Primary care professionals' views on population-based expanded carrier screening: an online focus group study.

BACKGROUND: Population-based expanded carrier screening (ECS) involves screening for multiple recessive diseases offered to all couples considering a pregnancy or during pregnancy. Previous research indicates that in some countries primary care professionals are perceived as suitable providers for ECS. However, little is known about their perspectives. We therefore aimed to explore primary care professionals' views on population-based ECS. METHODS: Four online focus groups with 14 general practitioners (GPs) and 16 community midwives were conducted in the Netherlands. RESULTS: Our findings highlight various perspectives on the desirability of population-based ECS. Participants agreed that ECS could enhance reproductive autonomy and thereby prevent suffering of the child and/or parents. However, they also raised several ethical, societal, and psychological concerns, including a tendency towards a perfect society, stigmatization, unequal access to screening and negative psychosocial consequences. Participants believed that provision of population-based ECS would be feasible if prerequisites regarding training and reimbursement for providers would be fulfilled. most GPs considered themselves less suitable or capable of providing ECS, in contrast to midwives who did consider themselves suitable. Nevertheless, participants believed that, if implemented, ECS should be offered in primary care or by public health services rather than as hospital-based specialized care, because they believed a primary care ECS offer increases access in terms of time and location. CONCLUSIONS: While participants believed that an ECS offer would be feasible, they questioned its desirability and priority. Studies on the desirability and feasibility of population-based ECS offered in primary care or public health settings are needed.

Identifying and prioritizing do-not-do recommendations in Dutch primary care.

BACKGROUND: Low-value care provides minimal or no benefit for the patient, wastes resources, and can cause harm. Explicit do-not-do recommendations in clinical guidelines are a first step in reducing low-value care. The aim of this study was to identify and prioritize do-not-do recommendations in general practice guidelines with priority for implementation. METHODS: We used a mixed method design in Dutch primary care. First, we identified do-not-do recommendations through a systematic assessment of 92 Dutch guidelines for general practitioners (GPs), resulting in 385 do-not-do recommendations. Second, we selected 146 recommendations addressing high prevalent conditions. Third, a random sample of 5000 Dutch GPs was invited for an online survey to prioritize recommendations based on the prevalence of the condition and low-value care practice, potential harm, and potential cost reduction on a scale from 1 to 5/6. Total scores could range from 4 to 22. Recommendations with a median score > 12 were included. In total, 440 GPs completed the survey. RESULTS: The selection process led to 30 prioritised recommendations. These covered drug treatments (n = 12), diagnostics (n = 10), referral to other healthcare professions (n = 5), and non-drug treatment (n = 3). CONCLUSION: Dutch clinical guidelines include many do-not-do recommendations that are perceived as highly relevant by the GPs. The list of 30 high-priority do-not-do recommendations can be used to raise awareness of low-value care among GPs. As the recommendations are supported with the latest evidence from international studies, primary healthcare professionals and policy makers worldwide can use the list for further validating the list in their local context and designing strategies to reduce low-value care.

Low-value pharmaceutical care among Dutch GPs: a retrospective cohort study.

BACKGROUND: Low-value pharmaceutical care exists in general practice. However, the extent among Dutch GPs remains unknown. AIM: To assess the prevalence of low-value pharmaceutical care among Dutch GPs. DESIGN AND SETTING: Retrospective cohort study using data from patient records. METHOD: The prevalence of three types of pharmaceutical care prescribed by GPs between 2016 and 2019 were examined: topical antibiotics for conjunctivitis, benzodiazepines for non-specific lower back pain, and chronic acid-reducing medication (ARM) prescriptions. Multilevel logistic regression analysis was performed to assess prescribing variation and the influence of patient characteristics on receiving a low-value prescription. RESULTS: Large variation in prevalence as well as practice variation was observed among the types of low-value pharmaceutical GP care examined. Between 53% and 61% of patients received an inappropriate antibiotics prescription for conjunctivitis, around 3% of patients with lower back pain received an inappropriate benzodiazepine prescription, and 88% received an inappropriate chronic ARM prescription during the years examined. The odds of receiving an inappropriate antibiotic or benzodiazepine prescription increased with age (P<0.001), but decreased for chronic inappropriate ARM prescriptions (P<0.001). Sex affected only the odds of receiving a non-indicated chronic ARM, with males being at higher risk (P<0.001). The odds of receiving an inappropriate ARM increased with increasing neighbourhood socioeconomic status (P<0.05). Increasing practice size decreased the odds of inappropriate antibiotic and benzodiazepine prescriptions (P<0.001). CONCLUSION: The results show that the prevalence of low-value pharmaceutical GP care varies among these three clinical problems. Significant variation in inappropriate prescribing exists between different types of pharmaceutical care - and GP practices.

