Anxiety Disorders and Depression in Older Adults

Anxiety disorders and depression are common and complex disorders. Despite decades of research, their etiology is largely unknown. Study of the occurrence and determinants, i.e. the epidemiology of anxiety disorders and depression, helps unravel their etiology. This thesis examines the epidemiology of anxiety disorders and depression in older adults. In particular, comorbidity, health care use, cortisol and atherosclerosis and genetic factors are studied in relation to anxiety and, or depression

To what extent does sociodemographic composition of the neighbourhood explain regional differences in demand of primary out-of-hours care:A multilevel study

Background:  In the Netherlands, primary out-of-hours (OOH) care is provided by large scale General Practitioner (GP) cooperatives. GP cooperatives can be contacted by patients living in the area surrounding the GP cooperative (catchment area) at hours when the patient's own general practice is closed. The frequency of primary OOH care use substantially differs between GP cooperative catchment areas. To enable a better match between supply and demand of OOH services, understanding of the factors associated with primary OOH care use is essential. The present study evaluated the contribution of sociodemographic composition of the neighbourhood in explaining differences in primary OOH care use between GP cooperative catchment areas. Methods:  Data about patients' contacts with primary OOH services (n = 1,668,047) were derived from routine electronic health records of 21 GP cooperatives participating in the NIVEL Primary Care Database in 2012. The study sample is representative for the Dutch population (for age and gender). Data were matched with sociodemographic characteristics (e.g. gender, age, low-income status, degree of urbanisation) on postcode level. Multilevel linear regression models included postcode level (first level), nested within GP cooperative catchment areas (second level). We investigated whether contacts in primary OOH care were associated with neighbourhood sociodemographic characteristics. Results:  The demand of primary OOH care was significantly higher in neighbourhoods with more women, low-income households, non-Western immigrants, neighbourhoods with a higher degree of urbanisation, and low neighbourhood socioeconomic status. Conversely, lower demand was associated with neighbourhoods with more 5 to 24 year old inhabitants. Sociodemographic neighbourhood characteristics explained a large part of the variation between GP cooperatives (R-squared ranging from 8% to 52%). Nevertheless, the multilevel models also showed that a considerable amount of variation in demand between GP cooperatives remained unexplained by sociodemographic characteristics, particularly regarding high-urgency contacts. Conclusions:  Although part of the variation between GP cooperatives could not be attributed to neighbourhood characteristics, the sociodemographic composition of the neighbourhood is a fair predictor of the demand of primary OOH care. Accordingly, this study provides a useful starting point for an improved planning of the supply of primary OOH care

Immediate release fentanyl in general practices: Mostly off-label prescribing

BACKGROUND: The immediacy of the onset of opioids may be associated with the risk of dependency and accidental overdose. Nasal and oromucosal fentanyl dosage forms are so called immediate release fentanyl (IRF). These IRFs have been approved to treat breakthrough pain in patients with cancer who are on chronic opioid treatment only. There are signals of increased off-label prescribing of IRFs in general practices. OBJECTIVES: This study aims to provide insight into the frequency of IRF prescription in Dutch general practices and the extent to which IRF is prescribed off-label. METHODS: Routinely collected electronic health records of general practices (GPs) participating in Nivel Primary Care Database were used. Adult patients with IRF prescriptions in 2019 were selected from whom dispensing data on 2018 and 2019 was available. Diagnoses were recorded by GPs using International Classification of Primary Care. Descriptive analyses were performed. RESULTS: This study included 342 GPs with a patient population of 1,297,942 patients, 1,368 patients received at least one IRF prescription in 2019, which is equal to 1.1 patients per 1,000 registered patients. Most patients (74.9%) with an IRF prescription received an off-label prescription. A slight majority had a cancer diagnosis but nearly 65.2% did not have a maintenance therapy and 14% were opioid-naive before receiving their first IRF prescription. CONCLUSION: IRFs are not prescribed frequently in Dutch general practices. However, when prescribed, a relatively large portion of patients received an off-label prescription

Electronic Health Record-Triggered Research Infrastructure Combining Real-world Electronic Health Record Data and Patient-Reported Outcomes to Detect Benefits, Risks, and Impact of Medication:Development Study

