Preclinical rheumatoid arthritis

Dijkmans, B.A.C. [Promotor]Schaardenburg, D. van [Copromotor]Horst-Bruinsma, I.E. van der [Copromotor

Recording of weight in electronic health records:An observational study in general practice

Background Routine weight recording in electronic health records (EHRs) could assist general practitioners (GPs) in the identification, prevention, and management of overweight patients. However, the extent to which weight management is embedded in general practice in the Netherlands has not been investigated. The purpose of this study was to evaluate the frequency of weight recording in general practice in the Netherlands for patients who self-reported as being overweight. The specific objectives of this study were to assess whether weight recording varied according to patient characteristics, and to determine the frequency of weight recording over time for patients with and without a chronic condition related to being overweight. Methods Baseline data from the Occupational and Environmental Health Cohort Study (2012) were combined with data from EHRs of general practices (2012–2015). Data concerned 3446 self-reported overweight patients who visited their GP in 2012, and 1516 patients who visited their GP every year between 2012 and 2015. Logistic multilevel regression analyses were performed to identify associations between patient characteristics and weight recording. Results In 2012, weight was recorded in the EHRs of a quarter of patients who self-reported as being overweight. Greater age, lower education level, higher self-reported body mass index, and the presence of diabetes mellitus, chronic obstructive pulmonary disease, and/or cardiovascular disorders were associated with higher rates of weight recording. The strongest association was found for diabetes mellitus (adjusted OR = 10.3; 95% CI [7.3, 14.5]). Between 2012 and 2015, 90% of patients with diabetes mellitus had at least one weight measurement recorded in their EHR. In the group of patients without a chronic condition related to being overweight, this percentage was 33%. Conclusions Weight was frequently recorded for overweight patients with a chronic condition, for whom regular weight measurement is recommended in clinical guidelines, and for which weight recording is a performance indicator as part of the payment system. For younger patients and those without a chronic condition related to being overweight, weight was less frequently recorded. For these patients, routine recording of weight in EHRs deserves more attention, with the aim to support early recognition and treatment of overweight

Cardiovascular disease prevalence in patients with inflammatory arthritis, diabetes mellitus and osteoarthritis: a cross-sectional study in primary care

<p>Abstract</p> <p>Background</p> <p>There is accumulating evidence for an increased cardiovascular burden in inflammatory arthritis, but the true magnitude of this cardiovascular burden is still debated. We sought to determine the prevalence rate of non-fatal cardiovascular disease (CVD) in inflammatory arthritis, diabetes mellitus and osteoarthritis (non-systemic inflammatory comparator) compared to controls, in primary care.</p> <p>Methods</p> <p>Data on CVD morbidity (ICPC codes K75 (myocardial infarction), K89 (transient ischemic attack), and/or K90 (stroke/cerebrovascular accident)) from patients with inflammatory arthritis (n = 1,518), diabetes mellitus (n = 11,959), osteoarthritis (n = 4,040) and controls (n = 158,439) were used from the Netherlands Information Network of General Practice (LINH), a large nationally representative primary care based cohort. Data were analyzed using multi-level logistic regression analyses and corrected for age, gender, hypercholesterolemia and hypertension.</p> <p>Results</p> <p>CVD prevalence rates were significantly higher in inflammatory arthritis, diabetes mellitus and osteoarthritis compared with controls. These results attenuated - especially in diabetes mellitus - but remained statistically significant after adjustment for age, gender, hypertension and hypercholesterolemia for inflammatory arthritis (OR = 1.5 (1.2-1.9)) and diabetes mellitus (OR = 1.3 (1.2-1.4)). The association between osteoarthritis and CVD reversed after adjustment (OR = 0.8 (0.7-1.0)).</p> <p>Conclusions</p> <p>These results confirm an increased prevalence rate of CVD in inflammatory arthritis to levels resembling diabetes mellitus. By contrast, lack of excess CVD in osteoarthritis further suggests that the systemic inflammatory load is critical to the CVD burden in inflammatory arthritis.</p

Reliably estimating prevalences of atopic children: An epidemiological study in an extensive and representative primary care database

