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Background: Increases in opioid prescriptions have been described; however, recent trends and prescribing patterns of analgesics in Dutch general practice are largely unknown., Objective: To investigate recent changes in the number of analgesic prescriptions, and the indications for prescribing strong opioids. Furthermore, we aim to identify risk factors for chronic opioid use in Dutch general practice., Design and Setting: A retrospective cohort study from 1 July 2013 to 31 June 2022, using a primary care practice based research network., Subjects: Patients with ≥1 prescription for analgesics during the study period were included., Main Outcome Measure: Changes in the number of prescriptions for paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs) and opioids in Dutch general practice during the 9-year study period. Moreover, we analyzed indications for prescribing strong opioids by the general practitioner (GP)., Results: A total of 18,433 analgesic users were identified. Over time, prescriptions for paracetamol, NSAIDs and weak opioids decreased, while the number of strong opioid prescriptions increased. General practitioners prescribed more strong opioids for non-malignant pain, whereas prescriptions for malignant pain remained stable over time. Risk factors for chronic opioid use (≥90 days) included older age, lower educational level, smoking status and having a history of a musculoskeletal or psychological disorder, a malignancy or sexual, physical or psychological abuse., Conclusions: Considering the increase in strong opioid prescriptions for benign conditions, GPs need to be vigilant for patients who are at risk for chronic use. Regular monitoring and awareness for psychosocial factors in treatment of chronic pain may be key in preventing harms associated with persistent opioid use.

Background: Respiratory tract infections (RTIs) are common in children with febrile illness visiting the general practitioner (GP) or emergency department. We studied the management of children with fever and RTI at 3 different levels of healthcare in The Netherlands, focusing on antibiotic prescription., Methods: This prospective observational study is part of the Management and Outcome of Febrile children in Europe study. Data were used from face-to-face patient contacts of children with febrile illness in three healthcare settings in Nijmegen, The Netherlands during 2017. These settings were primary (GP), secondary (general hospital) and tertiary care (university hospital)., Results: Of 892 cases with RTI without complex comorbidities, overall antibiotic prescription rates were 29% with no differences between the 3 levels of healthcare, leading to an absolute number of 5031 prescriptions per 100,000 children per year in primary care compared with 146 in secondary and tertiary care combined. The prescription rate in otitis media was similar in all levels: 60%. In cases with lower RTI who received nebulizations prescription rates varied between 19% and 55%., Conclusions: Antibiotic prescription rates for RTIs in children were comparable between the 3 levels of healthcare, thus leading to a majority of antibiotics being prescribed in primary care. Relatively high prescription rates for all foci of RTIs were found, which was not in agreement with the national guidelines. Antibiotic stewardship needs improvement at all 3 levels of healthcare. Guidelines to prescribe small spectrum antibiotics for RTIs need to be better implemented in hospital care settings., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

We studied the changes in presented health problems and demand for primary care since the outbreak of coronavirus disease 2019 (COVID-19) in the Netherlands. We analyzed prominent symptom features of COVID-19, and COVID-19 itself as the reason for encounter. Also, we analyzed the number and type of encounters for common important health problems. Respiratory tract symptoms related to COVID-19 were presented more often in 2020 than in 2019. We observed a dramatic increase of telephone/e-mail/Internet consultations in the months after the outbreak. Contacts for other health problems such as prevention and acute and chronic conditions plummeted substantially ( P <0.001); mental health problems stabilized., (© 2021 Annals of Family Medicine, Inc.)

