Patients with psychological ICPC codes in primary care; a case-control study investigating the decade before presenting with problems.

BACKGROUND: Recognizing patients with psychological problems can be difficult for general practitioners (GPs). Use of information collected in electronic medical records (EMR) could facilitate recognition. OBJECTIVES: To assess relevant EMR parameters in the decade before patients present with psychological problems. METHODS: Exploratory case-control study assessing EMR parameters of 58 228 patients recorded between 2013 and 2015 by 54 GPs. We compared EMR parameters recorded before 2014 of patients who presented with psychological problems in 2014 with those who did not. RESULTS: In 2014, 2406 patients presented with psychological problems. Logistic regression analyses indicated that having registrations of the following statistically significant parameters increased the chances of presenting with psychological problems in 2014: prior administration of a depression severity questionnaire (odds ratio (OR): 3.3); fatigue/sleeping (OR: 1.6), neurological (OR: 1.5), rheumatic (OR: 1.5) and substance abuse problems (OR: 1.5); prescriptions of opioids (OR: 1.3), antimigraine preparations (OR: 1.5), antipsychotics (OR: 1.7), anxiolytics (OR: 1.4), hypnotics and sedatives (OR: 1.4), antidepressants (OR: 1.7), and antidementia drugs (OR: 2.1); treatment with minimal interventions (OR: 2.2) and physical exercise (OR: 3.3), referrals to psychology (OR: 1.5), psychiatry (OR: 1.6), and psychosocial care (OR: 2.1); double consultations (OR: 1.2), telephone consultations (OR: 1.1), and home visits (OR: 1.1). CONCLUSION: This study demonstrates that possible indications of psychological problems can be identified in EMR. Many EMR parameters of patients presenting with psychological problems were different compared with patients who did not.

Phenotypic Variation in Patients with Chronic Obstructive Pulmonary Disease in Primary Care.

Introduction. Despite the high number of inactive patients with COPD, not all inactive patients are referred to physical therapy, unlike recommendations of general practitioner (GP) guidelines. It is likely that GPs take other factors into account, determining a subpopulation that is treated by a physical therapist (PT). The aim of this study is to explore the phenotypic differences between inactive patients treated in GP practice and inactive patients treated in GP practice combined with PT. Additionally this study provides an overview of the phenotype of patients with COPD in PT practice. Methods. In a cross-sectional study, COPD patient characteristics were extracted from questionnaires. Differences regarding perceived health status, degree of airway obstruction, exacerbation frequency, and comorbidity were studied in a subgroup of 290 inactive patients and in all 438 patients. Results. Patients treated in GP practice combined with PT reported higher degree of airway obstruction, more exacerbations, more vascular comorbidity, and lower health status compared to patients who were not referred to and treated by a PT. Conclusion. Unequal patient phenotypes in different primary care settings have important clinical implications. It can be carefully concluded that other factors, besides the level of inactivity, play a role in referral to PT.

Do we need tailored smoking cessation interventions for smokers with COPD? A comparative study of smokers with and without COPD regarding factors associated with tobacco smoking.

BACKGROUND: The prevalence of tobacco smoking in patients with chronic obstructive pulmonary disease (COPD) is high. It is assumed that this group of smokers has more difficulties quitting than smokers without COPD. In order to increase the effectiveness of smoking cessation treatments in smokers with COPD it is important to identify any smoking-related factors which are specific to this group of smokers. OBJECTIVE: To compare smokers with COPD with smokers without COPD regarding factors associated with tobacco smoking and quitting. METHODS: We conducted a questionnaire survey in all smoking patients with a recorded diagnosis of COPD from a large Dutch primary health care network. We compared this group with twice as many age-, sex- and health care centre-matched smokers without COPD. RESULTS: Respondents were 107 smokers with COPD and 86 smokers without COPD. The number of attempts to quit was similar in both groups but more smokers with COPD had ever used pharmacological, behavioural and alternative smoking cessation treatments. Furthermore, smokers with COPD more often received triggers to quit from their environment and from their general practitioner, and they were more concerned about, and aware of, the health risks of smoking. Importantly, smokers with COPD reported higher levels of depression and cigarette dependence and a lower self-efficacy to refrain from smoking than smokers without COPD. CONCLUSION: Smokers with COPD differ from smokers without COPD on several factors which are associated with tobacco smoking and quitting. Taking into account these differences may help to increase the effectiveness of smoking cessation treatments for the specific group of smokers with COPD.

Quality of diagnosis and monitoring of tuberculosis in Northern Ethiopia: medical records-based retrospective study.

