Applying evidence-based medicine in general practice : a video-stimulated interview study on workplace-based observation

BACKGROUND: Evidence-based medicine (EBM) in general practice involves applying a complex combination of best-available evidence, the patient's preferences and the general practitioner's (GP) clinical expertise in decision-making. GPs and GP trainees learn how to apply EBM informally by observing each other's consultations, as well as through more deliberative forms of workplace-based learning. This study aims to gain insight into workplace-based EBM learning by investigating the extent to which GP supervisors and trainees recognise each other's EBM behaviour through observation, and by identifying aspects that influence their recognition. METHODS: We conducted a qualitative multicentre study based on video-stimulated recall interviews (VSI) of paired GP supervisors and GP trainees affiliated with GP training institutes in Belgium and the Netherlands. The GP pairs (n = 22) were shown fragments of their own and their partner's consultations and were asked to elucidate their own EBM considerations and the ones they recognised in their partner's actions. The interview recordings were transcribed verbatim and analysed with NVivo. By comparing pairs who recognised each other's considerations well with those who did not, we developed a model describing the aspects that influence the observer's recognition of an actor's EBM behaviour. RESULTS: Overall, there was moderate similarity between an actor's EBM behaviour and the observer's recognition of it. Aspects that negatively influence recognition are often observer-related. Observers tend to be judgemental, give unsolicited comments on how they would act themselves and are more concerned with the trainee-supervisor relationship than objective observation. There was less recognition when actors used implicit reasoning, such as mindlines (internalised, collectively reinforced tacit guidelines). Pair-related aspects also played a role: previous discussion of a specific topic or EBM decision-making generally enhanced recognition. Consultation-specific aspects played only a marginal role. CONCLUSIONS: GP trainees and supervisors do not fully recognise EBM behaviour through observing each other's consultations. To improve recognition of EBM behaviour and thus benefit from informal observational learning, observers need to be aware of automatic judgements that they make. Creating explicit learning moments in which EBM decision-making is discussed, can improve shared knowledge and can also be useful to unveil tacit knowledge derived from mindlines

Acuut loopoor: niet laten lopen = Acute ear discharge, a reason for consultation

It is often thought that acute ear discharge as a presenting symptom of acute otitis media (AOM) means that the infection is petering out. However, children with AOM presenting with ear discharge due to a spontaneous perforation of the eardrum (AOMd) have a poorer prognosis (i.e. higher rates of ear pain and/or fever at 3-7 days) than those without ear discharge. In this article we emphasize the importance of physical examination and early treatment of children and adults who present with acute ear discharge

Accuracy of telephone triage in primary care patients with chest discomfort: a cross-sectional study

OBJECTIVE: To assess the accuracy of semi-automatic assisted telephone triage in patients with acute chest discomfort against the diagnosis of acute coronary syndrome (ACS) or other life-threatening events (LTEs). METHODS: A cross-sectional study was performed of telephone conversations with 2023 patients with acute chest discomfort (pain, pressure, tightness or discomfort) who called out-of-hours services for primary care (OHS-PC) between 2014 and 2016. Sensitivity, specificity, positive and negative predicted values were calculated for a high urgency (patient seen within one hour) against the diagnoses of ACS and other LTEs. Diagnoses were retrieved from the patients' medical records in general practice, including hospital specialists' discharge letters. RESULTS: Of 2023 patients who called because of chest discomfort, 227 (11.2%) had an ACS (men 14.9%, women 8.2%) and 58 (2.9%) had another LTE (men 3.6%, women 2.3%). The sensitivity and specificity of a high Netherlands Triage System (NTS) urgency allocation against ACS/other LTEs were 0.73 (95% CI 0.68 to 0.78) and 0.43 (95% CI 0.40 to 0.45), respectively. In 13.2% of the calls the triage nurse overruled the NTS urgency, mostly by upscaling (11.0%). The sensitivity and specificity of the final urgency allocation were 0.86 (95% CI 0.81 to 0.90) and 0.34 (95% CI 0.32 to 0.37). The positive and negative predictive values of the final urgency were 0.18 (95% CI 0.17 to 0.19) and 0.94 (95% CI 0.92 to 0.95), respectively. CONCLUSIONS: The semi-automatic triage NTS tool underestimated the urgency in 27% of patients with ACS/other LTEs. Overruling by triage nurses improved safety, but still 14% of men and women with ACS/other LTEs received too low urgency, while efficiency remained poor. TRIAL REGISTRATION NUMBER: NTR7331

Optimisation of telephone triage of callers with symptoms suggestive of acute cardiovascular disease in out-of-hours primary care: observational design of the Safety First study