BACKGROUND: Real-world data from electronic health records (EHRs) represent a wealth of information for studying the benefits and risks of medical treatment. However, they are limited in scope and should be complemented by information from the patient perspective. OBJECTIVE: The aim of this study is to develop an innovative research infrastructure that combines information from EHRs with patient experiences reported in questionnaires to monitor the risks and benefits of medical treatment. METHODS: We focused on the treatment of overactive bladder (OAB) in general practice as a use case. To develop the Benefit, Risk, and Impact of Medication Monitor (BRIMM) infrastructure, we first performed a requirement analysis. BRIMM’s starting point is routinely recorded general practice EHR data that are sent to the Dutch Nivel Primary Care Database weekly. Patients with OAB were flagged weekly on the basis of diagnoses and prescriptions. They were invited subsequently for participation by their general practitioner (GP), via a trusted third party. Patients received a series of questionnaires on disease status, pharmacological and nonpharmacological treatments, adverse drug reactions, drug adherence, and quality of life. The questionnaires and a dedicated feedback portal were developed in collaboration with a patient association for pelvic-related diseases, Bekkenbodem4All. Participating patients and GPs received feedback. An expert meeting was organized to assess the strengths, weaknesses, opportunities, and threats of the new research infrastructure. RESULTS: The BRIMM infrastructure was developed and implemented. In the Nivel Primary Care Database, 2933 patients with OAB from 27 general practices were flagged. GPs selected 1636 (55.78%) patients who were eligible for the study, of whom 295 (18.0% of eligible patients) completed the first questionnaire. A total of 288 (97.6%) patients consented to the linkage of their questionnaire data with their EHR data. According to experts, the strengths of the infrastructure were the linkage of patient-reported outcomes with EHR data, comparison of pharmacological and nonpharmacological treatments, flexibility of the infrastructure, and low registration burden for GPs. Methodological weaknesses, such as susceptibility to bias, patient selection, and low participation rates among GPs and patients, were seen as weaknesses and threats. Opportunities represent usefulness for policy makers and health professionals, conditional approval of medication, data linkage to other data sources, and feedback to patients. CONCLUSIONS: The BRIMM research infrastructure has the potential to assess the benefits and safety of (medical) treatment in real-life situations using a unique combination of EHRs and patient-reported outcomes. As patient involvement is an important aspect of the treatment process, generating knowledge from clinical and patient perspectives is valuable for health care providers, patients, and policy makers. The developed methodology can easily be applied to other treatments and health problems

Incentivizing appropriate prescribing in primary care:Development and first results of an electronic health record-based pay-for-performance scheme

Objective Part of the funding of Dutch General Practitioners (GPs) care is based on pay-for-performance, including an incentive for appropriate prescribing according to guidelines in national formularies. Aim of this paper is to describe the development of an indicator and an infrastructure based on prescription data from GP Electronic Health Records (EHR), to assess the level of adherence to formularies and the effects of the pay-for-performance scheme, thereby assessing the usefulness of the infrastructure and the indicator. Methods Adherence to formularies was calculated as the percentage of first prescriptions by the GP for medications that were included in one of the national formularies used by the GP, based on prescription data from EHRs. Adherence scores were collected quarterly for 2018 and 2019 and subsequently sent to health insurance companies for the pay-for-performance scheme. Adherence scores were used to monitor the effect of the pay-for-performance scheme. Results 75% (2018) and 83% (2019) of all GP practicesparticipated. Adherence to formularies was around 85% or 95%, depending on the formulary used. Adherence improved significantly, especially for practices that scored lowest in 2018. Discussion We found high levels of adherence to national formularies, with small improvements after one year. The infrastructure will be used to further stimulate formulary-based prescribing by implementing more actionable and relevant indicators on adherence scores for GPs

Newer long-acting insulin prescriptions for patients with type 2 diabetes: Prevalence and practice variation in a retrospective cohort study

BACKGROUND: Little is known about prescription patterns of expensive non-recommended newer long-acting insulins (glargine 300 U/mL and degludec) for patients with type 2 diabetes mellitus (T2DM). AIM: To identify practice variation in, and practice- and patient-related characteristics associated with, the prescription of newer long-acting insulins to patients with T2DM in primary care. DESIGN AND SETTING: A retrospective cohort study in Dutch general practices (Nivel Primary Care Database). METHOD: A first prescription for intermediate or long-acting insulins in 2018 was identified in patients aged ≥40 years using other T2DM drugs. Per practice, the median percentage and interquartile range (IQR) of patients with newer insulin prescriptions were calculated. Multilevel logistic regression models were constructed to calculate intraclass correlation coefficients (ICCs) and quantify the association of patient and practice characteristics with prescriptions for newer insulins (odds ratios [ORs] and 95% confidence intervals [CIs]). RESULTS: In total, 7757 patients with prescriptions for intermediate or long-acting insulins from 282 general practices were identified. A median percentage of 21.2% (IQR 12.5–36.4%) of all patients prescribed intermediate or long-acting insulins per practice received a prescription for newer insulins. After multilevel modelling, the ICC decreased from 20% to 19%. Female sex (OR 0.77, 95% CI = 0.69 to 0.87), age ≥86 years compared with 40–55 years (OR 0.22, 95% CI = 0.15 to 0.34), prescriptions for metformin (OR 0.66, 95% CI = 0.53 to 0.82), sulfonylurea (OR 0.58, 95% CI = 0.51 to 0.66), or other newer T2DM drugs (OR 3.10, 95% CI = 2.63 to 3.66), and dispensing practices (OR 1.78, 95% CI = 1.03 to 3.10) were associated with the prescription of newer insulins. CONCLUSION: The inter-practice variation in the prescription of newer insulins is large and could only be partially explained by patient- and practice-related differences. This indicates substantial opportunities for improvement