OBJECTIVES: To determine quality of diagnosis and monitoring of treatment response of patients with smear-negative pulmonary tuberculosis (TB) compared with smear-positive cases in Ethiopia. METHODS: A retrospective analysis of medical records of newly diagnosed pulmonary TB cases that were registered for taking anti-TB medication and had completed treatment between 2010 and 2012. We evaluated the percentage of cases that were managed according to the International Standards of Tuberculosis Care (ISTC) and compared smear-negative with smear-positive cases. RESULTS: We analysed 1168 cases of which 742 (64%) were sputum smear-negative cases. Chest radiography examination at diagnosis and microbiological testing at the end of the intensive phase of treatment was performed in a smaller proportion than in smear-positive TB cases (70% vs. 79%, P value <0.001) and (70% vs. 95%, P value <0.001), respectively. CONCLUSIONS: Clinical actions recommended in the ISTC are of greatest importance in minimising pitfalls in care of smear-negative TB yet were performed less often in smear-negative than smear-positive TB cases.

Smoking cessation in primary care: Exploration of barriers and solutions in current daily practice from the perspective of smokers and healthcare professionals.

BACKGROUND: Evidence based recommendations for smoking cessation are not followed in routine primary care. A better understanding is needed why smoking cessation treatment is still underutilized. OBJECTIVES: To explore barriers and solutions of smoking cessation treatment, from the perspective of smokers and healthcare professionals in Dutch primary care. METHODS: Focus groups were conducted with 14 smokers (smokers and ex-smokers) and semi-structured individual interviews with nine healthcare professionals (general practitioners and practice nurses). Data was analysed using the Constant Comparative Method. RESULTS: Barriers that prevented successful smoking cessation treatment were the lack of awareness regarding the available smoking cessation treatments at the healthcare centre among smokers and the resistance against preventive tasks among healthcare professionals. Nonetheless, general practitioners (GPs) did not fear jeopardizing the doctor-patient relationship by discussing smoking. Quitting was regarded as the smokers' own responsibility and GPs felt that merely using medication was no guarantee for successful quitting. Even so, practice nurses and smokers preferred medication use. Proposed solutions were that GPs should advise smokers to quit, whereas someone else should deliver intensive behavioural support, preferably the practice nurse. CONCLUSION: Smokers and healthcare professionals seem to wait for each other to start smoking cessation. GPs should know that they could discuss smoking cessation with every patient without jeopardizing the doctor-patient relationship, preferably followed by referral to a practice nurse for intensive behavioural support. Furthermore, more patients should know that they could receive pharmacological treatment as well as behavioural support for smoking cessation in their healthcare centre.

Screening for increased cardiometabolic risk in primary care: a systematic review.

BACKGROUND: Many programmes to detect and prevent cardiovascular disease (CVD) have been performed, but the optimal strategy is not yet clear. AIM: To present a systematic review of cardiometabolic screening programmes performed among apparently healthy people (not yet known to have CVD, diabetes, or cardiometabolic risk factors) and mixed populations (apparently healthy people and people diagnosed with risk factor or disease) to define the optimal screening strategy. DESIGN AND SETTING: Systematic review of studies performed in primary care in Western countries. METHOD: MEDLINE, Embase, and CINAHL databases were searched for studies screening for increased cardiometabolic risk. Exclusion criteria were studies designed to assess prevalence of risk factors without follow-up or treatment; without involving a GP; when fewer than two risk factors were considered as the primary outcome; and studies constrained to ethnic minorities. RESULTS: The search strategy yielded 11 445 hits; 26 met the inclusion criteria. Five studies (1995-2012) were conducted in apparently healthy populations: three used a stepwise method. Response rates varied from 24% to 79%. Twenty-one studies (1967-2012) were performed in mixed populations; one used a stepwise method. Response rates varied from 50% to 75%. Prevalence rates could not be compared because of heterogeneity of used thresholds and eligible populations. Observed time trends were a shift from mixed to apparently healthy populations, increasing use of risk scores, and increasing use of stepwise screening methods. CONCLUSION: The optimal screening strategy in primary care is likely stepwise, in apparently healthy people, with the use of risk scores. Increasing public awareness and actively involving GPs might facilitate screening efficiency and uptake.

Stepped collaborative depression care: primary care results before and after implementation of a stepped collaborative depression programme.