INTRODUCTION: In the Netherlands, the 'Netherlands Triage Standard' (NTS) is frequently used as digital decision support system for telephone triage at out-of-hours services in primary care (OHS-PC). The aim of the NTS is to guarantee accessible, efficient and safe care. However, there are indications that current triage is inefficient, with overestimation of urgency, notably in suspected acute cardiovascular disease. In addition, in primary care settings the NTS has only been validated against surrogate markers, and diagnostic accuracy with clinical outcomes as the reference is unknown. In the Safety First study, we address this gap in knowledge by describing, understanding and improving the diagnostic process and urgency allocation in callers with symptoms suggestive of acute cardiovascular disease, in order to improve both efficiency and safety of telephone triage in this domain. METHODS AND ANALYSIS: An observational study in which 3000 telephone triage recordings (period 2014-2016) will be analysed. Information is collected from the recordings including caller and symptom characteristics and urgency allocation. The callers' own general practitioners are contacted for the final diagnosis of each contact. We included recordings of callers with symptoms suggestive of acute coronary syndrome (ACS) or transient ischaemic attack (TIA)/stroke. With univariable and multivariable logistic regression analyses the diagnostic accuracy of caller and symptom characteristics will be analysed in terms of predictive values with urgency level, and ACS and TIA/stroke as outcomes, respectively. To further improve our understanding of the triage process at OHS-PC, we will carry out additional studies applying both quantitative and qualitative methods: (i) case-control study on serious adverse events (SAE), (ii) conversation analysis study and (iii) interview study with triage nurses. ETHICS AND DISSEMINATION: The Medical Ethics Committee Utrecht, the Netherlands endorsed this study (National Trial Register identification: NTR7331). Results will be disseminated at scientific conferences, regional educational sessions and publication in peer-reviewed journals

Non‐steroidal anti‐inflammatory drugs (NSAIDs) for acute sore throat

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the effects of non‐steroidal anti‐inflammatory drugs (NSAIDs) for acute sore throat in children and adults

Improving pain management in childhood acute otitis media in general practice: a cluster randomised controlled trial of a GP-targeted educational intervention

BACKGROUND: Pain management in acute otitis media (AOM) is often suboptimal, potentially leading to unnecessary discomfort, GP reconsultation, and antibiotic prescribing. AIM: To assess the effectiveness of a GP-targeted educational intervention to improve pain management in children with AOM. DESIGN AND SETTING: Pragmatic, cluster randomised controlled trial (RCT). GPs in 37 practices (intervention n = 19; control n = 18) across the Netherlands recruited 224 children with GP-confirmed AOM and ear pain (intervention n = 94; control n = 130) between February 2015 and May 2018. METHOD: GPs in practices allocated to the intervention group were trained (online and face-to-face) to discuss pain management with parents using an information leaflet, and prompted to prescribe weight-appropriate dosed paracetamol. Ibuprofen was additionally prescribed if pain control was still insufficient. GPs in the control group provided usual care. RESULTS: Mean ear pain scores over the first 3 days were similar between groups (4.66 versus 4.36; adjusted mean difference = -0.05; 95% confidence intervals [CI] = -0.93 to 0.83), whereas analgesic use, in particular ibuprofen, was higher in the intervention group. The total number of antibiotic prescriptions during the 28-day follow-up was similar (mean rate 0.43 versus 0.47; adjusted rate ratio [aRR] 0.97; 95% CI = 0.68 to 1.38). Parents of children in the intervention group were more likely to reconsult for AOM-related complaints (mean rate 0.70 versus 0.41; aRR 1.73; 95% CI = 1.14 to 2.62). CONCLUSION: An intervention aimed at improving pain management for AOM increases analgesic use, particularly ibuprofen, but does not provide symptomatic benefit. GPs are advised to carefully weigh the potential benefits of ibuprofen against its possible harms

Is the time of calling helpful for differentiating transient ischaemic attack and stroke from mimics in primary care out-of-hours services?: A cross-sectional study

OBJECTIVES: Telephone triage of patients suspected of transient ischaemic attack (TIA) or stroke is challenging. Both TIA and stroke more likely occur during daytime, with a peak in the morning hours. Thus, the time of calling might be a helpful determinant during telephone triage. We assessed the time of calling in patients with stroke-like symptoms who called the out-of-hours services in primary care (OHS-PC), and evaluated whether the time of calling differed between patients with TIA or stroke compared with those with mimics. DESIGN: Cross-sectional study. SETTING: Six OHS-PC locations in the Netherlands. PARTICIPANTS: 1269 telephone triage recordings of patients calling the OHS-PC because of stroke-like symptoms. We collected information on patient characteristics, symptoms, time of calling and urgency allocation. The final diagnosis related to each triage call was based on letters from the neurologist (retrieved from the patient's general practitioner). PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measures were the time of calling hourly and 4 hourly, and the risk of TIA or stroke/hour. The secondary outcome measure was the risk ratio of TIA or stroke in the morning (08:00-12:00h) versus other hours. RESULTS: Mean age was 68.6 (SD±18.5) years, 56.9% were women and 50.0% had a TIA or stroke. The risk ratio of TIA or stroke among people calling with stroke-like symptoms between 08:00-12:00h versus other hours was 1.13 (95% CI 1.00 to 1.28, p=0.070). After correction for age and sex, the adjusted risk ratio was 0.94 (95% CI 0.80 to 1.10, p=0.434). CONCLUSION: In patients who called the OHS-PC because of stroke-like symptoms, the time of calling did not differ between patients with TIA or stroke and patients with mimics. TRIAL REGISTRATION NUMBER: The Netherlands National Trial Registry (NTR7331)

