Primary care diagnostic and treatment pathways in Dutch women with urinary incontinence

OBJECTIVE: To investigate how GPs manage women with urinary incontinence (UI) in the Netherlands and to assess whether this is in line with the relevant Dutch GP guideline. Because UI has been an underreported and undertreated problem for decades despite appropriate guidelines being created for general practitioners (GPs). DESIGN: Retrospective cohort study. SETTING: Routine primary care data for 2017 in the Netherlands. SUBJECTS: We included the primary care records of women aged 18-75 years with at least one contact registered for UI, and then extracted information about baseline characteristics, diagnosis, treatment, and referral to pelvic physiotherapy or secondary care. RESULTS: In total, 374 records were included for women aged 50.3 ± 15.1 years. GPs diagnosed 31.0%, 15.2%, and 15.0% women with stress, urgency, or mixed UI, respectively; no diagnosis of type was recorded in 40.4% of women. Urinalysis was the most frequently used diagnostic test (42.5%). Education was the most common treatment, offered by 17.9% of GPs; however, no treatment or referral was reported in 15.8% of cases. As many as 28.7% and 21.7% of women were referred to pelvic physiotherapy and secondary care, respectively. CONCLUSION: Female UI is most probably not managed in line with the relevant Dutch GP guideline. It is also notable that Dutch GPs often fail to report the type of UI, to use available diagnostic approaches, and to provide appropriate education. Moreover, GPs referred to specialists too often, especially for the management of urgency UI.Key pointsUrinary incontinence (UI) has been an underreported and undertreated problem for decades. Despite various guidelines, UI often lies outside the GPs comfort zone.•According to this study: general practitioners do not treat urinary incontinence according to guidelines.•The type of incontinence is frequently not reported and diagnostic approaches are not fully used.•We believe that increased awareness will help improve treatment and avoidable suffering

Developing a regional transmural care database: A roadmap

INTRODUCTION: In primary care health care systems, primary care physicians (PCPs) provide most basic care services, and if necessary, refer to secondary care for specialized work-up and treatment. If hospital care is required, agreement between PCPs and secondary care physicians (SCPs) on the conditions for patient referral and back-referral are considered crucial to providing high quality patient care. The regional healthcare network of Utrecht, a region in the Netherlands, developed a set of collaborative patient care agreements (CPCAs) for specific chronic conditions. Even though these CPCA are endorsed by all relevant regional health care organisations, the adoption of these agreements in practice remains substandard. In this project, through linkage of routine care data, as registered in daily practice by PCPs and SCPs, a regional transmural care database (RTD) was developed for monitoring the use of the CPCAs. Its data was transformed into' mirror data' used to support PCPs and SCPs in discussing and improving current practice and to support a learning healthcare system within the region. METHODS: The development of the RTD is part of a larger action research project on joint care, called ZOUT (an acronym which is translated as "The right care at the right place in the Utrecht region"). The RTD includes data from three regional hospitals, and about 70 affiliated primary care practices which are united in the Julius General Practitioners Network (JGPN). These data were extracted, linked and presented in the form of mirror data, following simple methods to allow replication of our approach. CPCAs addressing transmural care for three chronic conditions were selected. Data from the primary care practices and the hospitals were linked by an independent trusted third party. This enabled relevant hospital data to be added to the primary care dataset, thereby providing transmural routine care data for individual patients. RESULTS: During the development of the RTD, a roadmap was created including a detailed step-by-step checklist of the organizational, administrative, technical and legal arrangements which needed to be made. Legal and administrative challenges proved most challenging. Also, incompleteness of data and the impossibility to translate several agreements into extractable data limited the potential for providing a comprehensive overview of the extent to which agreements in the CPCA were adhered to in daily care. DISCUSSION: We present a systematic, comprehensive (technical as well as practical) and reproducible roadmap to developing a regional transmural care database suitable for generating mirror data on joint transmural care between PCPs and SCPs. This approach includes all technical steps in data selection and linkage, as well as the substantive steps that need to be taken in the analysis and application of the results. The mirror data, which reflects the follow-up of agreements formulated in the CPCAs, enabled shared reflection and discussion between PCPs and SCPs. This supports the search for bottlenecks and potentialities for improving daily collaborative care, thereby showing great potential to serve a learning regional healthcare system

Impact of the COVID-19 Pandemic on Antibiotic Prescribing for Common Infections in The Netherlands: A Primary Care-Based Observational Cohort Study