BACKGROUND: Numerous intensive research projects to assess the effects of stepped collaborative care (SCC) for depressed patients have been reported in primary care, yet it is unclear how SCC is sustained in usual care. OBJECTIVE: To assess how SCC for depression is actually being used and how it performs in usual primary care by studying medical data that are routinely collected in family practice, outside the research setting. METHODS: Retrospective before and after comparison of electronic medical records (EMR) regarding the implementation of an SCC depression programme in a large primary care organization from 2003 to 2012. Depression care parameters included prevalences, minimal interventions, Beck Depression Inventory-2 (BDI-2), antidepressants, referrals to psychologists and psychiatrists and primary health care consumption. RESULTS: After programme implementation, differentiation between levels of depression severity increased, more patients were treated with minimal interventions and more patients were monitored with BDI-2. These effects occurred in both nonseverely and severely depressed patients, although they were larger for patients registered as nonseverely depressed. Antidepressant prescription rates and referral rates seemed not to have been influenced by the SCC programme. Health care consumption of the depressed patients increased significantly. CONCLUSIONS: The depression care parameters changed to a different extent and at a different pace than after previous implementation initiatives. Future research should identify whether SCC uptake in primary care is best enhanced by intensive external guidance or by making care providers themselves responsible for the implementation. Analyses of EMR can be valuable in monitoring the implementation effects, especially after research projects are completed.

eDiagnostics: a promising step towards primary mental health care.

INTRODUCTION: There is a growing interest in eHealth applications in daily health care. Considering that a psychological examination, to a large extent, consists of filling out questionnaires, the use of the Internet seems logical. We evaluated an eDiagnostic system for mental health disorders that has recently been introduced in primary care in the Netherlands. METHODS: We monitored the diagnoses produced by the system. Evaluation questionnaires from both GPs/practice nurses (PNs) and patients were collected. In addition, we compared the advice produced by the GPs/PNs and the advice produced by the system. RESULTS: The most prevalent disorders were mood, anxiety and somatoform disorders (n = 353). Patients (n = 242; 74% response rate) were moderately enthusiastic about the eHealth approach, and GPs/PNs (n = 49, 72% response rate per practice) were very enthusiastic. Patients showed no clear preference for a face-to-face consultation with a psychologist over an eDiagnostic system. GPs/PNs felt strengthened in their control function. In most cases, the system gave a different echelon advice (i.e. referral to primary or secondary mental health care) than the GPs/PNs (κ = 0.13, P = 0.003). Nevertheless, GPs/PNs accept the results of the examination and the advice given. CONCLUSIONS: Using the Internet to diagnose mental health problems in primary care seems very promising. This system of using eDiagnostics before referral to a mental health institution may change the management of mental health care. Further research should investigate whether this tool is valid, reliable and (cost) effective.

Development, implementation and yield of a cardiometabolic health check.

BACKGROUND: Cardiometabolic health checks are currently introduced in several countries in an attempt to reduce the population-wide increase of cardiometabolic disease. OBJECTIVE: Developing and implementing a health check for cardiometabolic disorders in a medium-sized primary health care centre and describing the participation rate and the numbers of disorders requiring treatment that are identified. METHODS: Observational research in Eindhoven, The Netherlands. All registered patients aged 40-75 years without known cardiometabolic disease (i.e. cardiovascular diseases, diabetes and chronic kidney disease) (n = 1704) were sent a written invitation to participate in a health check. A three-step procedure was used to determine whether a participant was at increased risk of developing cardiometabolic disease. Treatment was started if necessary, according to current guidelines. We recorded the numbers of patients proceeding through each step and the numbers of disorders identified. RESULTS: A total of 1270 patients (75%) returned the first screening questionnaire. Based on the information from this questionnaire, 952 were invited to visit the health care centre for further assessment. A total of 145 patients (11% of the 1270) were found to have at least one disorder for which treatment was indicated (e.g. increased cardiovascular risk, isolated systolic hypertension, diabetes mellitus, suspected familial hypercholesterolaemia or kidney disease). CONCLUSIONS: The response rate and the number of cases identified demonstrate that cardiometabolic disorders can be effectively detected at a primary health care centre. Further research is needed to assess the long-term effects and efficacy of health checks in general practice.

Effect of lifestyle intervention for people with diabetes or prediabetes in real-world primary care: propensity score analysis.