Diagnostic delay of pulmonary embolism in primary and secondary care : a retrospective cohort study

BACKGROUND: Delayed diagnosis of pulmonary embolism (PE) is common because symptoms can be non-specific. The few studies that have investigated diagnostic delay have not taken into account the role of primary care physicians in the diagnostic process. AIM: To document and quantify the stages of diagnostic delay of PE and to identify clinical factors associated with this delay. DESIGN AND SETTING: A retrospective cohort study conducted in Zwolle and its surroundings in the Netherlands. METHOD: Primary and secondary care records of all patients diagnosed with PE between January 2008 and December 2009 were reviewed for dates of symptom onset, date of presentation and diagnosis, and for clinical findings. Relationships between delay and clinical parameters were tested using multivariate regression analysis. RESULTS: The 261 patients enrolled in the study had an average total delay of 8.6 days. Patient delay (4.2 days average) and delay in primary care (3.9 days) were the major contributors to this delay. Chest pain (odds ratio [OR] 0.51, 95% confidence interval [CI] = 0.28 to 0.92, P = 0.03) and symptoms of deep venous thrombosis (calf pain) (OR 0.49, 95% CI = 0.24 to 0.98, P = 0.05) were associated with an early diagnosis. Patient delay was shorter in patients with chest pain (OR 0.49, 95% CI = 0.25 to 0.95, P = 0.03) and longer in patients with dyspnoea (OR 2.95, 95% CI = 0.99 to 8.85, P = 0.05). In primary care, chest pain (OR 0.37, 95% CI = 0.17 to 0.84, P = 0.02) and rales (OR 0.22, 95% CI = 0.06 to 0.83, P = 0.03) were associated with an early referral, whereas comorbidity led to a delayed referral. CONCLUSION: This study shows that the diagnostic delay of PE is substantial, especially patient delay and delay in primary care. There is room to reduce this delay by increasing the awareness of both patients and GPs. Further research is needed on clinical factors that raise suspicion of PE in primary care

Challenges in measuring interprofessional-interorganisational collaboration with a questionnaire

Background: Collaboration between medical professionals from separate organisations is necessary to deliver good patient care. This care is influenced by professionals' perceptions about their collaboration. Until now, no instrument to measure such perceptions was available in the Netherlands. A questionnaire developed and validated in Spain was translated to assess perceptions about clinicians' collaboration in primary and secondary care in the Dutch setting. Aim: Validation in the Dutch setting of a Spanish questionnaire that aimed to assess perceptions of clinicians about interorganisational collaboration. Design & setting: After translation, cultural adaptation, and pre-testing, the questionnaire was sent to GPs and secondary care clinicians (SCCs) in three regions in the Netherlands. The responses of 445 responders were used to assess the validity and reliability of the questionnaire. Method: A confirmatory factor analysis (CFA) and an exploratory factor analysis (EFA) were performed to study the construct validity of the hypothesised factor model underlying the questionnaire. Test-retest reliability was evaluated using weighted Kappa statistics. Results: Results of the CFA indicated poor fit of the hypothesised factor structure. EFA, executed separately for each region, showed a highly unstable factor structure. The test-retest reliability analysis demonstrated low re-test reliability. Conclusion: The underlying factor structure of a Spanish questionnaire could not be reproduced. The construct validity and reliability of this questionnaire were insufficient to warrant use in the Dutch setting. This study demonstrates the need for evaluating validity and reliability of questionnaires in local settings

Challenges in measuring interprofessional-interorganisational collaboration with a questionnaire

Background: Collaboration between medical professionals from separate organisations is necessary to deliver good patient care. This care is influenced by professionals' perceptions about their collaboration. Until now, no instrument to measure such perceptions was available in the Netherlands. A questionnaire developed and validated in Spain was translated to assess perceptions about clinicians' collaboration in primary and secondary care in the Dutch setting. Aim: Validation in the Dutch setting of a Spanish questionnaire that aimed to assess perceptions of clinicians about interorganisational collaboration. Design & setting: After translation, cultural adaptation, and pre-testing, the questionnaire was sent to GPs and secondary care clinicians (SCCs) in three regions in the Netherlands. The responses of 445 responders were used to assess the validity and reliability of the questionnaire. Method: A confirmatory factor analysis (CFA) and an exploratory factor analysis (EFA) were performed to study the construct validity of the hypothesised factor model underlying the questionnaire. Test-retest reliability was evaluated using weighted Kappa statistics. Results: Results of the CFA indicated poor fit of the hypothesised factor structure. EFA, executed separately for each region, showed a highly unstable factor structure. The test-retest reliability analysis demonstrated low re-test reliability. Conclusion: The underlying factor structure of a Spanish questionnaire could not be reproduced. The construct validity and reliability of this questionnaire were insufficient to warrant use in the Dutch setting. This study demonstrates the need for evaluating validity and reliability of questionnaires in local settings