Effect of faecal calprotectin testing on referrals for children with chronic gastrointestinal symptoms in primary care:study protocol for a cluster randomised controlled trial

Introduction Children with chronic gastrointestinal symptoms are frequently seen in primary care, yet general practitioners (GPs) often experience challenges distinguishing functional gastrointestinal disorders (FGID) from organic disorders. We, therefore, aim to evaluate whether a test strategy that includes point-of-care testing (POCT) for faecal calprotectin (FCal) can reduce the referral rate to paediatric specialist care among children with chronic gastrointestinal symptoms. The study findings will contribute to improving the recommendations on FCal use among children in primary care.Methods and analysis In this pragmatic cluster randomised controlled trial, we will randomise general practices into intervention and control groups. The intervention group will use FCal-POCT when indicated, after completing online training about its indication, interpretation and follow-up as well as communicating an FGID diagnosis. The control group will test and treat according to Dutch GP guidelines, which advise against FCal testing in children. GPs will include children aged 4–18 years presenting to primary care with chronic diarrhoea and/or recurrent abdominal pain. The primary outcome will be the referral rate for children with chronic gastrointestinal symptoms within 6 months after the initial assessment. Secondary outcomes will be evaluated by questionnaires completed at baseline and at 3- and 6-month follow-up. These outcomes will include parental satisfaction and concerns, gastrointestinal symptoms, impact of symptoms on daily function, quality of life, proportion of children with paediatrician-diagnosed FGID referred to secondary care, health service use and healthcare costs. A sample size calculation indicates that we need to recruit 158 GP practices to recruit 406 children.Ethics and dissemination The Medical Research Ethics Committee (MREC) of the University Medical Center Groningen (The Netherlands) approved this study (MREC number: 201900309). The study results will be made available to patients, GPs, paediatricians and laboratories via peer-reviewed publications and in presentations at (inter)national conferences.Trial registration number The Netherlands Trial Register: NL7690 (Pre-results

Management of children with non-acute abdominal pain and diarrhea in Dutch primary care:a retrospective cohort study based on a routine primary care database (AHON)

Objective: To describe the testing, prescription, referral, and follow-up management by general practitioners (GPs) for children presenting with non-acute abdominal pain and/or diarrhea in primary care. Design: Retrospective cohort study with one-year follow-up. Setting: Registry data from a Dutch primary care database (AHON) between 2015 and 2019. Subjects: Children aged 4–18 years old who presented by face-to-face consultation in primary care for non-acute abdominal pain and/or diarrhea (&gt;7 days). Main outcome measures: We recorded the proportions of children who received (1) diagnostic testing, medicine prescriptions, follow-up consultations, and referrals at their first visit and (2) repeat consultations and referrals by one-year of follow-up. Results: Among the 2200 children (median age, 10.5 years; interquartile range, 7.0–14.6) presenting to a GP with non-acute abdominal pain and/or diarrhea, most reported abdominal pain (78.7%). At the first visit, GPs performed diagnostic testing for 32.2%, provided a prescription to 34.5%, and referred 2.5% to secondary care. Twenty-five percent of the children had a follow-up consultation within four weeks and 20.8% had a repeat consultation between four weeks and one year. Thirteen percent of the children were referred to secondary care by one year. However, only 1% of all children had documentation of an organic diagnosis needing management in secondary care. Conclusion: One-third of children received diagnostic testing or a medicine prescription. Few had a follow-up consultation and &gt;10% was referred to pediatric care. Future research should explore the motivations of GPs why and which children receive diagnostic and medical interventions.</p

Management of children with non-acute abdominal pain and diarrhea in Dutch primary care:a retrospective cohort study based on a routine primary care database (AHON)