Opioid prescribing in out-of-hours primary care in Flanders and the Netherlands:A retrospective cross-sectional study

BACKGROUND: Increased opioid prescribing has raised concern, as the benefits of pain relief not always outweigh the risks. Acute and chronic pain is often treated in a primary care out-of-hours (OOH) setting. This setting may be a driver of opioid use but the extent to which opioids are prescribed OOH is unknown. We aimed to investigate weak and strong opioid prescribing at OOH primary care services (PCS) in Flanders (Northern, Dutch-speaking part of Belgium) and the Netherlands between 2015 and 2019. METHODS: We performed a retrospective cross sectional study using data from routine electronic health records of OOH-PCSs in Flanders and the Netherlands (2015–2019). Our primary outcome was the opioid prescribing rate per 1000 OOH-contacts per year, in total and for strong (morphine, hydromorphone, oxycodone, oxycodone and naloxone, fentanyl, tapentadol, and buprenorphine and weak opioids (codeine combinations and tramadol and combinations) and type of opioids separately. RESULTS: Opioids were prescriped in approximately 2.5% of OOH-contacts in both Flanders and the Netherlands. In Flanders, OOH opioid prescribing went from 2.4% in 2015 to 2.1% in 2017 and then increased to 2.3% in 2019. In the Netherlands, opioid prescribing increased from 1.9% of OOH-contacts in 2015 to 2.4% in 2017 and slightly decreased thereafter to 2.1% of OOH-contacts. In 2019, in Flanders, strong opioids were prescribed in 8% of the OOH-contacts with an opioid prescription. In the Netherlands a strong opioid was prescribed in 57% of these OOH-contacts. Two thirds of strong opioids prescriptions in Flanders OOH were issued for patients over 75, in the Netherlands one third was prescribed to this age group. CONCLUSION: We observed large differences in strong opioid prescribing at OOH-PCSs between Flanders and the Netherlands that are likely to be caused by differences in accessibility of secondary care, and possibly existing opioid prescribing habits. Measures to ensure judicious and evidence-based opioid prescribing need to be tailored to the organisation of the healthcare system

Antibiotic prescribing for children in general practice and adherence to treatment guidelines 2010-2012

Background Over 80% of antibiotics are prescribed in general practice, mainly for viral RTIs in children. In response, numerous efforts to improve antibiotic prescribing have been ongoing for decades. Treatment guidelines are developed to support GP decision-making on which RTIs require antibiotics. Yet, detailed information on adherence to RTI treatment guidelines for antibiotic prescribing in children is scarce. Trends in antibiotic use suggest an overall reduction in antibiotic rates for children since the late 1990s. On the other hand, antibiotics continue to be prescribed for non-specific URTIs diagnosis, and quite often as broad-spectrum products. The Netherlands has maintained low and stable antibiotic use in primary care. Even though, national guidelines for RTIs are generally accepted by Dutch GPs, antibiotic prescribing is not always in accordance with recommendations. Few studies have assessed adherence to RTI guidelines for children. Our study explores antibiotic prescribing patterns for fever, ear and respiratory infections in Dutch children 2010 - 2012. Our objective is to determine guideline adherence in antibiotic prescribing for different paediatric RTIs and choice of antibiotics. We also aim to examine potential variations in guideline adherence among GPs. Methods We use prescribing data and children’ diagnoses (ICPC-1) from NIVEL Primary Care Database. GP prescriptions include information on drug name (ATC), prescribing date and amount prescribed. Antibiotics are defined as antibacterial for systemic use (ATC code J01). We matched ICPC with clinical conditions from national guidelines. Different consultations concerning same health problem within a pre-set time frame are linked to one disease episode. First set of outcomes measure GP adherence to recommendations on whether or not to prescribe antibiotics for the diagnosis, while second one evaluate antibiotic types prescribed. Outcomes are defined by disease-specific indicators for outpatient antibiotic prescribing. Analysis SPSS is used to obtain overall incidence rates for each ICPC and % of disease episodes with prescribed antibiotics. We will calculate 95% CIs for overall figures and value range for each indicator at practice level. We will present the data by year and age groups. Multilevel analysis will be done for variability in antibiotic prescribing quality among general practices

Indications related to antidepressant prescribing in the Nivel-PCD database and the SIDIAP database

Altres ajuts: Acord transformatiu CRUE-CSICAntidepressant drug consumption has increased, mainly in the elderly. This trend could be explained by the use for indications other than depression. We aimed to describe the indications related to antidepressant drug new users in two primary care settings