BACKGROUND: Many lifestyle interventions for patients with prediabetes or type 2 diabetes mellitus (T2DM) have been investigated in randomised clinical trial settings. However, the translation of these programmes into primary care seems challenging and the prevalence of T2DM is increasing. Therefore, there is an urgent need for lifestyle programmes, developed and shown to be effective in real-world primary care. We evaluated a lifestyle programme, commissioned by the Dutch government, for patients with prediabetes or type 2 diabetes in primary care. METHODS: We performed a retrospective comparative medical records analysis using propensity score matching. Patients with prediabetes or T2DM were selected from ten primary healthcare centres. Patients who received the lifestyle intervention (n = 186) were compared with a matched group of patients who received usual care (n = 2632). Data were extracted from the electronic primary care records. Propensity score matching was used to control for confounding by indication. Outcome measures were exercise level, BMI, HbA1c, fasting glucose, systolic and diastolic blood pressure, total cholesterol, HDL and LDL cholesterol and triglycerides and the follow-up period was one year. RESULTS: There was no significant difference at follow-up in any outcome measure between either group. The reduction at one year follow-up of HbA1c and fasting glucose was positive in the intervention group compared with controls, although not statistically significant (-0.12%, P = 0.07 and -0.17 mmol/l, P = 0.08 respectively). CONCLUSIONS: The effects of the lifestyle programme in real-world primary care for patients with prediabetes or T2DM were small and not statistically significant. The attention of governments for lifestyle interventions is important, but from the available literature and the results of this study, it must be concluded that improving lifestyle in real-world primary care is still challenging.

[Cardiometabolic risk factors detected with a preventative screening programme]. / Cardiometabole risicofactoren opgespoord met preventieconsult.

OBJECTIVE: Design and implementation of a preventative screening programme for cardiometabolic risk assessment in a medium-sized general practice. Description of the response rate and number of detected diseases to be treated. DESIGN: Questionnaire and observational research. METHOD: All registered patients aged 40 to 75 years without prior cardiometabolic disease (cardiovascular diseases, diabetes and renal disorders) (n=1704) received a written invitation to participate in a preventative screening programme. During a maximum of 3 sequential screening steps the risk for cardiometabolic disease for each participant was determined. Based on their outcome, participants were offered treatment when necessary. The number of patients who completed each of the steps as well as the number of detected disorders were registered. RESULTS: In total 1270 patients (75%) returned an initial screening questionnaire. Based on the information provided in this questionnaire 952 patients were invited for an additional examination at the general practice. In 145 participants (11% of 1270) at least one condition was diagnosed that needed either treatment or follow-up according to the prevailing Dutch practice guidelines, such as elevated risk for cardiovascular diseases, isolated systolic hypertension, diabetes mellitus, suspected familiar hypercholesterolaemia or renal disorders. CONCLUSION: The response-rate as well as the number of newly diagnosed cases demonstrate that it is quite feasible to screen for cardiometabolic disorders in a primary healthcare centre. Follow-up studies are needed to assess the long-term health effects and efficiency of the preventative screening programme.

The SMILE study: a study of medical information and lifestyles in Eindhoven, the rationale and contents of a large prospective dynamic cohort study.

BACKGROUND: Health problems, health behavior, and the consequences of bad health are often intertwined. There is a growing need among physicians, researchers and policy makers to obtain a comprehensive insight into the mutual influences of different health related, institutional and environmental concepts and their collective developmental processes over time. METHODS/DESIGN: SMILE is a large prospective cohort study, focusing on a broad range of aspects of disease, health and lifestyles of people living in Eindhoven, the Netherlands. This study is unique in its kind, because two data collection strategies are combined: first data on morbidity, mortality, medication prescriptions, and use of care facilities are continuously registered using electronic medical records in nine primary health care centers. Data are extracted regularly on an anonymous basis. Secondly, information about lifestyles and the determinants of (ill) health, sociodemographic, psychological and sociological characteristics and consequences of chronic disease are gathered on a regular basis by means of extensive patient questionnaires. The target population consisted of over 30,000 patients aged 12 years and older enrolled in the participating primary health care centers. DISCUSSION: Despite our relatively low response rates, we trust that, because of the longitudinal character of the study and the high absolute number of participants, our database contains a valuable set of information.SMILE is a longitudinal cohort with a long follow-up period (15 years). The long follow-up and the unique combination of the two data collection strategies will enable us to disentangle causal relationships. Furthermore, patient-reported characteristics can be related to self-reported health, as well as to more validated physician registered morbidity. Finally, this population can be used as a sampling frame for intervention studies. Sampling can either be based on the presence of certain diseases, or on specific lifestyles or other patient characteristics.

Leisure time physical activity and sickness absenteeism; a prospective study.

AIM: To establish whether workers with frequent leisure time physical activities are at higher or lower risk of sickness absence compared to inactive workers. METHOD: Self reported and company recorded sickness absence data were collected during 18 months of follow-up for 8902 workers. Frequency of leisure time physical activities was queried at baseline. RESULTS: Overall, we found that workers active in their leisure time twice or more each week reported significantly less sickness absence compared to inactive workers (14.8 versus 19.5 days/year), mainly due to a decrease in sick leave because of musculoskeletal disorders. CONCLUSION: Demotivating sports participation by making workers liable for workdays lost due to sporting injuries might be counter-productive in decreasing absenteeism and its related costs. Promoting worker participation in sport might lead to reduced absenteeism.