Objective: To describe the testing, prescription, referral, and follow-up management by general practitioners (GPs) for children presenting with non-acute abdominal pain and/or diarrhea in primary care. Design: Retrospective cohort study with one-year follow-up. Setting: Registry data from a Dutch primary care database (AHON) between 2015 and 2019. Subjects: Children aged 4–18 years old who presented by face-to-face consultation in primary care for non-acute abdominal pain and/or diarrhea (&gt;7 days). Main outcome measures: We recorded the proportions of children who received (1) diagnostic testing, medicine prescriptions, follow-up consultations, and referrals at their first visit and (2) repeat consultations and referrals by one-year of follow-up. Results: Among the 2200 children (median age, 10.5 years; interquartile range, 7.0–14.6) presenting to a GP with non-acute abdominal pain and/or diarrhea, most reported abdominal pain (78.7%). At the first visit, GPs performed diagnostic testing for 32.2%, provided a prescription to 34.5%, and referred 2.5% to secondary care. Twenty-five percent of the children had a follow-up consultation within four weeks and 20.8% had a repeat consultation between four weeks and one year. Thirteen percent of the children were referred to secondary care by one year. However, only 1% of all children had documentation of an organic diagnosis needing management in secondary care. Conclusion: One-third of children received diagnostic testing or a medicine prescription. Few had a follow-up consultation and &gt;10% was referred to pediatric care. Future research should explore the motivations of GPs why and which children receive diagnostic and medical interventions.</p

Qualitative study evaluating the expectations and experiences of Dutch parents of children with chronic gastrointestinal symptoms visiting their general practitioner

Objectives Chronic gastrointestinal symptoms are common among children and affect their daily activities and quality of life. The majority will be diagnosed with a functional gastrointestinal disorder. Effective reassurance and education are, therefore, key components of the physician’s management. Qualitative studies have shown how parents and children experience specialist paediatric care, yet less is known about general practitioners (GPs), who manage most cases in the Netherlands and have a more personal and enduring relationship with their patients. Therefore, this study evaluates the expectations and experiences of parents of children visiting a GP for chronic gastrointestinal symptoms.Design We conducted a qualitative interview study. Online interviews were audio and video recorded, transcribed verbatim and independently analysed by the first two authors. Data were collected and analysed concurrently until data saturation was reached. Using thematic analysis, we developed a conceptual framework reflecting respondent expectations and experiences. We performed a member check of the interview synopsis and the conceptual framework.Setting Dutch primary care.Participants We purposively sampled participants from a randomised controlled trial evaluating the effectiveness of faecal calprotectin testing in children with chronic gastrointestinal complaints in primary care. Thirteen parents and two children participated.Results Three key themes emerged: disease burden, GP–patient relationship and reassurance. Often, the experienced disease burden and the pre-existing GP–patient relationship influenced expectations (eg, for further investigations or a sympathetic ear), and when a GP fulfilled these expectations, a trusting GP–patient relationship ensued that facilitated reassurance. We found that individual needs influenced these themes and their interrelationships.Conclusion Insights provided by this framework could help GPs managing children with chronic gastrointestinal symptoms in daily practice and may therewith improve the consultation experience for parents. Further research should evaluate whether this framework also holds true for children.Trial registration number NL7690

Accuracy of Brain Natriuretic Peptide for Diagnosing Pulmonary Hypertension in Severe Bronchopulmonary Dysplasia

BACKGROUND: Premature infants with severe bronchopulmonary dysplasia (sBPD) are at risk of pulmonary hypertension (PH). Serum brain natriuretic peptide (BNP) is used to predict disease severity in adult PH. Its diagnostic utility in sBPD-associated PH is unknown. OBJECTIVE: The aim of this paper was to determine the accuracy of BNP, against echocardiogram (echo), to diagnose PH in infants born ½ systemic blood pressure estimated from tricuspid regurgitant jet or patent ductus arteriosus (PDA) velocity, bidirectional or right-to left-PDA, and/or flat/bowing ventricular septum at end-systole. Receiver-operating characteristic (ROC) curves were constructed to test the diagnostic accuracy of BNP. RESULTS: Of 128 infants, 68 (53%) had echo evidence of PH. BNP was higher among the infants with PH (median [interquartile range]: 127 pg/mL [39-290] vs. 35 [20-76], p < 0.001). The area under the ROC curve for diagnosing PH using BNP was 0.74 (95% CI 0.66-0.83). At an optimal cutpoint of 130 pg/mL, BNP correctly classified the presence or absence of PH in 70% of the infants (specificity: 92, sensitivity: 50%). CONCLUSIONS: BNP, relative to concurrent echo, demonstrated moderate accuracy for diagnosing PH in this cohort of preterm infants with sBPD. BNP may help rule in PH in this population but has low utility to rule out the disease