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Background: Dutch standard diabetes care is generally protocol-driven. However, considering that general practices wish to tailor diabetes care to individual patients and encourage self-management, particularly in light of current COVID-19 related constraints, protocols and other barriers may hinder implementation. The impact of dispensing with protocol and implementation of self-management interventions on patient monitoring and experiences are not known. This study aims to evaluate tailoring of care by understanding experiences of well-organised practices 1) when dispensing with protocol; 2) determining the key conditions for successful implementation of self-management interventions; and furthermore exploring patients' experiences regarding dispensing with protocol and self-management interventions., Methods: in this mixed-methods prospective study, practices (n = 49) were invited to participate if they met protocol-related quality targets, and their adult patients with well-controlled type 2 diabetes were invited if they had received protocol-based diabetes care for a minimum of 1 year. For practices, study participation consisted of the opportunity to deliver protocol-free diabetes care, with selection and implementation of self-management interventions. For patients, study participation provided exposure to protocol-free diabetes care and self-management interventions. Qualitative outcomes (practices: 5 focus groups, 2 individual interviews) included experiences of dispensing with protocol and the implementation process of self-management interventions, operationalised as implementation fidelity. Quantitative outcomes (patients: routine registry data, surveys) consisted of diabetes monitoring completeness, satisfaction, wellbeing and health status at baseline and follow-up (24 months)., Results: Qualitative: In participating practices (n = 4), dispensing with protocol encouraged reflection on tailored care and selection of various self-management interventions A focus on patient preferences, team collaboration and intervention feasibility was associated with high implementation fidelity Quantitative: In patients (n = 126), likelihood of complete monitoring decreased significantly after two years (OR 0.2 (95% CI 0.1-0.5), p < 0.001) Satisfaction decreased slightly (- 1.6 (95% CI -2.6;-0.6), p = 0.001) Non-significant declines were found in wellbeing (- 1.3 (95% CI -5.4; 2.9), p = 0.55) and health status (- 3.0 (95% CI -7.1; 1.2), p = 0.16)., Conclusions: To tailor diabetes care to individual patients within well-organised practices, we recommend dispensing with protocol while maintaining one structural annual monitoring consultation, combined with the well-supported implementation of feasible self-management interventions. Interventions should be selected and delivered with the involvement of patients and should involve population preferences and solid team collaborations., (© 2021. The Author(s).)

Background: Acute care services are currently overstretched in many high income countries. Overcrowding also plays a major role in acute care in the Netherlands. In a region of the Netherlands, the general practice cooperative (GPC) and ambulance service have begun to integrate their care, and the rapid and complete transfer of information between these two care organisations is now the basis for delivering appropriate care. The primary aim of this mixed-methods study is to evaluate the Netherlands Triage System (NTS) merger project and answering the question: What is the added value of implementing a digital NTS merger in terms of healthcare use and healthcare costs? A secondary question is: What are the experiences of patients and care professionals in different acute healthcare organisations following implementation of the digital NTS merger?, Methods: Patients who made an acute care request during the 12 months before the NTS merge intervention (control period) were compared with matched patients in the 12 months following the start of the NTS merge. Outcomes included difference in healthcare use 30 days after an acute event and patient' and care professional' experiences during the intervention period. To assess healthcare costs, we used reference prices updated to 2021., Results: Compared to patients in the control period, patients in the intervention period were hospitalized less often (52.9% vs 64.4%, p = 0.061) and had fewer emergency department (ED) visits (58.7% vs 69.3%, p = 0.074) in the 30 days following the acute care request. The ED costs were significantly lower during the intervention period compared to the control period (p = 0.042). Furthermore, patients in the intervention period were very satisfied overall with the acute care network (4.63 of 5) and care professionals were fairly satisfied with the cooperation to date (2.73 of 4)., Conclusion: The Triple Aim for acute care can be met using relatively simple interventions, but medical data merging is a prerequisite for achieving more robust results covering on the various aspects of the Triple Aim. These successes should be communicated so that a common language can be developed that will support the successful further implementation of larger scale initiatives., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2021 The Author(s).)

Background: Observational studies have reported an inverse association between ultraviolet (UV) radiation and hypertension. The aim of this study was to assess differences in blood pressure changes between persons with dementia receiving UV light versus vitamin D (VD) supplementation., Methods: Post-hoc analysis of randomized controlled trial data concerning nursing home residents with dementia (N = 61; 41 women, mean age 84.8 years). The participants received half-body UV irradiation, twice weekly over 6 months, at one standard erythema dose (UV group, n = 22) or 5600 international units of cholecalciferol once a week (VD group, n = 39). Short-term effects were evaluated after 1 month and long-term effects after 3 and 6 months. Differences in blood pressure changes were assessed using linear mixed models., Results: With the VD group as a reference, the estimated difference in mean change of systolic blood pressure was - 26.0 mmHg [95% confidence interval (CI) -39.9, - 12.1, p = .000] at 1 month, 4.5 mmHg (95% CI -6.8, 15.9, p = 0.432) at 3 months, and 0.1 (95% CI -14.1, 14.3, p = 0.83) at 6 months. The estimated difference in diastolic blood pressure was - 10.0 mmHg (95% CI -19.2, - 0.7, p = 0.035) at 1 month, 3.6 mmHg (95% CI -4.1, 11.2, p = 0.358) at 3 months, and 2.7 (95% CI -6.8, 12.1, p = 0.580) at 6 months., Conclusions: UV light had only a short-term effect but not a long-term effect on blood pressure reduction compared to VD use in this sample of normotensive to mild hypertensive nursing home residents with dementia. Future studies will be needed to determine the effect of UV light in different samples of the population and especially in a population with hypertension., (© 2021. The Author(s).)

Objective: Persistent somatic symptoms (PSSs) are defined as symptoms not fully explained by well-established pathophysiological mechanisms and are prevalent in up to 10% of patients in primary care. The present study aimed to explore methods to identify patients with a recognisable risk of having PSS in routine primary care data., Design: A cross-sectional study to explore four identification methods that each cover part of the broad spectrum of PSS was performed. Cases were selected based on (1) PSS-related syndrome codes, (2) PSS-related symptom codes, (3) PSS-related terminology and (4) Four-Dimensional Symptom Questionnaire scores and all methods combined., Setting: Coded electronic health record data were extracted from 76 general practices in the Netherlands., Participants: Patients who were registered for at least 1 year during 2014-2018, were included (n=169 138)., Outcome Measures: Identification methods were explored based on (1) PSS sample sizes and demographics, (2) presence of chronic conditions and (3) healthcare utilisation (HCU) variables. Overlap between methods and practice specific differences were examined., Results: The percentage of cases identified varied between 0.3% and 7.0% across the methods. Over 58.1% of cases had chronic physical condition(s) and over 33.8% had chronic mental condition(s). HCU was generally higher for cases selected by any method compared with the total cohort. HCU was higher for method B compared with the other methods. In 26.7% of cases, cases were selected by multiple methods. Overlap between methods was low., Conclusions: Different methods yielded different patient samples which were general practice specific. Therefore, for the most comprehensive data-based selection of PSS cases, a combination of methods A, C and D would be recommended. Advanced (data-driven) methods are needed to create a more sensitive algorithm for identifying the full spectrum of PSS. For clinical purposes, method B could possibly support screening of patients who are currently missed in daily practice., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Persistent somatic symptoms (PSS) are common in primary care and often accompanied by an increasing disease burden for both the patient and healthcare. In medical practice, PSS is historically considered a diagnosis by exclusion or primarily seen as psychological. Besides, registration of PSS in electronic health records (EHR) is unambiguous and possibly does not reflect classification adequately. The present study explores how general practitioners (GPs) currently register PSS, and their view regarding the need for improvements in classification, registration, and consultations., Method: Dutch GPs were invited by email to participate in a national cross-sectional online survey. The survey addressed ICPC-codes used by GPs to register PSS, PSS-related terminology added to free text areas, usage of PSS-related syndrome codes, and GPs' need for improvement of PSS classification, registration and care., Results: GPs (n = 259) were most likely to use codes specific to the symptom presented (89.3%). PSS-related terminology in free-text areas was used sparsely. PSS-related syndrome codes were reportedly used by 91.5% of GPs, but this was primarily the case for the code for irritable bowel syndrome. The ambiguous registration of PSS is reported as problematic by 47.9% of GPs. Over 56.7% of GPs reported needing additional training, tools or other support for PSS classification and consultation. GPs also reported needing other referral options and better guidelines., Conclusions: Registration of PSS in primary care is currently ambiguous. Approximately half of GPs felt a need for more options for registration of PSS and reported a need for further support. In order to improve classification, registration and care for patients with PSS, there is a need for a more appropriate coding scheme and additional training., (© 2021. The Author(s).)