The effects of 6 months of increased water intake on blood sodium, glomerular filtration rate, blood pressure, and quality of life in elderly (aged 55-75) men.

OBJECTIVES: To study whether there are any negative or positive effects of 6 months of increased fluid intake in reasonably healthy elderly men. DESIGN: Randomized trial. SETTING: Community-based. PARTICIPANTS: One hundred forty-one healthy participants aged 55 to 75. INTERVENTION: One group was given the advice to increase their daily fluid intake by 1.5 L of water; the other group was given placebo medication (8 mL inactive syrup per day). MEASUREMENTS: At 6 months blood sodium, glomerular filtration rate (GFR), blood pressure, and quality of life (QOL) were measured. The changes in water turnover were measured using deuterium. RESULTS: Most subjects did not manage to increase their fluid intake by 1.5 L. The average increase in the intervention group was approximately 1 L. Twenty-four-hour water turnover in the water group was 359 mL (95% confidence interval=171-548) higher than that of the control group at 6-month follow-up. Blood pressure, sodium level, GFR, and QOL did not change significantly in either group during the intervention period. In addition, the cases reporting a worsening on the effect measures were equally distributed over the two study groups. CONCLUSION: The advice to increase fluid intake by 1.5 L had no negative effects in reasonably healthy men aged 55 to 75.

Predictive factors for nocturia in elderly men: a cross-sectional study in 21 general practices.

OBJECTIVE: To measure the prevalence of nocturia in general practice and to determine which factors are associated with nocturia. SUBJECTS AND METHODS: Data were collected from 3048 elderly men, who completed a questionnaire that was sent to every man aged 55-75 years in 21 general practices in Maastricht (the Netherlands). The symptom of nocturia was defined as two or more nocturnal voids. We investigated the prevalence of nocturia and the predictive relationships with the following factors: cerebrovascular disease, diabetes mellitus/insipidus (DMI), Parkinson's diseases, cardiovascular disease, hypertension, bladder/prostate cancer, kidney diseases, urinary bladder inflammation, congenital diseases (kidneys or prostate), using medical treatment for lower urinary tract symptoms, other treatment, psychological depression, symptoms suggestive of benign prostatic hyperplasia (BPH), and alcohol intake. RESULTS: Data from 2934 respondents were analysed; the prevalence of nocturia (two or more nocturnal voids) was 32.9% (965 men). The frequency of the number of nocturnal voids was: zero in 588 (20.0%), one in 1344 (45.8%), two in 611 (20.8%), three in 208 (7.1%), four in 70 (2.4%), and five or more in 76 (2.6%), with 37 values missing. A multivariate logistic regression analysis showed that nocturia in elderly men was significantly related to bladder/prostate cancer, cerebrovascular disease, treatment of voiding disorders, and moderate alcohol consumption. Next to these, BPH had a significant relationship with nocturia, especially in respondents with DMI and hypertension. Cardiovascular disease or hypertension was significantly related to nocturia, mutually replacing each other as a risk factor. CONCLUSION: Nocturia in elderly men is be related to many sources of potential risk factors: earlier urological diseases, cardiovascular and cerebrovascular diseases, BPH, DMI and behavioural habits. Some of these sources may interact and generate especially high risk in some groups for nocturia.

Short-term effects of increased urine output on male bladder function and lower urinary tract symptoms.

OBJECTIVES: To determine whether the human bladder can also adapt to an increased physiologic load, because bladder dysfunction is considered to be an important factor in the development of lower urinary tract symptoms. Animal studies have shown that bladder function can be improved by increasing the urine output. METHODS: A total of 44 men between 55 and 75 years of age were asked to increase their daily fluid intake by 2 L for a 2-month period. The objective outcome measures were maximal urinary flow rate (Da Capo home uroflowmeter), maximal voided volume (frequency-volume chart), and average voided volume (frequency-volume chart). The International Prostate Symptom Score and global perceived benefit of the intervention were recorded to assess the subjective effects of the intervention. RESULTS: The maximal flow rate increased by 13% (2.3 mL/s), the maximal voided volume increased by 23% (93.8 mL), and average voided volume increased by 25% (60.1 mL). Of the 44 participants, 56% reported an improvement in their lower urinary tract function, but the International Prostate Symptom Score increase was statistically significant at 1.2 point. CONCLUSIONS: The human bladder seems able to adapt to an increased load. Future randomized effectiveness studies with longer follow-up should be done to determine the upper limit of objective bladder adaptation. In addition, future studies should address the long-term efficacy in the prevention of symptoms.