[Change takes time and energy. The law of inertia also applies to medicine]. / Veranderen kost tijd en energie.

The first guidelines of the Dutch College of General Practitioners aimed at the abolishment of unnecessary medical treatment. These guidelines were rather successful. In retrospect, one may get the impression that the intended changes happened by themselves. However, when the pill controls were abolished, it was important to get the patient along. When moving diabetes care and assessing and treating ankle sprains to primary care, GPs had to train themselves in glucose control and become familiar with the assessment and taping of sprained ankles. The changes therefore took several years and were facilitated by the creation of new remuneration schemes. The law of inertia also applies to medical treatment.

[Important alteration of the Dutch treatment algorithm in patients with type 2 diabetes mellitus]. / Belangrijke wijziging van behandelrichtlijn 'Diabetes mellitus type 2'.

Recent trials of two classes of glucose-lowering drugs (SGLT2 inhibitors and GLP1RAs) have shown consistent cardiovascular and renal benefits that appear independent of glycaemic control. These results have prompted the Dutch College of General Practitioners (NHG) together with the Dutch Society of Internal Medicine (NIV) to update the treatment algorithm in patients with type 2 diabetes mellitus (T2D) at very high CVD risk. The use of SGLT2 inhibitors or GLP1RAs is now recommended in 3 groups of people with T2D. 1. patients with established CVD; 2. Patients with chronic kidney disease and a moderately to high CVD risk according to KDIGO; 3. patients with heart failure with reduced ejection fraction (HFrEF). Treatment algorithms differ for drug-naïve and drug-treated patients with T2D. In both drug-naïve and drug-treated patients the use of a SGLT2 inhibitor respectively as monotherapy or add-on is recommended as first step. If HbA1c is above the individual target, metformin will be added in drug-naive patients whereas GLP1-RAs could be considered in drug-treated patients. GLP1-RAs should also be considered when SGLT2-inhibitors are contraindicated.

Identifying and de-implementing low-value care in primary care: the GP's perspective-a cross-sectional survey.

OBJECTIVE: General practitioners have an important role in reducing low-value care as gatekeepers of the health system. The aim of this study was to assess the experiences of Dutch general practitioners regarding low-value care and to identify their needs to decrease low-value primary care. DESIGN: We performed a cross-sectional study. PARTICIPANTS: We sent a survey to 500 general practitioners. SETTING: Primary care in the Netherlands. PRIMARY AND SECONDARY OUTCOMES: The survey contained questions about the provision of low-value care and on clinical cases about lumbosacral spine X-rays in patients with low back pain and vitamin B12 laboratory tests without an evidence-based indication. We also asked general practitioners what they needed to reduce low-value care. RESULTS: A total of 182 general practitioners (37%) responded. 67% indicated that low-value care practices are regularly provided in general practice. 57% of the general practitioners have seen negative consequences of low-value care, in particular side effects of medication. The most provided low-value care practices are medication prescriptions such as antibiotics and laboratory tests such as vitamin B12 tests. The most reported drivers are patient-related. General practitioners want to maintain a good relationship with their patients by offering their patients an intervention instead of watchful waiting. Lack of time also plays a major role. In order to reduce low-value care, general practitioners suggested that educating patients on the value of tests and treatments might help. Supporting general practitioners and other healthcare professionals with clear guidelines as well as having more time for consultation were also mentioned by general practitioners. CONCLUSION: General practitioners are aware of providing unnecessary care despite their role as gatekeepers and have reasons for this. They need support in order to change their practice. This support might consist of better education of healthcare professionals and providing more time for consultation. Local and national media, such as websites and television, could be used to educate patients while guidelines could support professionals in reducing low-value care.

[Application of new glucose lowering drugs: DPP-4 inhibitors, GLP-1 receptor agonists and SGLT-2 inhibitors]. / Toepassing van nieuwe bloedglucoseverlagende middelen.

A comprehensive review of the literature on DPP-4 inhibitors, GLP-1 receptor agonists and SGLT-2 inhibitors has resulted in small changes to the medication roadmap of the type 2 diabetes mellitus standard of the Dutch College of General Practitioners. SGLT-2 inhibitors and GLP-1 receptor agonists may have benefits related to cardiovascular outcomes in patients with high cardiovascular risk, especially in those who have experienced a cardiovascular event. However, ascribing effectiveness related to cardiovascular outcomes on the basis of a single cardiovascular safety trial is premature. Metformin, sulfonylurea derivatives and insulin are still the cornerstone of type 2 diabetes mellitus treatment in primary care.

