Adequate use of asthma inhalation medication in children: more involvement of the parents seems useful

Background. Asthma and other chronic airway diseases can be effectively treated by inhaler therapy. Inhaler therapy depends on appropriate use of the inhaler. This study evaluates the knowledge among Dutch children and their parents regarding asthma inhaler therapy and appropriateness of its use. Findings. Five general practices selected all children aged 0 to 12 years on asthma inhalation medication. Children demonstrated inhaler use and were interviewed with their parents. 46 subjects were enrolled; mean age 5.5 years (SD 3.4) years; 26 (57%) were boys. Of the children using one inhaler only, 70% used the inhaler as indicated and of those using more than one inhaler 46%. On average 2.6 mistakes were made during demonstration of the technique, and 2 mistakes were reported in the interview. In total, 87% of the parents decided when and how the inhaler had to be used. Spacer cleaning was performed correctly by 49%; 26% reported a correct way of assessing how many doses were remaining. Conclusion. Dutch children make essential mistakes related to inhaler use that are easy to avoid. We recommend a better explanation and demonstration of the technique, and recommend involvement of the parents during instruction

Abnormal vaginal bleeding in women of reproductive age: a descriptive study of initial management in general practice

<p>Abstract</p> <p>Background</p> <p>Abnormal vaginal bleeding (AVB) in women of reproductive age is a common reason for consulting a general practitioner. Nevertheless, how general practitioners (GPs) choose to initially manage AVB is largely unknown, as is the prevalence of underlying pathology of AVB in primary care.</p> <p>Methods</p> <p>To investigate the initial diagnostic procedures and treatment for AVB used in general practice, we performed a descriptive study based on computerised medical records. New consultations for AVB in 2000 and 2001 were selected. Patient characteristics, diagnostic procedures and treatment were analysed.</p> <p>Results</p> <p>In total, 270 new consultations were included. The majority of patients (75%) consulted the GP for AVB only once. GPs performed diagnostic procedures in 54% of all consultations. Overall, additional diagnostic procedures revealed abnormalities in 11% of women. However, the diagnostic procedures implemented by the GPs varied widely per bleeding type and contraceptive use. Anaemia was found in 36% of 45 women tested. Uterine fibroids were found in 41% of 27 women examined by ultrasound. Medication was prescribed in 34% of all consultations. A gynaecological referral was registered in 4% of all contacts.</p> <p>Conclusion</p> <p>Initially, GPs tend to follow a policy of expectant management in women of reproductive age with AVB. However, when additional diagnostic procedures were performed, anaemia and uterine fibroids were found in a considerable number of women.</p

E-health intervention for preventing recurrent ankle sprains:a randomised controlled trial in general practice

BACKGROUND: Ankle sprains are frequent injuries in general practice. However, no effective treatment is available yet. AIM: resultTo examine the effectiveness of an unsupervised e-health-supported neuromuscular training programme in combination with usual care compared with usual care alone in patients with acute lateral ankle sprains in general practice. DESIGN AND SETTING: Randomised controlled trial with 1-year follow-up among patients (14-65 years) who visited the GP with an acute lateral ankle sprain within 3 weeks of injury. METHOD: The intervention group received, in addition to usual care, an unsupervised e-health-supported neuromuscular training programme and the control group received usual care alone. The primary outcome was self-reported re-sprains during 52 weeks of follow-up. Secondary outcomes were ankle function, pain in rest and during activity, subjective recovery, and return to the same type and level of sport. RESULTS: In total, 165 participants (mean age 38.3 years and 69 [41.8%] male) were included. No statistically significant difference in the occurrence of a re-sprain were found between the intervention 20.7% (17/82) and control group 24.1% (20/83) (hazard ratio 1.14, 95% confidence interval = 0.59 to 2.21). Also, no statistically significant differences in secondary outcomes were found between groups. The adherence rate to the programme was low (6.1%, 5/82). CONCLUSION: The rate of re-sprains was relatively high and an unsupervised e-health-supported neuromuscular training programme does not yield meaningful effects and does not encourage adherence in preventing re-sprains in patients in general practice. More research is necessary to indicate the best treatment modality and way of delivery for these patients.</p

Nurse telephone triage in out-of-hours GP practice: determinants of independent advice and return consultation