In 2020, the COVID-19 pandemic brought dramatic changes in the delivery of primary health care across the world, presumably changing the number of consultations for infectious diseases and antibiotic use. We aimed to assess the impact of the pandemic on infections and antibiotic prescribing in Dutch primary care. All patients included in the routine health care database of the Julius General Practitioners' Network were followed from March through May 2019 (n = 389,708) and March through May 2020 (n = 405,688). We extracted data on consultations for respiratory/ear, urinary tract, gastrointestinal and skin infections using the International Classification of Primary Care (ICPC) codes. These consultations were combined in disease episodes and linked to antibiotic prescriptions. The numbers of infectious disease episodes (total and those treated with antibiotics), complications, and antibiotic prescription rates (i.e., proportion of episodes treated with antibiotics) were calculated and compared between the study periods in 2019 and 2020. Fewer episodes were observed during the pandemic months than in the same months in 2019 for both the four infectious disease entities and complications such as pneumonia, mastoiditis and pyelonephritis. The largest decline was seen for gastrointestinal infections (relative risk (RR), 0.54; confidence interval (CI), 0.51 to 0.58) and skin infections (RR, 0.71; CI, 0.67 to 0.75). The number of episodes treated with antibiotics declined as well, with the largest decrease seen for respiratory/ear infections (RR, 0.54; CI, 0.52 to 0.58). The antibiotic prescription rate for respiratory/ear infections declined from 21% to 13% (difference -8.0% (CI, -8.8 to -7.2)), yet the prescription rates for other infectious disease entities remained similar or increased slightly. The decreases in primary care infectious disease episodes and antibiotic use were most pronounced in weeks 15-19, mid-COVID-19 wave, after an initial peak in respiratory/ear infection presentation in week 11, the first week of lock-down. In conclusion, our findings indicate that the COVID-19 pandemic has had profound effects on the presentation of infectious disease episodes and antibiotic use in primary care in the Netherlands. Consequently, the number of infectious disease episodes treated with antibiotics decreased. We found no evidence of an increase in complications

General practice trainees' information searching strategies for clinical queries encountered in daily practice

Background. Earlier studies have shown that clinical queries are common among doctors. Data on the information-seeking behaviour of general practice (GP) trainees are scarce though, and numbers studied are small. Objective. The objective of this study was to determine how often and how GP trainees search for answers to clinical queries encountered in daily clinical practice. Methods. Third-year GP trainees kept logs on all patient contacts for eight consecutive practice days. Information was obtained on patient contacts (description), clinical queries (frequency, type), seeking behaviour (frequency, moment, reason not to search, resources used, duration of search) and answers (frequency, impact). Descriptive analyses were performed; frequencies and percentages were computed. We calculated the number of clinical queries per patient, the number of searches per query and the number of answers per search. Results. Seventy-six trainees reported 1533 clinical queries about 7300 patients presenting 7619 complaints [mean of 0.2 queries per patient, standard deviation (SD) 0.1]. For most of the queries trainees pursued an answer (mean of 0.8 per query, SD 0.2), mostly during consultation (61% of searches), and frequently retrieved answers (mean of 0.8 per search, SD 0.17) they reported to improve clinical decision making in 26%. Most common resources were colleagues or supervisors (28%), and national GP guidelines (26%). The median duration of a search was 4 minutes (interquartile range 3). Conclusion. GP trainees have one clinical query per five patients. They often attempted to find answers and reported to succeed in most of the searches, primarily by consulting supervisors or colleagues and national GP guidelines

Attitude and behaviour of Dutch Otorhinolaryngologists to Evidence Based Medicine.

OBJECTIVE:The objective of this study was to assess the attitude and behaviour of Dutch ENT surgeons and ENT residents towards Evidence Based Medicine. INTRODUCTION:Evidence Based Medicine is the cornerstone of modern clinical care. It is considered of crucial importance for optimal patient care and health care quality. Practicing it requires positive attitude and behaviour. Little is known about the attitude and behaviour towards Evidence Based Medicine in otorhinolaryngology. METHODS:We performed a web-based questionnaire among 607 Dutch Ear- Nose & Throat surgeons of whom 106 residents (cross-sectional study). The questionnaire consisted of 3 parts; (1) personal characteristics, (2) questions regarding Evidence Based Medicine attitude (McColl questionnaire, scale 0-100%) and (3) questions regarding Evidence Based Medicine behaviour (barriers and information seeking behaviour). Data were collected between March 26th 2018 and June 1st 2018. RESULTS:The median score on the overall McColl questionnaire was 50 (IQR 35). The main barriers respondents experienced were time related. Limited time in the outpatient clinic was considered a more important barrier for residents to practice EBM compared to ENT surgeons. Respondents' gut feeling and their own preference were identified as the main contributing factors in clinical decision making. CONCLUSION:In conclusion Dutch ENT surgeons have a moderate attitude on the McColl questionnaire. The main barriers to practice Evidence Based Medicine they experience are time related

Laser-assisted endoscopic third ventriculostomy: long-term results in a series of 202 patients