[120 mmHg for everyone?]. / Iedereen naar 120 mmHg?

The recently published Systolic Blood Pressure Intervention Trial (SPRINT) casts new light on the issue of lowering blood pressure to 120 mmHg. The trial randomized 9161 patients with systolic blood pressures of 130 mmHg - 180 mmHg and increased cardiovascular risk into a group receiving intensive treatment (target 120 mmHg) and a group given standard treatment (target 140 mmHg). The trial was stopped earlier than foreseen because interim analysis showed a lower incidence rate of myocardial infarction, stroke, heart failure and death from cardiovascular causes in the group given intensive treatment (1.65 versus 2.19 per year, hazard ratio 0.75; 95% CI 0.64-0.89; p < 0.001). These results open up the possibility of aiming for lower blood pressure targets in antihypertensive treatment. It is questionable whether this strategy would be preferred by every patient. New guidelines on cardiovascular risk management should pay more attention to shared decision-making where doctors inform patients about the benefits and risks of strict or less strict blood pressure control and patients choose personal targets.

[The revised Dutch College of General Practitioners (NHG) practice guideline on 'Visual symptoms']. / De NHG-standaard 'Visusklachten' herzien.

The 2001 NHG practice guideline on 'Refraction disorders' was revised for the second time in October 2015. The title has been changed to 'Visual symptoms', since besides refraction disorders other conditions such as glaucoma, macular degeneration, cataract and acute eye symptoms are also covered. The ophthalmologist is the specialist to whom GPs refer patients most often. Apart from the GP, ophthalmologist and youth health care physician, various other allied health professions are involved in eye healthcare. Orthoptist and optometrist are registered allied health professions; the title 'optician' is however not registered - on the so-called BIG-register - with the Dutch Ministry of Health, Welfare and Sport. The NHG practice guideline particularly focuses on ophthalmological diagnostics with limited equipment, and on specific referrals to ophthalmology and allied health professions.

[The Dutch College of General Practitioners practice guideline on 'Sexual problems']. / NHG-standaard 'Seksuele klachten'.

The Dutch College of General Practitioners practice guideline on 'Sexual problems' describes the diagnostics and management of common sexual problems. An adequate sexual anamnesis is essential in order to obtain a good picture of the patient's symptoms and of any underlying causes. Additional physical or other medical examination is of limited value. The provision of information and advice are central to the treatment of sexual problems. Attention should be paid to the different aspects of sexual functioning: physical, psychological, relational and sociocultural, and to gender differences. In many cases, management is determined by the causal factor, for instance comorbidity, sexual trauma or relational problems. In other cases, a more specific problem is diagnosed, and management is based on this.

[NHG guideline 'Deep-vein thrombosis and pulmonary embolus']. / NHG-standaard 'Diepe veneuze trombose en longembolie'.

The revised Dutch College of General Practitioners (Nederlands Huisartsen Genootschap [NHG]) guideline 'Deep-vein thrombosis and pulmonary embolus' includes recommendations for the treatment of patients with deep-vein thrombosis (DVT) and thrombophlebitis, and for the exclusion of pulmonary embolism (PE). The general practitioner (GP) can exclude the presence of DVT or PE in some patients by using a decision rule and a D-dimer test. When using D-dimer test as a point-of-care test, meticulous care is essential during the test procedure and storage of blood. The GP can treat many patients with DVT; the NHG guideline does not advise use of direct oral anticoagulants. In the case of an isolated DVT in the calf, treatment with anticoagulants or ultrasound follow-up can be chosen in consultation with the patient or on the basis of regional agreements. In the case of patients with superficial thrombophlebitis, a wait-and-see approach is usually sufficient.

[Summary of the Dutch College of General Practitioners' (NHG) practice guideline 'ADHD in children']. / Samenvatting van de NHG-standaard 'ADHD bij kinderen'.

The diagnosis of ADHD may be considered if a child is hyperactive, impulsive or inattentive, and if this behaviour results in evidently impaired functioning in multiple settings. Children with behavioural problems and slightly impaired functioning may benefit from patient information, education and parenting advice. From the age of 6 years, children can be offered diagnostic testing and professional support within the primary care setting, provided sufficient knowledge and expertise is available and there is collaboration with other health care providers. Management of a child with ADHD but no comorbid psychiatric disorder, consists of a step-by-step plan including education, parent and teacher guidance and, optionally, behavioural therapy for the child. In consultation with parents, child and other therapists, methylphenidate can be prescribed if behavioural interventions are not sufficiently effective. Children taking medication for ADHD should be monitored periodically, including assessment of the effectiveness and side effects.