BACKGROUND: Nowadays, nurses play a central role in telephone triage in Dutch out-of-hours primary care. The percentage of calls that is handled through nurse telephone advice alone (NTAA) appears to vary substantially between GP cooperatives. This study aims to explore which determinants are associated with NTAA and with subsequent return consultations to the GP. METHODS: For the ten most frequently presented problems, a two-week follow-up cohort study took place in one cooperative run by 25 GPs and 8 nurses, serving a population of 62,291 people. Random effects logistic regression analysis was used to study the determinants of NTAA and return consultation rates. The effect of NTAA on hospital referral rates was also studied as a proxy for severity of illness. RESULTS: The mean NTAA rate was 27.5% – ranging from 15.5% to 39.4% for the eight nurses. It was higher during the night (RR 1.63, CI 1.48–1.76) and lower with increasing age (RR 0.96, CI 0.93–0.99, per ten years) or when the patient presented >2 problems (RR 0.65; CI 0.51–0.83). Using cough as reference category, NTAA was highest for earache (RR 1.49; CI 1.18–1.78) and lowest for chest pain (RR 0.18; CI 0.06–0.47). After correction for differences in case mix, significant variation in NTAA between nurses remained (p < 0.001). Return consultations after NTAA were higher after nightly calls (RR 1.23; CI 1.04–1.40). During first return consultations, the hospital referral rate after NTAA was 1.5% versus 3.8% for non-NTAA (difference -2.2%; CI -4.0 to -0.5). CONCLUSION: Important inter-nurse variability may indicate differences in perception on tasks and/or differences in skill to handle telephone calls alone. Future research should focus more on modifiable determinants of NTAA rates

Incidence and management of Osgood-Schlatter disease in general practice:retrospective cohort study

BACKGROUND: Osgood–Schlatter disease (OSD) is a non-traumatic knee problem that is primarily observed in sports-active children and adolescents aged 8–15 years. AIM: To determine the incidence of OSD and to gain an insight into the management of children and adolescents with OSD in general practice. DESIGN AND SETTING: A retrospective cohort study was conducted using a healthcare database containing full electronic health records of over 200 000 patients in general practice in and around the Dutch city of Rotterdam. METHOD: Patients with a new diagnosis of OSD from 1 January 2012 to 31 December 2017 were extracted using a search algorithm based on International Classification of Primary Health Care coding and search terms in free text. Data on the management of OSD were manually interpreted. RESULTS: The mean incidence over the study period was 3.8 (95% confidence interval [CI] = 3.5 to 4.2) per 1000 person–years in those aged 8–18 years. Boys had a higher incidence rate of 4.9 (95% CI = 4.3 to 5.5) compared with girls (2.7, 95% CI = 2.3 to 3.2). Peak incidence was at 12 years of age for boys and 11 years for girls. Advice was the most commonly applied strategy (55.1%), followed by rest (21.0%), referral for imaging (19.5%), and physiotherapy (13.4%). CONCLUSION: To the authors’ knowledge, for the first time the incidence of OSD has been calculated using GP electronic medical files. There is a discrepancy, especially for imaging and referral to a medical specialist, between the current Dutch general practice guidelines and how GPs actually manage the condition in clinical practice

Prediction and treatment of asthma in preschool children at risk: study design and baseline data of a prospective cohort study in general practice (ARCADE)

Background: Asthma is a difficult diagnosis to establish in preschool children. A few years ago, our group presented a prediction rule for young children at risk for asthma in general practice. Before this prediction rule can safely be used in practice, cross-validation is required. In addition, general practitioners face many therapeutic management decisions in children at risk for asthma. The objectives of the study are: (1) identification of predictors for asthma in preschool children at risk for asthma with the aim of cross-validating an earlier derived prediction rule; (2) compare the effects of different treatment strategies in preschool children. Design: In this prospective cohort study one to five year old children at risk of developing asthma were selected from general practices. At risk was defined as 'visited the general practitioner with recurrent coughing (≥ 2 visits), wheezing (≥ 1) or shortness of breath (≥ 1) in the previous 12 months'. All children in this prospective cohort study will be followed until the age of six. For our prediction rule, demographic data, data with respect to clinical history and additional tests (specific immunoglobulin E (IgE), fractional exhaled nitric oxide (FENO), peak expiratory flow (PEF)) are collected. History of airway specific medication use, symptom severity and health-related quality of life (QoL) are collected to estimate the effect of different treatment intensities (as expressed in GINA levels) using recently developed statistical techniques. In total, 1,938 children at risk of asthma were selected from general practice and 771 children (40%) were enrolled. At the time of writing, follow-up for all 5-year olds and the majority of the 4-year olds is complete. The total and specific IgE measurements at baseline were carried out by 87% of the children. Response rates to the repeated questionnaires varied from 93% at baseline to 73% after 18 months follow-up; 89% and 87% performed PEF and FENO measurements, respectively. Discussion: In this study a prediction rule for asthma inyoung children, to be used in (general) practice, will be cross-validated. Our study will also provide more insight in the effect of treatment of asthma in preschool children