Background: Socioeconomic status and ethnicity are not incorporated as predictors in country-level cardiovascular risk charts on mainland Europe. The aim of this study was to quantify the sex-specific cardiovascular death rates stratified by ethnicity and socioeconomic factors in an urban population in a universal healthcare system., Methods: Age-standardized death rates (ASDR) were estimated in a dynamic population, aged 45-75 in the city of The Hague, the Netherlands, over the period 2007-2018, using data of Statistics Netherlands. Results were stratified by sex, ethnicity (country of birth) and socioeconomic status (prosperity) and compared with a European cut-off for high-risk countries (ASDR men 225/100,000 and women 175/100,000)., Findings: In total, 3073 CVD deaths occurred during 1·76 million person years follow-up. Estimated ASDRs (selected countries of birth) ranged from 126 (95%CI 89-174) in Moroccan men to 379 (95%CI 272-518) in Antillean men, and from 86 (95%CI 50-138) in Moroccan women to 170 (95%CI 142-202) in Surinamese women. ASDRs in the highest and lowest prosperity quintiles were 94 (95%CI 90-98) and 343 (95%CI 334-351) for men, and 43 (95%CI 41-46) and 140 (95%CI 135-145), for women, respectively., Interpretation: In a diverse urban population, large health disparities in cardiovascular ASDRs exists across ethnic and socioeconomic subgroups. Identifying these high-risk subgroups followed by targeted preventive efforts, might provide a basis for improving cardiovascular health equity within communities. Instead of classifying countries as high-risk or low-risk, a shift towards focusing on these subgroups within countries might be needed., Funding: Leiden University Medical Center and Leiden University., Competing Interests: None of the authors reported a conflict of interest., (© 2021 The Author(s).)

After the second corona vaccination, a number of GPs in Utrecht dropped out for 2-3 days due to the side effects. Through a simple email survey, we arrived at a 14% dropout rate during the days following vaccination. We explored options to anticipate dropout during following vaccination rounds and advocate transparency with regard to the side effects.

Background and Aims: In our current healthcare situation, burden on healthcare services is increasing, with higher costs and increased utilization. Structured population health management has been developed as an approach to balance quality with increasing costs. This approach identifies sub-populations with comparable health risks, to tailor interventions for those that will benefit the most. Worldwide, the use of routine healthcare data extracted from electronic health registries for risk stratification approaches is increasing. Different risk stratification tools are used on different levels of the healthcare continuum. In this systematic literature review, we aimed to explore which tools are used in primary healthcare settings and assess their performance., Methods: We performed a systematic literature review of studies applying risk stratification tools with health outcomes in primary care populations. Studies in Organisation for Economic Co-operation and Development countries published in English-language journals were included. Search engines were utilized with keywords, for example, "primary care," "risk stratification," and "model." Risk stratification tools were compared based on different measures: area under the curve (AUC) and C-statistics for dichotomous outcomes and R 2 for continuous outcomes., Results: The search provided 4718 articles. Specific election criteria such as primary care populations, generic health utilization outcomes, and routinely collected data sources identified 61 articles, reporting on 31 different models. The three most frequently applied models were the Adjusted Clinical Groups (ACG, n = 23), the Charlson Comorbidity Index (CCI, n = 19), and the Hierarchical Condition Categories (HCC, n = 7). Most AUC and C-statistic values were above 0.7, with ACG showing slightly improved scores compared with the CCI and HCC (typically between 0.6 and 0.7)., Conclusion: Based on statistical performance, the validity of the ACG was the highest, followed by the CCI and the HCC. The ACG also appeared to be the most flexible, with the use of different international coding systems and measuring a wider variety of health outcomes., Competing Interests: All authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported., (© 2021 The Authors. Health Science Reports published by Wiley Periodicals LLC.)

Introduction: Lifestyle interventions are shown to be effective in improving cardiovascular disease (CVD) risk factors. It has been suggested that general practitioners can play an essential role in CVD prevention. However, studies into lifestyle interventions for primary care patients at high cardiovascular risk are scarce and structural implementation of lifestyle interventions can be challenging. Therefore, this study aims to (1) evaluate (cost-)effectiveness of implementation of an integrated group-based lifestyle programme in primary care practices; (2) identify effective intervention elements and (3) identify implementation determinants of an integrated group-based lifestyle intervention for patients with high cardiovascular risk., Methods and Analysis: The Healthy Heart study is a non-randomised cluster stepped-wedge trial. Primary care practices will first offer standard care during a control period of 2-6 months, after which practices will switch (step) to the intervention, offering participants a choice between a group-based lifestyle programme or standard care. Participants enrolled during the control period (standard care) will be compared with participants enrolled during the intervention period (combined standard care and group-based lifestyle intervention). We aim to include 1600 primary care patients with high cardiovascular risk from 55 primary care practices in the area of The Hague, the Netherlands. A mixed-methods process evaluation will be used to simultaneously assess effectiveness and implementation outcomes. The primary outcome measure will be achievement of individual lifestyle goals after 6 months. Secondary outcomes include lifestyle change of five lifestyle components (smoking, alcohol consumption, diet, weight and physical activity) and improvement of quality of life and self-efficacy. Outcomes are assessed using validated questionnaires at baseline and 3, 6, 12 and 24 months of follow-up. Routine care data will be used to compare blood pressure and cholesterol levels. Cost-effectiveness of the lifestyle intervention will be evaluated. Implementation outcomes will be assessed using the RE-AIM model, to assesses five dimensions of implementation at different levels of organisation: reach, efficacy, adoption, implementation and maintenance. Determinants of adoption and implementation will be assessed using focus groups consisting of professionals and patients., Ethics and Dissemination: This study is approved by the Ethics Committee of the Leiden University Medical Center (P17.079). Results will be shared with the primary care group, healthcare providers and patients, and will be disseminated through journal publications and conference presentations., Trial Registration Number: NL60795.058.17. Status: pre-results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Professionalism is a key competence for physicians. Patient complaints provide a unique insight into patient expectations regarding professionalism. Research exploring the exact nature of patient complaints in general practice, especially focused on professionalism, is limited., Aim: To characterise patient complaints in primary care and to explore in more detail which issues with professionalism exist., Design & Setting: A retrospective observational study in which all unsolicited patient complaints to a representative out-of-hours general practice (OOH GP) service provider in The Netherlands were analysed over a 10-year period (2009-2019)., Method: Complaints were coded for general characteristics and thematically categorised using the CanMEDS Physician Competency Framework (CanMEDS) as sensitising concepts. Complaints categorised as professionalism were subdivided using open coding., Results: Out of 746 996 patient consultations (telephone, face-to-face, and home visits) 484 (0.065%) resulted in eligible complaint letters. The majority consisted of two or more complaints, resulting in 833 different complaints. Most complaints concerned GPs (80%); a minority (19%) assistants. Thirty-five per cent concerned perceived professionalism lapses of physicians. A rich diversity in the wording of professionalism lapses was found, where ' not being taken seriously ' was mentioned most often. Forty-five per cent related to medical expertise, such as missed diagnoses or unsuccessful clinical treatment. Nineteen per cent related to management problems, especially waiting times and access to care. Communication issues were only explicitly mentioned in 1% of the complaints., Conclusion: Most unsolicited patient complaints were related to clinical problems. A third, however, concerned professionalism issues. Not being taken seriously was the most frequent mentioned theme within the professionalism category., (Copyright © 2021, The Authors.)

Background: Monitoring of symptoms and behavior may enable prediction of emerging COVID-19 hotspots. The COVID Radar smartphone app, active in the Netherlands, allows users to self-report symptoms, social distancing behaviors, and COVID-19 status daily. The objective of this study is to describe the validation of the COVID Radar., Methods: COVID Radar users are asked to complete a daily questionnaire consisting of 20 questions assessing their symptoms, social distancing behavior, and COVID-19 status. We describe the internal and external validation of symptoms, behavior, and both user-reported COVID-19 status and state-reported COVID-19 case numbers., Results: Since April 2nd, 2020, over 6 million observations from over 250,000 users have been collected using the COVID Radar app. Almost 2,000 users reported having tested positive for SARS-CoV-2. Amongst users testing positive for SARS-CoV-2, the proportion of observations reporting symptoms was higher than that of the cohort as a whole in the week prior to a positive SARS-CoV-2 test. Likewise, users who tested positive for SARS-CoV-2 showed above average risk social-distancing behavior. Per-capita user-reported SARS-CoV-2 positive tests closely matched government-reported per-capita case counts in provinces with high user engagement., Discussion: The COVID Radar app allows voluntarily self-reporting of COVID-19 related symptoms and social distancing behaviors. Symptoms and risk behavior increase prior to a positive SARS-CoV-2 test, and user-reported case counts match closely with nationally-reported case counts in regions with high user engagement. These results suggest the COVID Radar may be a valid instrument for future surveillance and potential predictive analytics to identify emerging hotspots., Competing Interests: Salaries of first and second authors were funded by the ZonMW grants. ORTEC provided support in the form of the salary of author MeB. The other authors have declared that no competing interests exist. This does not alter our adherence to PLOS ONE policies on sharing data and materials. The restrictions on sharing of data are due to national legal regulations.