[Practice guideline 'Delirium' from the Dutch College of General Practitioners]. / NHG-standaard 'Delier'.

The revised practice guideline 'Delirium' of the Dutch College of General Practitioners (NHG) provides recommendations about the prevention, early detection, diagnosis and treatment of delirium in elderly patients in general practice. The guideline now also offers tools for the treatment of delirium in terminally-ill patients. A patient with delirium can only be cared for at home if a safe environment and the continuous presence of carers can be guaranteed. This requires close cooperation between the care services and the home carers involved and good coordination with the general practice health centre. The discharge from hospital of patients with persistent symptoms of delirium to their homes requires optimal transfer from the specialist/nursing staff to the general practitioner and home carers involved. The NHG guideline therefore pays considerable attention to collaboration and transfer in the care of patients with delirium. The revised version of this guideline was developed in close collaboration with the revision of the multidisciplinary guideline on delirium produced by the Dutch Order of Medical Specialists.

A patient-centered network approach to multidisciplinary-guideline development: a process evaluation.

BACKGROUND: Guideline development and uptake are still suboptimal; they focus on clinical aspects of diseases rather than on improving the integration of care. We used a patient-centered network approach to develop five harmonized guidelines (one multidisciplinary and four monodisciplinary) around clinical pathways in fertility care. We assessed the feasibility of this approach with a detailed process evaluation of the guideline development, professionals' experiences, and time invested. METHODS: The network structure comprised the centrally located patients and the steering committee; a multidisciplinary guideline development group (gynecologists, physicians, urologists, clinical embryologists, clinical chemists, a medical psychologist, an occupational physician, and two patient representatives); and four monodisciplinary guideline development groups. The guideline development addressed patient-centered, organizational, and medical-technical key questions derived from interviews with patients and professionals. These questions were elaborated and distributed among the groups. We evaluated the project performance, participants' perceptions of the approach, and the time needed, including time for analysis of secondary sources, interviews with eight key figures, and a written questionnaire survey among 35 participants. RESULTS: Within 20 months, this approach helped us develop a multidisciplinary guideline for treating infertility and four related monodisciplinary guidelines for general infertility, unexplained infertility, male infertility, and semen analysis. The multidisciplinary guideline included recommendations for the main medical-technical matters and for organizational and patient-centered issues in clinical care pathways. The project was carried out as planned except for minor modifications and three extra consensus meetings. The participants were enthusiastic about the approach, the respect for autonomy, the project coordinator's role, and patient involvement. Suggestions for improvement included timely communication about guideline formats, the timeline, participants' responsibilities, and employing a librarian and more support staff. The 35 participants spent 4497 hours in total on this project. CONCLUSIONS: The novel patient-centered network approach is feasible for simultaneously and collaboratively developing a harmonized set of multidisciplinary and monodisciplinary guidelines around clinical care pathways for patients with fertility problems. Further research is needed to compare the efficacy of this approach with more traditional approaches.

The use of tetanus post-exposure prophylaxis guidelines by general practitioners and emergency departments in the Netherlands: a cross-sectional questionnaire study.

BACKGROUND: The Dutch National Immunisation Programme includes six tetanus toxoid (TT) vaccinations and reaches a high rate of vaccination coverage. In the Netherlands, several guidelines related to tetanus post-exposure prophylaxis (T-PEP) are in place. In 2003, the Dutch Health Council (HC) reviewed the use of T-PEP. The aim of this study is to evaluate whether the HC recommendations have been implemented. METHODS: We asked 178 Dutch General Practitioner (GP) offices and 60 Emergency Departments (EDs) to participate in a cross-sectional questionnaire study and requested that participating facilities send in the T-PEP guidelines adopted by their practice. The differences, based on categories mentioned in the HC recommendations, between GPs and EDs and the type of T-PEP guidelines adopted were assessed. RESULTS: The response rates for the GPs and EDs were 38% (n=67) and 70% (n=42), respectively. 98% percent (n=107) of the participants reported having T-PEP guidelines. Of the guidelines described in the survey responses, 28% (n=23; EDs 41%, GPs 21%) were consistent with the HC-recommendations, 36% (n=29; EDs 7%, GPs 52%) adhered to the guidelines of the College of GPs (CGP), which restricts the use of T-PEP to tetanus prone wounds but for these wounds is in line with the recommendations of the HC. The remaining 36% had adopted other guidelines, most of which can lead to over-prescription of T-PEP. Information on T-PEP was lacking in patients with higher risk vaccination histories. CONCLUSION: Almost all participants have adopted T-PEP guidelines. Strict adherence to the HC recommendations is low. More than half of GPs have adopted the more restrictive CGP-guideline, which limits T-PEP to tetanus prone wounds.