OBJECTIVE: Endoscopic third ventriculostomy is a well-known surgical option in the treatment of noncommunicating hydrocephalus. We studied complications and long-term success in 202 patients to demonstrate the safety and efficacy of laser-assisted endoscopic third ventriculostomy (LA-ETV) using a unique "black" fiber tip/diode laser combination for controlled tissue ablation. METHODS: We studied 213 LA-ETVs, which were performed in 202 patients. Patients' ages ranged from 2 days to 83 years (mean age, 27 yr). The mean follow-up period for all patients was 2.7 years (range, 2 d to 12 yr). Hydrocephalus was caused by aqueductal stenosis in 65 patients, tumors in 67 patients, hemorrhages in 24 patients, myelomeningoceles in 20 patients, cysts in 15 patients, and other causes in 11 patients. The long-term effectiveness of LA-ETV was studied with Kaplan-Meier analysis. RESULTS: Technically successful LA-ETVs were accomplished in 196 of the 202 patients (97%). The overall success rate for a functional LA-ETV was 68% at the 2-year follow-up evaluation. LA-ETV was more effective in patients aged 1 year and older (70% success rate) than in younger patients (59% success rate). Success rates were greater in patients with aqueductal stenosis or tumors as compared to other etiologies. Complications occurred in 22 procedures (10.3%). Only one patient (0.5%) experienced a major complication. No surgical mortalities or laser-related complications occurred. CONCLUSION: This study demonstrates that LA-ETV is a safe and effective procedure that is comparable to other techniques for ETV. LA-ETV is most effective in patients aged 1 year and older and in patients with aqueductal stenosis and tumors, with a low major complication rate

Development and validation of a new instrument measuring guideline adherence in clinical practice

Background: Education in evidence-based medicine (EBM) is an important part of the postgraduate training of GPs. Evaluation of its effect on EBM behaviour in daily clinical practice is difficult and instruments are scarce. Working in accordance with guidelines is considered as one of the key indicators of EBM behaviour. Objective: To develop and validate an instrument assessing guideline adherence of GP trainees in clinical practice. Methods: We developed an instrument that assesses guideline adherence, taking conscious deviation into account. The instrument assesses guideline adherence on 59 different management decisions (diagnosis N = 17, therapy N = 20, referral N = 22) for 23 conditions as described in 27 different clinical practice guidelines. We validated this instrument using performance data as collected by third-year GP trainees on three important properties: validity, reliability and feasibility. Results: Performance data were collected by 76 GP trainees on 12106 patient consultations with 12587 different reasons for encounter. Overall, guideline adherence was 82% (95% confidence interval 77-88%). The significant correlation with the national GP knowledge test (r 0.33, P 0.004) showed the instrument to be a valid instrument. Interrater reliabilities (intraclass correlation coefficient) varied between moderate and excellent (0.64-1.00, P < 0.001). The instrument proved feasible with coverage of 24% (N = 3082) of reasons for encounter presented to GP trainees and a mean and median time of 1 minute to score a patient consultation. Conclusion: This instrument proved valid, reliable and feasible to assess guideline adherence among trainees in the clinical primary care setting

The Utrecht questionnaire (U-CEP) measuring knowledge on clinical epidemiology proved to be valid

Objectives: Knowledge on clinical epidemiology is crucial to practice evidence-based medicine. We describe the development and validation of the Utrecht questionnaire on knowledge on Clinical epidemiology for Evidence-based Practice (U-CEP); an assessment tool to be used in the training of clinicians. Study Design and Setting: The U-CEP was developed in two formats: two sets of 25 questions and a combined set of 50. The validation was performed among postgraduate general practice (GP) trainees, hospital trainees, GP supervisors, and experts. Internal consistency, internal reliability (item-total correlation), item discrimination index, item difficulty, content validity, construct validity, responsiveness, test-retest reliability, and feasibility were assessed. The questionnaire was externally validated. Results: Internal consistency was good with a Cronbach alpha of 0.8. The median item-total correlation and mean item discrimination index were satisfactory. Both sets were perceived as relevant to clinical practice. Construct validity was good. Both sets were responsive but failed on test-retest reliability. One set took 24 minutes and the other 33 minutes to complete, on average. External GP trainees had comparable results. Conclusion: The U-CEP is a valid questionnaire to assess knowledge on clinical epidemiology, which is a prerequisite for practicing evidence-based medicine in daily clinical practice

Incidence and management of acute otitis media in adults: a primary care-based cohort study

BACKGROUND: Although primarily considered a childhood disease, acute otitis media (AOM) also occurs in adults. Data on the burden of this condition in adults are, however, scarce. OBJECTIVE: To explore the primary care incidence and current management of AOM in adults. METHODS: All patients aged 15 and older included in the routine health care database of the Julius General Practitioners' Network were followed from 2015 to 2018 (contributing to a total of 1 261 575 person-years). We extracted data on AOM episodes, AOM-related consultations, comorbidities, and antibiotic and analgesic prescriptions. RESULTS: Five thousand three hundred and fifty-eight patients experienced one or more AOM episodes (total number of AOM episodes: 6667; mean 1.2 per patient). The overall AOM incidence was 5.3/1000 person-years and was fairly stable over the study period. Incidence was particularly high in atopic patients (7.3/1000 person-years) and declined with age (from 7.1 in patients 15-39 years of age to 2.7/1000 person-years in those aged 64 years and older). Oral antibiotics, predominantly amoxicillin, were prescribed in 46%, and topical antibiotics in 21% of all episodes. CONCLUSION: Over the past years, the incidence of AOM in adults in primary care has been stable. Oral antibiotic prescription rates resemble those in children with AOM, whereas a remarkably high topical antibiotic prescription rate was observed. Future prognostic research should inform on the need and feasibility of prospective studies into the best management strategy in this condition