Background: Little is known about the presentation and management of Lyme disease in general practice., Objective: To investigate the incidence of Lyme disease over a 6-year period, and its presentation and management in Dutch general practice., Methods: Observational study using routine data from a practice-based research network in the Netherlands with 7 practices, 24 GPs and 30000 registered patients. From 2009 to 2014, we calculated the incidence of patients presenting with Lyme disease in general practice. We analysed patient characteristics and symptoms that patients presented with at first visit. Furthermore, we analysed General Practitioners' (GPs') diagnostic and therapeutic strategies, and adherence to the national guideline., Results: Over a 6-year period, we found 212 episodes with clinical- or laboratory-based diagnosed Lyme disease, resulting in a mean incidence of 117 cases per 100000 patients per year. We did not identify a significant linear trend over time. The most frequently reported symptoms at first visit were rash (77%) and/or insect bite (58%). In 25% of patients, GPs performed a serological test, in 99% an antibiotic was prescribed and 11% were referred to a medical specialist. Frequently (in 46% of patients), the GP did not adhere to the guideline completely., Conclusion: This study shows that there is no linear trend in the incidence of Lyme disease over a 6-year period and that most patients present to GPs with unspecific symptoms like rash or insect bites. We show that GPs frequently (in 46% of patients) do not fully adhere to recommendations stated in the national guideline., (© The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Study Question: What is the current guideline adherence by general practitioners (GPs) for work-up and subsequent referral from primary to secondary care for patients suffering from infertility?, Summary Answer: Guideline adherence by GPs concerning infertility was 9.2% in couples referred., What Is Known Already: Adherence to recommendations can decrease unnecessary referral, diagnostics and treatments, and consequently result in lower expenditures. Moreover, patients can be saved from unnecessary hospital visits, emotional burden and out of pocket costs., Study Design, Size, and Duration: A retrospective cohort study among 306 patients referred for basic fertility work-up between January 2011 and June 2013 from primary care to a secondary care teaching hospital or a tertiary hospital with IVF facilities., Participants/materials, Setting and Methods: Couples were eligible to participate when there was no previous referral for fertility problems and the duration of the child wish was <2 years. Data to assess guideline adherence were collected from the referral letter and the medical records. A patient questionnaire was used to determine patients' general and fertility-related characteristics., Main Results and the Role of Chance: The GP performed a Chlamydia Antibody Titre (CAT) testing and semen analysis as recommended in 15.9% and 42.2% of the referred patients, respectively. According to the guideline, 39% of the couples were under referred (i.e. not immediately referred as recommended), 8.8% were unnecessarily referred and the CAT and semen analysis were unnecessarily repeated in secondary care in 80.0% and 57.1% of cases, respectively., Limitations Reasons for Caution: We could not include non-referred patients with expectant management in primary care, an unknown number of whom became pregnant in this period. This may have resulted in an underestimation of primary care performance., Wider Implications of the Findings: Our findings show that guideline adherence concerning work-up and subsequent referral for fertility problems is low. The influence of patient demands for referral remains largely unknown. Barriers and facilitators for guideline adherence should be determined to develop interventions to improve guideline adherence in the areas of work-up and referral for fertility care and to diminish duplicate tests in secondary care., Study Funding/competing Interest(s): Funded by CZ, a Dutch healthcare insurer (grant number AFVV 11-232). CZ had no role in designing the study, data collection, analysis and interpretation of data or writing of the report. Competing interests: None., Trial Registration Number: Not applicable., (© The Author 2017. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com)

Background: Physician's prescribing preference is increasingly used as an instrumental variable in studies of therapeutic effects. However, differences in prescribing patterns among physicians may reflect differences in preferences or in case-mix. Furthermore, there is debate regarding the possible assumptions for point estimation using physician's preference as an instrument., Methods: A survey was sent to general practitioners (GPs) in The Netherlands, the United Kingdom, New Zealand, Ireland, Switzerland, and Germany, asking whether they would prescribe levothyroxine to eight fictitious patients with subclinical hypothyroidism. We investigated (1) whether variation in physician's preference was observable and to what extent it was explained by characteristics of GPs and their patient populations and (2) whether the data were compatible with deterministic and stochastic monotonicity assumptions., Results: Levothyroxine prescriptions varied substantially among the 526 responding GPs. Between-GP variance in levothyroxine prescriptions (logit scale) was 9.9 (95% confidence interval: 8.0, 12) in the initial mixed effects logistic model, 8.3 (6.7, 10) after adding a fixed effect for country and 8.2 (6.6, 10) after adding GP characteristics. The occurring prescription patterns falsified the deterministic monotonicity assumption. All cases in all countries were more likely to receive levothyroxine if a different case of the same GP received levothyroxine, which is compatible with the stochastic monotonicity assumption. The data were incompatible with this assumption for a different definition of the instrument., Conclusions: Our study supports the existence of physician's preference as a determinant in treatment decisions. Deterministic monotonicity will generally not be plausible for physician's preference as an instrument. Depending on the definition of the instrument, stochastic monotonicity may be plausible.