A cost minimisation analysis in teledermatology: model-based approach

<p>Abstract</p> <p>Background</p> <p>Although store-and-forward teledermatology is increasingly becoming popular, evidence on its effects on efficiency and costs is lacking. The aim of this study, performed in addition to a clustered randomised trial, was to investigate to what extent and under which conditions store-and-forward teledermatology can reduce costs from a societal perspective.</p> <p>Methods</p> <p>A cost minimisation study design (a model based approach) was applied to compare teledermatology and conventional process costs per dermatology patient care episode. Regarding the societal perspective, total mean costs of investment, general practitioner, dermatologists, out-of-pocket expenses and employer costs were calculated. Uncertainty analysis was performed using Monte Carlo simulation with 31 distributions in the used cost model. Scenario analysis was performed using one-way and two-way sensitivity analyses with the following variables: the patient travel distance to physician and dermatologist, the duration of teleconsultation activities, and the proportion of preventable consultations.</p> <p>Results</p> <p>Total mean costs of teledermatology process were €387 (95%CI, 281 to 502.5), while the total mean costs of conventional process costs were €354.0 (95%CI, 228.0 to 484.0). The total mean difference between the processes was €32.5 (95%CI, -29.0 to 74.7). Savings by teledermatology can be achieved if the distance to a dermatologist is larger (> = 75 km) or when more consultations (> = 37%) can be prevented due to teledermatology.</p> <p>Conclusions</p> <p>Teledermatology, when applied to all dermatology referrals, has a probability of 0.11 of being cost saving to society.</p> <p>In order to achieve cost savings by teledermatology, teledermatology should be applied in only those cases with a reasonable probability that a live consultation can be prevented.</p> <p>Trail Registration</p> <p>This study is performed partially based on PERFECT D Trial (Current Controlled Trials No.ISRCTN57478950).</p

Population prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae in the Netherlands. should asymptomatic persons be tested during Population-based chlamydia Screening also for gonorrhoea or only if chlamydial infection is found?

BACKGROUND: Screening and active case finding for Chlamydia trachomatis (CT) is recommended to prevent reproductive morbidity. However insight in community prevalence of gonococcal infections and co-infections with Neisseria gonorrhoea (NG) is lacking. METHODS: Nested study within a large population-based Chlamydia Screening Pilot among 21.000 persons 15–29 year. All CT-positive (166) and a random sample of 605 CT-negative specimens were as well tested for gonococcal infection. RESULTS: Overall Chlamydia prevalence in the Pilot was 2.0% (95% CI: 1.7–2.3), highest in very urban settings (3.2%; 95% CI: 2.4–4.0) and dependent of several risk factors. Four gonococcal infections were found among 166 participants with CT infection (4/166 = 2.4%; 95% CI: 0.1%–4.7%). All four had several risk factors and reported symptoms. Among 605 CT-negative persons, no infection with NG could be confirmed. CONCLUSION: A low rate of co-infections and a very low community prevalence of gonococcal infections were found in this population based screening programme among young adults in the Netherlands. Population screening for asymptomatic gonococcal infections is not indicated in the Netherlands. Although co-infection with gonorrhoea among CT-positives is dependent on symptoms and well-known algorithms for elevated risks, we advise to test all CT-positives also for NG, whether symptomatic or asymptomatic

Defining frequent attendance in general practice

Background: General practitioners (GPs) or researchers sometimes need to identify frequent attenders (FAs) in order to screen them for unidentified problems and to test specific interventions. We wanted to assess different methods for selecting FAs to identify the most feasible and effective one for use in a general (group) practice. Methods: In the second Dutch National Survey of General Practice, data were collected on 375 899 persons registered with 104 practices. Frequent attendance is defined as the top 3% and 10% of enlisted patients in each one-year age-sex group measured during the study year. We used these two selections as our reference standard. We also selected the top 3% and 10% FAs (90 and 97 percentile) based on four selection methods of diminishing preciseness. We compared the test characteristics of these four methods. Results: Of all enlisted patients, 24 % did not consult the practice during the study year. The mean number of contacts in the top 10% FAs increased in men from 5.8 (age 15-24 years) to 17.5 (age 64-75 years) and in women from 9.7 to 19.8. In the top 3% of FAs, contacts increased in men from 9.2 to 24.5 and in women from 14 to 27.8. The selection of FAs becomes more precise when smaller age classes are used. All selection methods show acceptable results (kappa 0.849 - 0.942) except the three group method. Conclusion: To correctly identify frequent attenders in general practice, we recommend dividing patients into at least three age groups per se