[Summary of the 'Stroke' guideline of the Dutch College of General Practitioners' (NHG)]. / Samenvatting van de NHG-standaard 'Beroerte'.

The Dutch College of General Practitioners (NHG) guideline 'Stroke' covers the diagnosis, management and long-term care of stroke in general practice. Patients with neurological symptoms suspected to be due to cerebral infarction or haemorrhage should be transferred directly to a stroke unit. The specialized care provided by these units, including emergency interventions (e.g. intravenous thrombolysis) and early mobilization help improve outcomes. If neurological symptoms have resolved completely, the patient should be referred to a TIA service as soon as possible, preferably within 1 day. Stroke often leads to permanent disability and neuropsychological impairments. The general practitioner (GP) should provide patients and caregivers with information and support, and should be alert to the psychological consequences of stroke, both in patients and caregivers. Secondary prevention measures are started as soon as the diagnosis of stroke is confirmed. GPs should regularly evaluate and monitor risk factors and compliance.

[The ICD in the terminal stage]. / De ICD in de terminale fase.

ICDs are used to prevent sudden death caused by ventricular fibrillation. The number of patients with an ICD will keep growing. ICD shocks can severely disturb the dying process in terminally ill patients. Patients must be informed about this at the time of ICD implantation. The attending physician is responsible for proactive communication regarding deactivation when death is expected imminently. The decision to deactivate the ICD depends on personal wishes, and has proved to be difficult even if the patient has been well informed. Deactivation at home must be available so that severely ill patients do not need to travel to a hospital.

[Revised Dutch College of General Practitioners' practice guideline 'Acute coronary syndrome']. / Herziene NHG-standaard 'Acuut coronair syndroom'.

The practice guideline 'Acute coronary syndrome' gives the general practitioner (GP) guidance on the diagnosis, treatment and long-term management of adults with (experienced) acute coronary syndrome (ACS). Not every patient with ACS presents with chest pain as the main symptom. The GP should evaluate every sign and symptom that may indicate ACS in the same way in both men and women. In patients with ACS the GP should immediately call an ambulance and the patient should be given oral salicylic acid 160-320 mg. If there is chest pain, sublingual nitroglycerine spray is indicated, if necessary followed by intravenous morphine or fentanyl. A normal ECG does not exclude ACS. Patients who have had symptoms indicative of ACS for less than 12 hours, and whose ECG shows abnormalities consistent with myocardial infarction with ST elevation should be referred to a cardiological intervention centre for percutaneous coronary intervention without delay whatever age they are. Patients who have symptoms indicative of ACS but who do not fulfil the above criteria may be given an emergency referral to a general hospital.

[Summary of Dutch College of General Practitioners' (NHG) practice guideline 'Dementia']. / Samenvatting van de NHG-standaard 'Dementie'.

Dementia is a clinical diagnosis which a general practitioner can either make him/herself or by specific referral. If no abnormalities are found on further clinical investigations by the GP, the risk of missing a treatable cause of dementia is very small; therefore routine imaging examinations are not necessary. GPs are not recommended to prescribe cholinesterase inhibitors or memantine. The implementation of various psycho-social interventions has a positive effect on patients and their home carers and can postpone admission to a nursing home. Dementia care requires working agreements and collaboration amongst local care providers.

[Summary of the multidisciplinary guideline on cardiovascular risk management (revision 2011)]. / Samenvatting van de multidisciplinaire richtlijn 'Cardiovasculair risicomanagement' (herziening 2011).

The decision whether to treat individuals not previously known to have cardiovascular disease is based on a new risk table in which Dutch research data on morbidity have been incorporated. An explanation of the roles of additional risk factors ignored in the cardiovascular risk function, such as a sedentary lifestyle and a high BMI, is provided. A method for estimating the cardiovascular risk in patients with diabetes mellitus and rheumatoid arthritis has been developed. New recommendations concerning the measurement of blood pressure at home and in the ambulatory setting have been formulated. The recommendations for the choice of antihypertensive drugs have been revised. The recommendations on handling therapy-resistant hypertension are provided. Recommendations for choosing statins based on a current cost-effectiveness analysis are provided.