Background: There is limited evidence about the impact of treatment for subclinical hypothyroidism, especially among older people., Aim: To investigate the variation in GP treatment strategies for older patients with subclinical hypothyroidism depending on country and patient characteristics., Design and Setting: Case-based survey of GPs in the Netherlands, Germany, England, Ireland, Switzerland, and New Zealand., Method: The treatment strategy of GPs (treatment yes/no, starting-dose thyroxine) was assessed for eight cases presenting a woman with subclinical hypothyroidism. The cases differed in the patient characteristics of age (70 versus 85 years), vitality status (vital versus vulnerable), and thyroid-stimulating hormone (TSH) concentration (6 versus 15 mU/L)., Results: A total of 526 GPs participated (the Netherlands n = 129, Germany n = 61, England n = 22, Ireland n = 21, Switzerland n = 262, New Zealand n = 31; overall response 19%). Across countries, differences in treatment strategy were observed. GPs from the Netherlands (mean treatment percentage 34%), England (40%), and New Zealand (39%) were less inclined to start treatment than GPs in Germany (73%), Ireland (62%), and Switzerland (52%) (P = 0.05). Overall, GPs were less inclined to start treatment in 85-year-old than in 70-year-old females (pooled odds ratio [OR] 0.74 [95% confidence interval [CI] = 0.63 to 0.87]). Females with a TSH of 15 mU/L were more likely to get treated than those with a TSH of 6 mU/L (pooled OR 9.49 [95% CI = 5.81 to 15.5])., Conclusion: GP treatment strategies of older people with subclinical hypothyroidism vary largely by country and patient characteristics. This variation underlines the need for a new generation of international guidelines based on the outcomes of randomised clinical trials set within primary care., (© British Journal of General Practice 2015.)

Background: Structured care is proposed as a lever for improving care for patients with chronic conditions. The purpose of this study was to explore the associations of structured care characteristics, derived from the Chronic Care Model, with health-related quality of life (HRQOL) and optimal clinical management in chronic heart failure (CHF) patients in primary care, as well as the association between optimal management and HRQOL., Methods: Cross-sectional observational study using multi-level random-coefficient analyses of a representative sample of 357 patients diagnosed with CHF from 42 primary care practices in the Netherlands. We combined individual medical record data with patient and physician questionnaires., Results: There was large variation in the levels and presence of structured care elements. A 91% of physicians indicated that next appointments for CHF patients were made immediately after visits, while 11% indicated that reminders on CHF management were periodically received in their practice. Few associations were found between the organizational characteristics and optimal treatment or HRQOL. Optimal pharmacological treatment related to better quality of life (beta = -11.5, P < .0001). Also, more lifestyle advice was given in practices with an appointment system allowing contact with more than one professional during the encounter (beta = 1.0, P = .04)., Conclusion: HRQOL and treatment quality in CHF patients were not consistently associated with characteristics of structured care in primary care practices.

The Dutch College of General Practitioners has launched its revised guideline for thyroid disorders. By including palpable lesions this guideline now covers a broad range of thyroid disorders. In general, the guideline is clear, usable and evidence-based. The measurement of thyroid antibody concentrations has been added to the work-up of hyperthyroidism, and the treatment of hyperthyroidism is considered optional for the general practitioner. Nearly all forms of hypothyroidism can be diagnosed and treated by a general practitioner, and the guideline provides well-defined recommendations on this topic. Regarding the treatment of subclinical hypothyroidism, however, the guidelines are ambivalent and less clear. The work-up for palpable lesions is unambiguous; this addition certainly enriches the new guideline for thyroid disorders.

Study Design: Qualitative study design, using semi-structured interviews., Objective: To explore factors that determine non-adherence to the guidelines for low back pain., Summary of Background Data: Guidelines for low back pain have been published in the past decade in various countries. In the Netherlands, general practitioners adhere to them to a fair extent, and it is unclear whether room for improvement remains., Methods: Forty semistructured, in-depth interviews were conducted with twenty patients who consulted for low back pain, and with their general practitioners. The interviews were fully transcribed and analyzed qualitatively., Results: Patients often had limited expectations of the consultation. They wanted to hear a diagnosis or expected to receive simple advice. The general practitioners said they were well informed about the guideline and mostly agreed with its content. Reasons for non-adherence were mainly related to patients' experiences in the past and general practitioners' interpretations of their preferences. General practitioners stated that they were inclined to give in to patients' demands, for example the request for radiographic films or a referral to a physical therapist. In general, patients and their general practitioners were satisfied with the chosen management., Conclusions: Improvement of the quality of back pain care may still be possible. Implementation strategies should aim at training physicians in communication skills, especially about subjects for debate, where patients' beliefs and experiences color their expectations.