Objective: When lifestyle changes are needed, life events or crises such as COVID-19 may function as "teachable moments". This study aimed to explore whether the pandemic can provoke a teachable moment regarding lifestyle change in cardiovascular disease patients. Method: In this cross-sectional survey study, 830 cardiovascular disease patients reported their intentions to change lifestyle, instigated by the corona crisis, together with risk perception, affective impact, and changed self-concept, based on a "teachable moments" framework. Results: Between 8 and 28% of the sample reported increased intentions to optimize lifestyle behaviors, particularly related to general lifestyle (28%), physical activity (25%), and diet (21%). Multivariate regression analyses revealed that changed self-concept was associated with higher intentions to improve general lifestyle ( B = 0.26; CI = 0.19-0.33), physical activity ( B = 0.23; CI = 0.16-0.30), and smoking ( B = 0.29; CI = 0.01-0.57). In addition, changed self-concept and affective impact were both significantly associated with higher intentions to improve diet (resp. B = 0.29; CI = 0.21-0.36 and B = 0.12; CI = 0.04-0.21) and to limit alcohol consumption (resp. B = 0.22; CI = 0.13-0.30 and B = 0.11; CI = 0.01-0.20). We did not find evidence for an important role of risk perception on behavior change intentions. Conclusion: The COVID-19 crisis evoked a potential teachable moment for lifestyle change in cardiovascular disease patients, driven by a change in a patient's self-concept and to a lesser extent by an affective impact of the COVID-19 crisis. These results suggest an important window of opportunity for healthcare professionals to utilize the pandemic to promote a healthy lifestyle to their patients., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Brust, Gebhardt, Numans and Kiefte-de Jong.)

Background: Many countries organize population-based cervical cancer screening programs (CSP). In the Netherlands, eligible women are invited by mail. Marginalized women living in unstable conditions and homeless women often fail to receive the invitation letter. These women also experience access barriers to regular healthcare. Consequently, despite presumably being at higher risk of developing cervical cancer due to prevalent risk factors, marginalized women are rarely screened for cervical cancer. The aim of the study was to identify the prevalence of (pre)cancerous abnormalities among marginalized women, and subsequently explore invitation approaches to enhance their screening participation., Methods: A cross-sectional intervention study was conducted in Rotterdam, the Netherlands. Between February and May 2019, marginalized women aged 20-60 years were invited to participate in cervical screening. A participant was considered screen-positive when they tested positive for high-risk human papilloma virus (HR-HPV) and showed cytological abnormalities. Data of the study population were compared with regional data of the Dutch CSP. Various invitation approaches were used to recruit women., Results: Out of 74 included women, 12 participants (16%) were found screen-positive, against 3.4% in women screened by the Dutch CSP. The prevalence ratio for the study population was 4.4 (95% CI 1.9-8.6) compared with women screened by the Dutch CSP. Using a direct, pro-active approach resulted in participation of 92% of the included women., Conclusion: Marginalized women have an increased risk of (pre)cancerous cervical abnormalities in screening, compared with women screened by the Dutch CSP. A direct pro-active approach was the most effective to stimulate screening participation. Enhancement of screening uptake for this population needs special effort., Competing Interests: The authors report no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The authors received non-financial support from the Netherlands Streetdoctors Group, non-financial support from Erasmus Medical Center, and non-financial support from Stichting Bevolkingsonderzoek Zuid-West., (© 2021 Bongaerts et al.)

Background and Objectives: Early identification of child mental health problems (MHPs) is important to provide adequate, timely treatment. Dutch preventive youth healthcare monitors all aspects of a child's healthy development. We explored the usefulness of their electronic health records (EHRs) in scientific research and aimed to develop prediction models for child MHPs. Methods: Population-based cohort study with anonymously extracted electronic healthcare data from preventive youth healthcare centers in the Leiden area, the Netherlands, from the period 2005-2015. Data was analyzed with respect to its continuity, percentage of cases and completeness. Logistic regression analyses were conducted to develop prediction models for the risk of a first recorded concern for MHPs in the next scheduled visit at age 3/4, 5/6, 10/11, and 13/14 years. Results: We included 26,492 children. The continuity of the data was low and the number of concerns for MHPs varied greatly. A large number of determinants had missing data for over 80% of the children. The discriminatory performance of the prediction models were poor. Conclusions: This is the first study exploring the usefulness of EHRs from Dutch preventive youth healthcare in research, especially in predicting child MHPs. We found the usefulness of the data to be limited and the performance of the developed prediction models was poor. When data quality can be improved, e.g., by facilitating accurate recording, or by data enrichment from other available sources, the analysis of EHRs might be helpful for better identification of child MHPs., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Koning, Büchner, van den Berg, Choi, Leeuwenburgh, Paijmans, van Dijk-van Dijk, Numans and Crone.)

Background: Structured primary diabetes care within a collectively supported setting is associated with better monitoring of biomedical and lifestyle-related target indicators amongst people with type 2 diabetes and with better HbA1c levels. Whether socioeconomic status affects the delivery of care in terms of monitoring and its association with HbA1c levels within this approach, is unclear. This study aims to understand whether, within a structured care approach, (1) socioeconomic categories differ concerning diabetes monitoring as recommended; (2) socioeconomic status modifies the association between monitoring as recommended and HbA1c., Methods: Observational real-life cohort study with primary care registry data from general practitioners within diverse socioeconomic areas, who are supported with the implementation of structured diabetes care. People with type 2 diabetes mellitus were offered quarterly diabetes consultations. "Monitoring as recommended" by professional guidelines implied minimally one annual registration of HbA1c, systolic blood pressure, LDL, BMI, smoking behaviour and physical activity. Regarding socioeconomic status, deprived, advantageous urban and advantageous suburban categories were compared to the intermediate category concerning (a) recommended monitoring; (b) association between recommended monitoring and HbA1c., Results: Aim 1 (n = 13 601 people): Compared to the intermediate socioeconomic category, no significant differences in odds of being monitored as recommended were found in the deprived (OR 0.45 (95% CI 0.19-1.08)), advantageous urban (OR 1.27 (95% CI 0.46-3.54)) and advantageous suburban (OR 2.32 (95% CI 0.88-6.08)) categories. Aim 2 (n = 11 164 people): People with recommended monitoring had significantly lower HbA1c levels than incompletely monitored people (-2.4 (95% CI -2.9; -1.8) mmol/mol). SES modified monitoring-related HbA1c differences, which were significantly higher in the deprived (-3.3 (95% CI -4.3; -2.4) mmol/mol) than the intermediate category (-1.3 (95% CI -2.2; -0.4) mmol/mol)., Conclusions: Within a structured diabetes care setting, socioeconomic status is not associated with recommended monitoring. Socioeconomic differences in the association between recommended monitoring and HbA1c levels advocate further exploration of practice and patient-related factors contributing to appropriate monitoring and for care adjustment to population needs., (© 2020 The Authors. International Journal of Clinical Practice published by John Wiley & Sons Ltd.)

