referred by family physicians to mental health care did not have a psychiatric disorder. Conclusion A recent reform of Dutch mental health care, including new referral criteria, will likely increase the number of patients with psychological or social problems that family physicians have to treat or support. Enabling and improving diagnostic assessment and treatment in family practices seems essential for substitution of mental health care. Electronic supplementary material The online version of this article (doi:10.1186/s12875-017-0586-4) contains supplementary material, which is available to authorized users.