Objectives: Overcrowding in acute care services gives rise to major problems, such as reduced accessibility and delay in treatment. In order to be able to continue providing high-quality health care, it is important that organizations are well integrated at all organizational levels. The objective of this study was to to gain an understanding in which extent cooperation within an urban acute care network in the Netherlands (The Hague) improved because of the COVID-19 crisis., Methods: Exploratory mixed-methods questionnaire and qualitative interview study. Semistructured interviews with stakeholders in the acute care network at micro (n = 10), meso (n = 9), and macro (n = 3) levels of organization. Thematic analysis took place along the lines of the 6 dimensions of the Rainbow Model of Integrated Care., Results: In this study we identified themes that may act as barriers or facilitators to cooperation: communication, interaction, trust, leadership, interests, distribution of care, and funding. During the crisis many facilitators were identified at clinical, professional, and system level such as clear agreements about work processes, trust in each other's work, and different stakeholders growing closer together. However, at an organizational and communicative level there were many barriers such as interference in each other's work and a lack of clear policies., Conclusion: The driving force behind all changes in integration of acute care organizations in an urban context during the COVID-19 crisis seemed to be a great sense of urgency to cooperate in the shared interest of providing the best patient care. We recommend shifting the postcrisis focus from overcoming the crisis to overcoming cooperative challenges., Competing Interests: The authors declare no conflict of interest., (© 2021 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Aims: To examine the feasibility and validity of obtaining International Classification of Primary Care (ICPC)-coded diagnoses of diabetes mellitus (DM) from general practice electronic health records for case definition in epidemiological studies, as alternatives to self-reported DM., Methods: The Netherlands Epidemiology of Obesity study is a population-based cohort study of 6671 persons aged 45-65 years at baseline, included between 2008-2012. Data from electronic health records were collected between 2012-2014. We defined a reference standard using diagnoses, prescriptions and consultation notes and investigated its agreement with ICPC-coded diagnoses of DM and self-reported DM., Results: After a median follow-up of 1.8 years, data from 6442 (97%) participants were collected. With the reference standard, 506 participants (79/1000 person-years) were classified with prevalent DM at baseline and 131 participants (11/1000 person-years) were classified with incident DM during follow-up. The agreement of prevalent DM between self-report and the reference standard was 98% (kappa 0.86), the agreement between ICPC-coded diagnoses and the reference standard was 99% (kappa 0.95). The agreement of incident DM between ICPC-coded diagnoses and the reference standard was >99% (kappa 0.92)., Conclusions: ICPC-coded diagnoses of DM from general practice electronic health records are a feasible and valid alternative to self-reported diagnoses of DM., (Copyright © 2020 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction: South Asians with diabetes have more severe diabetic retinopathy (DR) and cardiovascular complications than white Caucasians. However, how big this gap is and the relation with the severity of DR has not been studied. Here, we quantify the difference in time from diabetes diagnosis until a first non-fatal Major Adverse Cardiovascular Event (TUF MACE) in different DR groups in South Asians and Europeans., Methods: 3831 adults with type 2 diabetes, 1358 South Asians and 2473 Europeans, treated in our diabetes clinic between 2006 and 2017 were included. Data on risk factors, diabetes duration, age of diagnosis and diabetes complications were collected from the diabetes-specific database and analysed using descriptive statistics and Cox regression. DR was graded in 3 categories, and non-fatal MACE was pre-specified., Results: Prevalence of non-fatal MACE was the same when DR was absent, increased with increasing severity of DR in both ethnic groups, but was more frequent in South Asians with DR (mild: 50 vs. 42% and severe 62 vs. 46%. Classic risk factors only differed in relation to smoking habits, which were significantly lower in South Asians.After correction for classic risk factors and age at diabetes diagnosis TUF MACE was significantly shorter in South Asians, an effect also seen in the no-DR group (4.1 yrs. HR 1.5, 95% CI 1.3-1.8 and 7.4 yrs. earlier, HR 2.0, 95% CI 1.6-2.6 for no-DR and severe DR, respectively)., Conclusions: When adjusted for age at diabetes diagnosis, we show that time until first non-fatal MACE in South Asians is significantly shorter compared to Europeans and increases from no- to severe DR., Competing Interests: All authors declare no conflict of interest related to the manuscript., (© 2021 The Authors. Endocrinology, Diabetes & Metabolism published by John Wiley & Sons Ltd.)

Background: Within the Dutch health care system the focus is shifting from a disease oriented approach to a more population based approach. Since every inhabitant in the Netherlands is registered with one general practice, this offers a unique possibility to perform Population Health Management analyses based on general practitioners' (GP) registries. The Johns Hopkins Adjusted Clinical Groups (ACG) System is an internationally used method for predictive population analyses. The model categorizes individuals based on their complete health profile, taking into account age, gender, diagnoses and medication. However, the ACG system was developed with non-Dutch data. Consequently, for wider implementation in Dutch general practice, the system needs to be validated in the Dutch healthcare setting. In this paper we show the results of the first use of the ACG system on Dutch GP data. The aim of this study is to explore how well the ACG system can distinguish between different levels of GP healthcare utilization., Methods: To reach our aim, two variables of the ACG System, the Aggregated Diagnosis Groups (ADG) and the mutually exclusive ACG categories were explored. The population for this pilot analysis consisted of 23,618 persons listed with five participating general practices within one region in the Netherlands. ACG analyses were performed based on historical Electronic Health Records data from 2014 consisting of primary care diagnoses and pharmaceutical data. Logistic regression models were estimated and AUC's were calculated to explore the diagnostic value of the models including ACGs and ADGs separately with GP healthcare utilization as the dependent variable. The dependent variable was categorized using four different cut-off points: zero, one, two and three visits per year., Results: The ACG and ADG models performed as well as models using International Classification of Primary Care chapters, regarding the association with GP utilization. AUC values were between 0.79 and 0.85. These models performed better than the base model (age and gender only) which showed AUC values between 0.64 and 0.71., Conclusion: The results of this study show that the ACG system is a useful tool to stratify Dutch primary care populations with GP healthcare utilization as the outcome variable.

Objective: Although behavioral changes are common in nursing home residents with dementia and caffeine is known to influence behavior in healthy adults, the effects of caffeine on the behavior of persons with dementia has received little attention. In this study we assessed the relationship of caffeine and behavioral symptoms in older persons with dementia., Design: A multicenter sub-cohort study embedded in the Elderly Care Physicians (ECP) training program., Setting: Dutch nursing homes associated with the ECP training program., Participants: A total of 206 individuals with both diabetes and dementia resident in Dutch nursing homes., Measurements: Trainee ECPs collected data on caffeine consumption, cognition and behavioral symptoms using the NPI-NH, MDS-DRS and AES-C. Data on factors known to influence behavior in persons with dementia (e.g. marital status, kidney function, urinary tract infection and medication) were also collected., Results: Of the 206 participants, 70% showed behavioral symptoms. An increase in caffeine consumption was associated with a decrease in the presence of behavioral symptoms in the NPI-NH cluster affect and NPI-NH item agitation. Caffeine consumption groups also differed on the presence of disinhibition and depression. In addition, the severity of dementia influenced agitation, anxiety and the clusters affect and psychomotor., Conclusion: In a large group of older persons with dementia resident in nursing homes, a low daily consumption of caffeine was associated with greater behavioral symptoms., Competing Interests: All authors declare that they have no competing interests.

Effectiveness of health interventions can be substantially impaired by implementation failure. Context-driven implementation strategies are critical for successful implementation. However, there is no practical, evidence-based guidance on how to map the context in order to design context-driven strategies. Therefore, this practice paper describes the development and validation of a systematic context-mapping tool. The tool was cocreated with local end-users through a multistage approach. As proof of concept, the tool was used to map beliefs and behaviour related to chronic respiratory disease within the FRESH AIR project in Uganda, Kyrgyzstan, Vietnam and Greece. Feasibility and acceptability were evaluated using the modified Conceptual Framework for Implementation Fidelity. Effectiveness was assessed by the degree to which context-driven adjustments were made to implementation strategies of FRESH AIR health interventions. The resulting Setting-Exploration-Treasure-Trail-to-Inform-implementatioN-strateGies (SETTING-tool) consisted of six steps: (1) Coset study priorities with local stakeholders, (2) Combine a qualitative rapid assessment with a quantitative survey (a mixed-method design), (3) Use context-sensitive materials, (4) Collect data involving community researchers, (5) Analyse pragmatically and/or in-depth to ensure timely communication of findings and (6) Continuously disseminate findings to relevant stakeholders. Use of the tool proved highly feasible, acceptable and effective in each setting. To conclude, the SETTING-tool is validated to systematically map local contexts for (lung) health interventions in diverse low-resource settings. It can support policy-makers, non-governmental organisations and health workers in the design of context-driven implementation strategies. This can reduce the risk of implementation failure and the waste of resource potential. Ultimately, this could improve health outcomes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

In this study we describe changes in perceived food insecurity and eating habits in the Netherlands since the start of the COVID-19-crisis, how these changes were experienced, and which options were indicated for a healthier diet. The study was conducted through online questionnaires among adults with a relatively low socioeconomic position living in the Netherlands. We included 1033 participants. The results show changes in perceived food insecurity in the Netherlands since the start of the COVID-19 crisis, with some participants experiencing lower food security and others experiencing higher food security. About one-fifth of the participants reported that their eating pattern had changed since the start of the COVID-19-crisis, while more than half of the food insecure participants reported a changed eating pattern: in particular, they reported eating less healthily and fewer fruits and vegetables. Participants experiencing food insecurity more often reported to want help for a healthier diet. A cheaper food supply was seen as a promising solution, while food bank use was rarely mentioned in this regard. The COVID-19-crisis can lead to financial insecurity and changes in food availability/accessibility, known risk factors for food insecurity. Therefore, these findings highlight the urgency of reducing food insecurity and providing appropriate support for healthy eating, particularly for people experiencing food insecurity., (© The Author(s) 2021, corrected publication 2021.)

One application of personalized medicine is the tailoring of medication to the individual, so that the medication will have the highest chance of success. In order to individualize medication, one must have a complete inventory of all current pharmaceutical compounds (a detailed formulary) combined with pharmacogenetic datasets, the genetic makeup of the patient, their (medical) family history and other health-related data. For healthcare professionals to make the best use of this information, it must be visualized in a way that makes the most medically relevant data accessible for their decision-making. Similarly, to enable bioinformatics analysis of these data, it must be prepared and provided through an interface for controlled computational analysis. Due to the high degree of personal information gathered for such initiatives, privacy-sensitive implementation choices and ethical standards are paramount. The Personal Genetic Locker project provides an approach to enable the use of personal genomic data in primary care. In this paper, we provide a description of the Personal Genetic Locker project and show its utility through a use case based on open standards, which is illustrated by the 4MedBox system.

Background: Assessment of sexual health is important in chronically ill patients, as many experience sexual dysfunction (SD). The general practice nurse (GPN) can play a crucial part in addressing SD., Objective: The aim of this cross-sectional study was to examine to which extent GPNs discuss SD with chronically ill patients and what barriers may refrained them from discussing SD. Furthermore, we examined which factors had an association with a higher frequency of discussing SD., Methods: A cross-sectional survey using a 48-item questionnaire was send to 637 GPNs across the Netherlands., Results: In total, 407 GPNs returned the questionnaire (response rate 63.9%) of which 337 completed the survey. Two hundred and twenty-one responding GPNs (65.6%) found it important to discuss SD. More than half of the GPNS (n = 179, 53.3%) never discussed SD during a first consultation, 60 GPNs (18%) never discussed SD during follow-up consultations. The three most important barriers for discussing SD were insufficient training (54.7%), 'reasons related to language and ethnicity' (47.5%) and 'reasons related to culture and religion' (45.8%). More than half of the GPNs thought that they had not enough knowledge to discuss SD (n = 176, 54.8%). A protocol on addressing SD would significantly increase discussing during SD., Conclusions: This study indicates that GPNs do not discuss SD with chronically ill patients routinely. Insufficient knowledge, training and reasons related to cultural diversity were identified as most important reasons for this practice pattern. Implementation of training in combination with guidelines on SD in the general practice could improve on the discussing of sexual health with chronic patients., (© The Author(s) 2020. Published by Oxford University Press.)

Background: Electronic health records (EHRs) are increasingly used for research; however, multicomponent outcome measures such as daily functioning cannot yet be readily extracted., Aim: To evaluate whether an electronic frailty index based on routine primary care data can be used as a measure for daily functioning in research with community-dwelling older persons (aged ≥75 years)., Design and Setting: Cohort study among participants of the Integrated Systemic Care for Older People (ISCOPE) trial (11 476 eligible; 7285 in observational cohort; 3141 in trial; over-representation of frail people)., Method: At baseline (T0) and after 12 months (T12), daily functioning was measured with the Groningen Activities Restriction Scale (GARS, range 18-72). Electronic frailty index scores (range 0-1) at T0 and T12 were computed from the EHRs. The electronic frailty index (electronic Frailty Index - Utrecht) was tested for responsiveness and compared with the GARS as a gold standard for daily functioning., Results: In total, 1390 participants with complete EHR and follow-up data were selected (31.4% male; median age = 81 years, interquartile range = 78-85). The electronic frailty index increased with age, was higher for females, and lower for participants living with a partner. It was responsive after an acute major medical event; however, the correlation between the electronic frailty index and GARS at T0 and over time was limited., Conclusion: Because the electronic frailty index does not reflect daily functioning, further research on new methods to measure daily functioning with routine care data (for example, other proxies) is needed before EHRs can be a useful data source for research with older persons., (© British Journal of General Practice 2020.)

Objective: The objective of this study was to identify key features to be addressed in the reporting of deprescribing trials and to elaborate and explain CONSORT items in this regard., Study Design and Setting: As a first step in a multistage process and based on a systematic review of deprescribing trials, we elaborated variation in design, intervention, and reporting of the included trials of the review. We identified items that were missed or insufficiently described, using the CONSORT and TIDieR checklists. The resulting list of items, which we considered relevant to be reported in deprescribing trials, were discussed in a single-round Delphi exercise and subsequently in a full-day face-to-face meeting with an international panel of 14 experts. We agreed on CONSORT items for further elaboration with regard to design and reporting of deprescribing trials., Results: We identified seven CONSORT items on trial design, participants, intervention, outcomes, flowchart, and harms, where the investigators of deprescribing trials should take into consideration specific aspects, such as whether or not to use placebo or how to inform participants., Conclusion: This article presents an elaboration to the CONSORT statement for the reporting of deprescribing trials. It may also support investigators in motivated design choices., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Healthcare professionals can play a significant role in the prevention of lifestyle-related diseases. Yet there is still relatively little attention to lifestyle counseling, partly because of limited available time and doubts about its effectiveness. During so-called 'teachable moments', patients may be more receptive towards lifestyle advices and more motivated to change their lifestyle. For example during pregnancy, disease diagnoses, abnormal test results or even the corona crisis, patients may suddenly face lifestyle change differently. In this paper, we provide guidelines to healthcare professionals regarding utilization of these situations. General practitioners or specialists can create a potential teachable moment by discussing risk perception, emotions and self-image with the patient. Subsequently, paramedics can encourage patients to change health behaviors by increasing their motivation, self-efficacy and lifestyle-related skills. Recognizing and making optimal use of potential teachable moments can contribute to desired behavior change of patients with relatively little time investment.

This study proposes a framework for mining temporal patterns from Electronic Medical Records. A new scoring scheme based on the Wilson interval is provided to obtain frequent and predictive patterns, as well as to accelerate the mining process by reducing the number of patterns mined. This is combined with a case study using data from general practices in the Netherlands to identify children at risk of suffering from mental disorders. To develop an accurate model, feature engineering methods such as one hot encoding and frequency transformation are proposed, and the pattern selection is tailored to this type of clinical data. Six machine learning models are trained on five age groups, with XGBoost achieving the highest AUC values (0.75-0.79) with sensitivity and specificity above 0.7 and 0.6 respectively. An improvement is demonstrated by the models learning from patterns in addition to non-temporal features., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: The Netherlands host three population-based cancer screening programmes: for cervical, breast, and colorectal cancer. For screening programmes to be effective, high participation rates are essential, but participation in the Netherlands' programmes is starting to fall below the minimal effective rate. We aimed to produce a systematic overview of the current known determinants of (non-)attendance at the Dutch cancer screening programmes., Methods: A literature search was conducted in the electronic databases Academic Search Premier, Cochrane Library, Embase, EMCare, PubMed, PsycINFO, Web of Science, and also in grey literature, including all articles published before February 2018. The I-Change model was used to categorize the identified determinants of cancer screening attendance., Results: In total, 19/1232 identified studies and 6 grey literature reports were included. Fifteen studies reported on predisposing factors. Characteristics such as social economic status, country of birth, and residency were most often reported, and correlate with cancer screening attendance. Thirteen studies addressed information factors. Factors on awareness, motivation, ability, and barriers were less often studied., Conclusion: Current studies tend to describe the general characteristics of (non-)attendance and (non-)attenders, but rarely provide in depth information on other factors of (non-)participation. The I-Change model proved to be a useful tool in mapping current knowledge on cancer screening attendance and revealed knowledge gaps regarding determinants of (non-)participation in the screening programmes. More research is needed to fully understand determinants of participation, in order to influence and optimize attendance rates over the long term.

Many older adults do not reach the recommended level of physical activity, despite many professional-delivered physical activity interventions. Here we study the implementation of a novel physical activity intervention for older adults that is self-sustainable (no financial support) and self-organizing (participants act as organizers) due to peer coaching. We implemented three groups and evaluated process and effect using participatory observations, questionnaires, six-minute walk tests and body composition measures from October 2016 to September 2018. The intervention was implemented by staff without experience in physical activity interventions. Facilitators were a motivated initiator and a non-professional atmosphere for participants to take ownership. Barriers were the absence of motivated participants to take ownership and insufficient participants to ensure the presence of participants at every exercise session. The groups exercised outside five days a week and were self-organizing after 114, 216 and 263 days. The initial investments were 170€ for sport equipment and 81-187 h. The groups reached 118 members and a retention of 86.4% in two years. The groups continue to exist at the time of writing and are self-sustainable. Quality of life increased 0.4 on a ten-point scale (95%CI 0.1-0.7; p = 0.02) and six-minute walk test results improved with 33 m (95%CI 18-48; p < 0.01) annually. Self-organizing peer coach groups for physical activity are feasible, have positive effects on health and require only a small investment at the start. It is a sustainable and potentially scalable intervention that could be a promising method to help many older adults age healthier., (© 2020 The Author(s).)

In the iZi study in The Hague, use and acceptance of commercially available technology by home-dwelling older citizens was studied, by comparing self-efficacy and perceived physical and mental Quality of Life (QoL)-related parameters on an intervention location of 279 households and a control location of 301 households. Technology adoption was clinically significantly associated with increased perceived physical QoL, as compared with control group, depending on the number of technology interventions that were used. A higher number of adopted technologies was associated with a stronger effect on perceived QoL. We tried to establish a way to measure clinical significance by using mixed methods, combining quantitative and qualitative evaluation and feeding results and feedback of participants directly back into our intervention. In general, this research is promising, since it shows that successful and effective adoption of technology by older people is feasible with commercially available products amongst home-dwelling older citizens. We think this way of working provides a better integration of scientific methods and clinical usability but demands a lot of communication and patience of researchers, citizens, and policymakers. A change in policy on how to target people for this kind of intervention might be warranted.

Background: Caloric restriction is an effective way to treat Type 2 diabetes (T2D). However, chronic and severe restriction of food intake is difficult to sustain and is known to promote slower metabolism. Intermittent and frequent fasting can exert similar metabolic effects, but may be even more challenging for most patients. A fasting-mimicking diet (FMD) is low in calories, sugars and proteins, but includes relatively high levels of plant based complex carbohydrates and healthy fats. The metabolic effects of such a diet mimic the benefits of water-only fasting. The effects of a FMD applied periodically in T2D patients are still unknown. The Fasting In diabetes Treatment (FIT) trial was designed to determine the effect of intermittent use (5 consecutive days a month during a year) of a FMD in T2D patients on metabolic parameters and T2D medication use compared to usual care., Methods: One hundred T2D patients from general practices in the Netherlands with a BMI ≥ 27 kg/m 2 , treated with lifestyle advice only or lifestyle advice plus metformin, will be randomised to receive the FMD plus usual care or usual care only. Primary outcomes are HbA1c and T2D medication dosage. Secondary outcomes are anthropometrics, blood pressure, plasma lipid profiles, quality of life, treatment satisfaction, metabolomics, microbiome composition, MRI data including cardiac function, fat distribution and ectopic fat storage, cost-effectiveness, and feasibility in clinical practice., Discussion: This study will establish whether monthly 5-day cycles of a FMD during a year improve metabolic parameters and/or reduce the need for medication in T2D. Furthermore, additional health benefits and the feasibility in clinical practice will be measured and a cost-effectiveness evaluation will be performed., Trial Registration: The trial was registered on ClinicalTrials.gov. Identifier: NCT03811587. Registered 21th of January, 2019; retrospectively registered.

Background: There is little evidence on the child and family factors that affect the intensity of care use by children with complex problems. We therefore wished to identify changes in these factors associated with changes in care service use and its intensity, for care use in general and psychosocial care in particular., Methods: Parents of 272 children with problems in several life domains completed questionnaires at baseline (response 69.1%) and after 12 months. Negative binominal Hurdle analyses enabled us to distinguish between using care services (yes/ no) and its intensity, i.e. number of contacts when using care., Results: Change in care use was more likely if the burden of adverse life events (ALE) decreased (odds ratio, OR = 0.94, 95% confidence interval, CI = 0.90-0.99) and if parenting concerns increased (OR = 1.29, CI = 1.11-1.51). Psychosocial care use became more likely for school-age children (vs. pre-school) (OR = 1.99, CI = 1.09-3.63) if ALE decreased (OR = 0.93, CI = 0.89-0.97) and if parenting concerns increased (OR = 1.26, CI = 1.10-1.45). Intensity of use (>0 contacts) of any care decreased when ALE decreased (relative risk, RR = 0.95, CI = 0.92-0.98) and when psychosocial problems became less severe (RR = 0.38, CI = 0.20-0.73). Intensity of psychosocial care also decreased when severe psychosocial problems became less severe (RR = 0.39, CI = 0.18-0.84)., Conclusions: Changes in care-service use (vs. no use) and its intensity (>0 contacts) are explained by background characteristics and changes in a child's problems. Care use is related to factors other than changes in its intensity, indicating that care use and its intensity have different drivers. ALE in particular contribute to intensity of any care use., Competing Interests: The authors have declared that no competing interests exist.

Background: Food insecurity is related to risk of adverse health outcomes such as obesity, but the explanatory factors underlying this association are still unclear. This study aimed to assess the association between food insecurity and obesity, and to explore potential mediation by sociodemographic and lifestyle factors., Methods: This cross-sectional study was conducted among 250 participants in a deprived urban area in the Netherlands. Data on sociodemographic and lifestyle factors, food insecurity status and diet quality were collected using questionnaires. Diet quality was determined based on current national dietary guidelines. BMI was calculated from self-reported height and weight. Regression analyses were performed to explore the association between food insecurity and BMI status. Mediation analyses were performed to estimate the total-, direct-, and indirect effect and proportion of total effect mediated of the food insecurity-obesity association., Results: The overall prevalence of food insecurity was 26%. Food insecurity was associated with obesity (OR = 2.49, 95%CI = 1.16, 5.33), but not with overweight (OR = 1.15, 95%CI = 0.54, 2.45) in the unadjusted model. The food insecurity-obesity association was partially mediated by living situation (proportion mediated: 15.4%), diet quality (- 18.6%), and smoking status (- 15.8%) after adjustment for other covariates., Conclusions: The findings of this study suggest an association between food insecurity and obesity. Living situation, diet quality and smoking status explained part, but not all, of the total association between food insecurity and obesity. Future longitudinal studies are warranted to examine the temporal order of the food insecurity-obesity association and potential mediators in this relationship. In addition, food insecurity and its potential consequences need to be taken into account in obesity prevention programs and policies.

Objective: Whether care group participation by general practitioners improves delivery of diabetes care is unknown. Using 'monitoring of biomedical and lifestyle target indicators as recommended by professional guidelines' as an operationalisation for quality of care, we explored whether (1) in new practices monitoring as recommended improved a year after initial care group participation (aim 1); (2) new practices and experienced practices differed regarding monitoring (aim 2)., Design: Observational, real-life cohort study., Setting: Primary care registry data from Eerstelijns Zorggroep Haaglanden (ELZHA) care group., Participants: Aim 1: From six new practices (n=538 people with diabetes) that joined care group ELZHA in January 2014, two practices (n=211 people) were excluded because of missing baseline data; four practices (n=182 people) were included. Aim 2: From all six new practices (n=538 people), 295 individuals were included. From 145 experienced practices (n=21 465 people), 13 744 individuals were included., Exposure: Care group participation includes support by staff nurses on protocolised diabetes care implementation and availability of a system providing individual monitoring information. 'Monitoring as recommended' represented minimally one annual registration of each biomedical (HbA1c, systolic blood pressure, low-density lipoprotein) and lifestyle-related target indicator (body mass index, smoking behaviour, physical exercise)., Primary Outcome Measures: Aim 1: In new practices, odds of people being monitored as recommended in 2014 were compared with baseline (2013). Aim 2: Odds of monitoring as recommended in new and experienced practices in 2014 were compared., Results: Aim 1: After 1-year care group participation, odds of being monitored as recommended increased threefold (OR 3.00, 95% CI 1.84 to 4.88, p<0.001). Aim 2: Compared with new practices, no significant differences in the odds of monitoring as recommended were found in experienced practices (OR 1.21, 95% CI 0.18 to 8.37, p=0.844)., Conclusions: We observed a sharp increase concerning biomedical and lifestyle monitoring as recommended after 1-year care group participation, and subsequently no significant difference between new and experienced practices-indicating that providing diabetes care within a collective approach rapidly improves registration of care., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To quantify general practitioners' (GPs) sensitivity to anxiety disorders (ADs) when confronted with the range of symptoms common to children with ADs. Also, to explore GPs' conscious preferences and implicit tendencies for referral of children with ADs to mental healthcare., Design and Setting: In a cross-sectional vignette-based survey, all attendees of a Dutch continuing medical education conference for primary care physicians were presented with subtitled audio fragments of five vignettes that we constructed to mimic symptom presentation of children with ADs in general practice. We asked attendees to select per vignette the most plausible diagnoses and most adequate referral option, and for their general referral preferences when they suspect each of the most common mental health problems., Participants: A sample of 229 GPs, resulting in a total of 1128 vignette evaluations., Main Outcome Measure: GPs' selection rate of ADs in the five vignettes compared with a benchmark provided by mental health professionals (MHPs)., Results: Overall, recognition of ADs was less likely in GPs compared with MHPs (OR=0.26, 95% CI 0.15 to 0.46). GPs varied in their recognition of anxiety, with 44.1% not once selecting anxiety as the probable presenting problem. When asked explicitly, 63.9% of the GPs reported that they would refer a child to mental healthcare when they suspect probable ADs. By contrast, only 12.0% of the GPs who recognised anxiety in the vignettes actually selected that referral option., Conclusion: A significant fraction of GPs did not notice the depicted symptoms as anxiety. Despite the widespread prevalence of ADs, GPs seem to overlook anxiety already in their early diagnostic opinion. Improving GPs' familiarity with initial symptom presentation, ADs' base-rate, relevance and impact yields potential for timely recognition., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

There are indications that ultraviolet B (UVB) exposure has beneficial effects on well-being through mechanisms other than vitamin D synthesis alone. We conducted a randomized controlled multicenter trial to compare the effects of UVB light and vitamin D supplementation (VD) in terms of the well-being of nursing home residents with dementia. Participants were randomly assigned to the intervention group (UVB group, n = 41; half-body UVB irradiation, twice weekly over 6 months, with 1 standard erythema dose (SED)) or to the control group (VD group, n = 37; 5600 International units (IU) cholecalciferol supplementation once a week). The main outcome was well-being, measured by the Cohen-Mansfield Agitation Inventory (CMAI) and the Cornell scale for depression in dementia at 0, 3, and 6 months. Secondary outcomes were QUALIDEM quality of life domains and biochemical parameters of bone homeostasis. Intention-to-treat analysis with linear mixed modeling showed no significant between-group differences on agitation ( p = 0.431) or depressive symptoms ( p = 0.982). At six months, the UVB group showed less restless/tense behavior compared to the VD group (mean difference of the mean change scores 2.2, 95% CI 0.8 to 3.6; p = 0.003 for group x time interaction) and lower serum 25(OH)D3 concentration (estimated mean difference - 21.9, 95% CI -32.6 to -11.2; p = 0.003 for group difference). The exposure of nursing home residents with dementia to UVB light showed no positive benefits in terms of wellbeing. UVB treatment may have a positive effect on the restless/tense behavior characteristic of advanced dementia but more research is needed to confirm this finding.

Blood for determining 25-hydroxyvitamin D 3 [25(OH)D 3 ] is usually obtained through venipuncture although, as an alternative for serum, dried blood spot (DBS) can be considered. The aim of this proof-of-concept study was to investigate levels of agreement between measurements of 25(OH)D 3 obtained with DBS compared with serum. 301 Chinese participants were included who completed 25(OH)D 3 measurement from DBS and from simultaneously collected blood samples obtained by venipuncture. Measurements of both DBS and serum 25(OH)D 3 were performed using liquid chromatography followed by tandem mass spectrometry. Agreement between the two methods was assessed with Passing and Bablok regression analysis and Bland-Altman plot. Measurements showed a good correlation (Pearson's correlation coefficient r = 0.929, P < 0.001) between the two methods. After recalculating for a 13% difference, a regression equation of DBS 25(OH)D 3 = -1.91 + 1.00 serum 25(OH)D 3 was found in Passing and Bablok regression analysis. Bland-Altman analysis showed a fixed bias of 1.7 nmol/L; upper and lower limit of agreement was 24.1 nmol/L and -20.7 nmol/L, respectively. Sensitivity of recalculated DBS for 25(OH)D 3 concentrations <30 and <50 nmol/L was 87.8% and 91.1%, respectively, and specificity was 89.2% and 83.1%, respectively. In conclusion, a good agreement was found between the measurement of 25(OH)D 3 obtained with DBS compared with serum. DBS may possibly be used in a future screening program, but it is less suitable for individualized vitamin D status assessment., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Healthy eating behaviour is an essential determinant of overall health. This behaviour is generally poor among people at risk of experiencing food insecurity, which may be caused by many factors including perceived higher costs of healthy foods, financial stress, inadequate nutritional knowledge, and inadequate skills required for healthy food preparation. Few studies have examined how these factors influence eating behaviour among people at risk of experiencing food insecurity. We therefore aimed to gain a better understanding of the needs and perceptions regarding healthy eating in this target group., Methods: We conducted a qualitative exploration grounded in data using inductive analyses with 10 participants at risk of experiencing food insecurity. The analysis using an inductive approach identified four core factors influencing eating behaviour: Health related topics; Social and cultural influences; Influences by the physical environment; and Financial influences., Results: Overall, participants showed adequate nutrition knowledge. However, eating behaviour was strongly influenced by both social factors (e.g. child food preferences and cultural food habits), and physical environmental factors (e.g. temptations in the local food environment). Perceived barriers for healthy eating behaviour included poor mental health, financial stress, and high food prices. Participants had a generally conscious attitude towards their financial situation, reflected in their strategies to cope with a limited budget. Food insecurity was mostly mentioned in reference to the past or to others and not to participants' own current experiences. Participants were familiar with several existing resources to reduce food-related financial strain (e.g. debt assistance) and generally had a positive attitude towards these resources. An exception was the Food Bank, of which the food parcel content was not well appreciated. Proposed interventions to reduce food-related financial strain included distributing free meals, facilitating social contacts, increasing healthy food supply in the neighbourhood, and lowering prices of healthy foods., Conclusion: The insights from this study increase understanding of factors influencing eating behaviour of people at risk of food insecurity. Therefore, this study could inform future development of potential interventions aiming at helping people at risk of experiencing food insecurity to improve healthy eating, thereby decreasing the risk of diet-related diseases.

Aim: This study aimed to assess the prevalence of symptoms glioma patients may present with to the general practitioner, and whether these can be distinguished from patients with other CNS disorders or any other condition. Methods: Glioma patients were matched to CNS patients and 'other controls' using anonymized general practitioner registries. Prevalences were evaluated in the 5 years prior to diagnosis. Result: CNS patients reported significantly more motor symptoms in the period 60-24 months, (p = 0.039). Moreover, <6 months before diagnosis CNS patients differed significantly in mood disorders/fear compared with 'other controls' (p = 0.012) but not glioma patients (p = 0.816). Conclusion: Glioma patients could not be distinguished from both control groups with respect to the number or type of prediagnostic symptoms.

Introduction: Identifying ST-elevation myocardial infarction (STEMI) patients who can be referred back to the general practitioner (GP) can improve patient-tailored care. However, the long-term prognosis of patients who are returned to the care of their GP is unknown. Therefore, the aim of this study was to assess the long-term prognosis of patients referred back to the GP after treatment in accordance with a 1-year institutional guideline-based protocol., Methods: All consecutive patients treated between February 2004 up to May 2013 who completed the 1‑year institutional MISSION! Myocardial Infarction (MI) follow-up and who were referred to the GP were evaluated. After 1 year of protocolised monitoring, asymptomatic patients with a left ventricular ejection fraction >45% on echocardiography were referred to the GP. Long-term prognosis was assessed with Kaplan-Meier curves and Cox proportional hazards analysis was used to identify independent predictors for 5‑year all-cause mortality and major adverse cardiovascular events (MACE)., Results: In total, 922 STEMI patients were included in this study. Mean age was 61.6 ± 11.7 years and 74.4% were male. Median follow-up duration after the 1‑year MISSION! MI follow-up was 4.55 years (interquartile range [IQR] 2.28-5.00). The event-free survival was 93.2%. After multivariable analysis, age, not using an angiotensin-converting enzyme (ACE) inhibitor/angiotensin-II (AT2) antagonist and impaired left ventricular function remained statistically significant predictors for 5‑year all-cause mortality. Kaplan-Meier curves revealed that 80.3% remained event-free for MACE after 5 years. Multivariable predictors for MACE were current smoking and a mitral regurgitation grade ≥2., Conclusion: STEMI patients who are referred back to their GP have an excellent prognosis after being treated according to the 1‑year institutional MISSION! MI protocol.

Background: Despite being common and having long lasting effects, mental health problems in children are often under-recognised and under-treated. Improving early identification is important in order to provide adequate, timely treatment. We aimed to develop prediction models for the one-year risk of a first recorded mental health problem in children attending primary care., Methods: We carried out a population-based cohort study based on readily available routine healthcare data anonymously extracted from electronic medical records of 76 general practice centers in the Leiden area, the Netherlands. We included all patients aged 1-19 years on 31 December 2016 without prior mental health problems. Multilevel logistic regression analyses were used to predict the one-year risk of a first recorded mental health problem. Potential predictors were characteristics related to the child, family and healthcare use. Model performance was assessed by examining measures of discrimination and calibration., Findings: Data from 70,000 children were available. A mental health problem was recorded in 27•7% of patients during the period 2007-2017. Age independent predictors were somatic complaints, more than two GP visits in the previous year, one or more laboratory test and one or more referral/contact with other healthcare professional in the previous year. Other predictors and their effects differed between age groups. Model performance was moderate ( c -statistic 0.62-0.63), while model calibration was good., Interpretation: This study is a first promising step towards developing prediction models for identifying children at risk of a first mental health problem to support primary care practice by using routine healthcare data. Data enrichment from other available sources regarding e.g. school performance and family history could improve model performance. Further research is needed to externally validate our models and to establish whether we are able to improve under-recognition of mental health problems., Competing Interests: The authors declared to have no declaration of interest., (© 2019 Published by Elsevier Ltd.)

Background: Epidemiological studies have suggested an increased risk of cardiovascular events (CVE) during acute stressful and/or frightful moments. A possible explanation for this could be an effect of acute stress on hemostasis. A recent study demonstrated an increase in factor VIII after watching a horror movie. Primary hemostasis, however, is thought to play a more prominent role in the etiology of CVE. The objective of this study was therefore to assess the influence of viewing a 'bloodcurdling' horror movie on platelet reactivity in healthy volunteers., Methods: We performed a randomized cross-over study in healthy adults. Subjects were allocated to two movies in random sequence: a horror and a control movie. Blood was drawn at baseline and after 24 min of viewing time. The primary endpoint was the change in Platelet Function Analyzer® Closure Time (Δ PFA-CT) after watching the movie., Results: In total, 20 participants, aged 18-30 years, completed the study protocol. The delta PFA-CT was statistically significantly shorter with a mean in the delta difference of -9.7 s (SEM 4.0, 95% C.I. -18.0 to -1.3) during the horror movie versus the control movie. The Light Transmission Aggregometry endpoints were in line with the PFA-CT, albeit only the highest level of Arachidonic Acid agonist demonstrated a statistically significant mean difference in the delta of aggregation of 13.15% (SEM 7.0, 95% C.I. 1.6-27.9)., Conclusion: A 'blood curdling' horror movie increases platelet reactivity. These data are supportive of a role of platelet reactivity in acute stress induced cardiovascular event risk., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: The consumption of caffeine has well known effects on the behavior and sleep of healthy adults. Behavioral symptoms and sleeping difficulties are common in patients with dementia which may be affected by caffeine consumption. This systematic review examines the association between caffeine intake and neuropsychiatric symptoms in patients with dementia., Methods: In January 2019 an extensive search was conducted in Medline (PubMed), Embase, Emcare, Cochrane, PsychInfo, Web of Science and gray literature. Studies were included when they: i) investigated patients diagnosed with dementia, ii) reported neuropsychiatric symptoms, iii) used caffeine or coffee consumption as an intervention, and iv) reported associations between caffeine or coffee consumption and neuropsychiatric symptoms. Studies were excluded when they also included participants without a diagnosis of dementia, or presented a review or expert opinion. Two reviewers independently rated the studies and reached consensus on the appraisal., Results: Of the seven studies eligible for this review, four reported on sleeping difficulties and five on behavioral symptoms. There was no consistent effect of caffeine administration on neuropsychiatric symptoms: e.g., both high caffeine consumption and eliminating caffeine were associated with less apathy, the total Neuropsychiatric Inventory (Nursing Home) decreased after both coffee therapy and after eliminating caffeine, and both caffeine consumption and eliminating caffeine improved sleep., Conclusion: These findings suggest that caffeine can either induce or reduce neuropsychiatric symptoms in individual patients with dementia. Therefore, in these patients, caffeine consumption requires a prudent individualized approach and further research on the effects of caffeine on individual neuropsychiatric symptoms is required., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background This research is an investigation into the role of expert quotes in health news, specifically whether news articles containing a quote from an independent expert are less often exaggerated than articles without such a quote. Methods Retrospective quantitative content analysis of journal articles, press releases, and associated news articles was performed. The investigated sample are press releases on peer-reviewed health research and the associated research articles and news stories. Our sample consisted of 462 press releases and 668 news articles from the UK (2011) and 129 press releases and 185 news articles from The Netherlands (2015). We hand-coded all journal articles, press releases and news articles for correlational claims, using a well-tested codebook. The main outcome measures are types of sources that were quoted and exaggeration of correlational claims. We used counts, 2x2 tables and odds ratios to assess the relationship between presence of quotes and exaggeration of the causal claim. Results Overall, 99.1% of the UK press releases and 84.5% of the Dutch press releases contain at least one quote. For the associated news articles these percentages are: 88.6% in the UK and 69.7% in the Netherlands. Authors of the study are most often quoted and only 7.5% of UK and 7.0% of Dutch news articles contained a new quote by an expert source, i.e. one not provided by the press release. The relative odds that an article without an external expert quote contains an exaggeration of causality is 2.6. Conclusions The number of articles containing a quote from an independent expert is low, but articles that cite an external expert do contain less exaggeration., Competing Interests: Competing interests: IS is columnist for one of the investigated Dutch newspapers. She was not involved in collecting, coding or analysing of the related data. The other authors of this manuscript have no conflicts of interest to declare.

Background: Although common and often with long-lasting effects, child mental health problems (MHPs) are still under-recognized and under-treated. A better understanding of the factors associated with the identification of MHPs in primary care may improve the recognition of MHPs. Objectives: To review studies on factors associated with the identification of child MHPs in primary care. Methods: Six leading databases were systematically searched until 1 October 2018. Two independent researchers selected articles and extracted data on study characteristics and factors associated with MHP identification. Inclusion criteria were the investigation of factors associated with MHP identification by primary care professionals (PCPs) in children aged 0-18 years. Results: Of the 6215 articles identified, 26 were included. Prevalence rates of PCP-identified MHPs varied between 7 and 30%. PCPs identified 26-60% of children with an increased risk of MHPs as indicated by MHP assessment tools, but associated factors were investigated in relatively few studies. MHPs were more often identified in children with a family composition other than married parents, with worse mental health symptoms, prior MHPs, among boys in elementary school, when contact with PCPs was related to parental psychosocial concerns or routine health check-ups, when PCPs were recently trained in MHPs or when PCPs felt less burdened treating MHPs. Conclusion: MHP identification varied substantially between studies and PCPs and was related to several child, family and practice factors. Future studies should systematically investigate factors associated with MHP identification by PCPs and specifically in children with an increased risk of MHPs according to mental health assessment tools.

Almost all the systems in our body adhere to a daily 24 h rhythm. The cardiovascular system is also affected by this 24 h rhythm. In the morning there is a change in various cardiovascular processes, including platelet aggregability. These changes may play a role in the relative excess of early morning cardiovascular events. The number of recurrent cardiovascular diseases (CVD) could, in theory, be reduced by responding to this 24 h rhythm with timed medication intake (chronotherapy), which also applies to aspirin. Multiple studies on chronotherapy with low-dose aspirin are promising, showing a decrease in early morning platelet activity with evening intake compared with morning intake. However, in order to further demonstrate its clinical impact, randomized trials with cardiovascular events as a primary outcome are needed. This review discusses the available evidence of the effects of circadian rhythm on CVD and the potential positive effect of chronotherapy with aspirin.

Objective: To provide insight into the motives for hospital self-referral during office hours and the barriers deterring general practitioner (GP) consultation with a primary care request., Setting: People who self-referred at a Daytime General Practice Cooperative (GPC) in two hospitals in The Hague, The Netherlands., Participants: A total of 44 people who self-referred were interviewed in two hospitals. The average age of interviewees was 35 years (range 19 months to 83 years), a parent of a young patient was interviewed, but the age of patients is shown here. There were more male patients (66%) than female patients (34%). Patients were recruited using a sampling method after triage. Triage was the responsibility of an emergency department (ED) nurse in one hospital and of a GP in the other. Those excluded from participation included (a) children under the age of 18 years and not accompanied by a parent or legal guardian, (b) foreign patients not resident in the Netherlands, (c) patients unable to communicate in Dutch or English and (d) patients directly referred to the ED after triage by the GP (in one hospital)., Results: People who self-referred generally reported several motives for going to the hospital directly. Information and awareness factors played an important role, often related to a lack of information regarding where to go with a medical complaint. Furthermore, many people who self-referred mentioned hospital facilities, convenience and perceived medical necessity as motivational factors. Barriers deterring a visit to the own GP were mainly logistical, including not being registered with a GP, the GP was too far away, poor GP telephone accessibility or a waiting list for an appointment., Conclusion: Information and awareness factors contribute to misperceptions among people who self-referred concerning the complaint, the GP and the hospital. As a range of motivational factors are involved, there is no straightforward solution. However, better dissemination of information might alleviate misconceptions and contribute to providing the right care to the right patient in the right setting., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)