Electronic health records stored in primary care databases might be a valuable source to study the epidemiology of atopic disorders and their impact on health-care systems and costs. However, the prevalence of atopic disorders in such databases varies considerably and needs to be addressed. For this study, all children aged 0-18 years listed in a representative primary care database in the period 2002-2014, with sufficient data quality, were selected. The effects of four different strategies on the prevalences of atopic disorders were examined: (1) the first strategy examined the diagnosis as recorded in the electronic health records, whereas the (2) second used additional requirements (i.e., the patient had at least two relevant consultations and at least two relevant prescriptions). Strategies (3) and (4) assumed the atopic disorders to be chronic based on strategy 1 and 2, respectively. When interested in cases with a higher probability of a clinically relevant disorder, strategy 2 yields a realistic estimation of the prevalence of atopic disorders derived from primary care data. Using this strategy, of the 478,076 included children, 28,946 (6.1%) had eczema, 29,182 (6.1%) had asthma, and 28,064 (5.9%) had allergic rhinitis; only 1251 (0.3%) children had all three atopic disorders. Prevalence rates are highly dependent on the clinical atopic definitions used. The strategy using cases with a higher probability of clinically relevant cases, yields realistic prevalences to establish the impact of atopic disorders on health-care systems. However, studies are needed to solve the problem of identifying atopic disorders that are missed or misclassified

Risks for comorbidity in children with atopic disorders: an observational study in Dutch general practices

OBJECTIVE: This study aimed to investigate both atopic and non-atopic comorbid symptoms and diseases in children with physician-diagnosed atopic disorders (atopic eczema, asthma and allergic rhinitis).METHODS: All children aged 0-18 years listed in a nationwide primary care database (the Netherlands Institute for Health Services Research-Primary Care Database) with routinely collected healthcare data in 2014 were selected. Children with atopic disorders were matched on age and gender with non-atopic controls within the same general practice. A total of 404 International Classification of Primary Care codes were examined. Logistic regression analyses were performed to examine the associations between the presence of atopic disorders and (non-)atopic symptoms and diseases by calculating ORs.RESULTS: Having one of the atopic disorders significantly increased the risk of having other atopic-related symptoms, even if the child was not registered as having the related atopic disorder. Regarding non-atopic comorbidity, children with atopic eczema (n=15 530) were at significantly increased risk for (infectious) skin diseases (OR: 1.2-3.4). Airway symptoms or (infectious) diseases (OR: 2.1-10.3) were observed significantly more frequently in children with asthma (n=7887). Children with allergic rhinitis (n=6835) had a significantly distinctive risk of ear-nose-throat-related symptoms and diseases (OR: 1.5-3.9). Neither age nor gender explained these increased risks.CONCLUSION: General practitioners are not always fully aware of relevant atopic and non-atopic comorbidity. In children known to have at least one atopic disorder, specific attention is required to avoid possible insufficient treatment and unnecessary loss of quality of life

Calculating incidence rates and prevalence proportions: not as simple as it seems

Background: Incidence rates and prevalence proportions are commonly used to express the populations health status. Since there are several methods used to calculate these epidemiological measures, good comparison between studies and countries is difficult. This study investigates the impact of different operational definitions of numerators and denominators on incidence rates and prevalence proportions. Methods: Data from routine electronic health records of general practices contributing to NIVEL Primary Care Database was used. Incidence rates were calculated using different denominators (person-years at-risk, person-years and midterm population). Three different prevalence proportions were determined: 1 year period prevalence proportions, pointprevalence proportions and contact prevalence proportions. Results: One year period prevalence proportions were substantially higher than point-prevalence (58.3 - 206.6%) for long-lasting diseases, and one year period prevalence proportions were higher than contact prevalence proportions (26.2 - 79.7%). For incidence rates, the use of different denominators resulted in small differences between the different calculation methods (-1.3 - 14.8%). Using person-years at-risk or a midterm population resulted in higher rates compared to using person-years. Conclusions: All different operational definitions affect incidence rates and prevalence proportions to some extent. Therefore, it is important that the terminology and methodology is well described by sources reporting these epidemiological measures. When comparing incidence rates and prevalence proportions from different sources, it is important to be aware of the operational definitions applied and their impact

Cost-Effectiveness of Including a Nurse Specialist in the Treatment of Urinary Incontinence in Primary Care in the Netherlands.

#### Objective Incontinence is an important health problem. Effectively treating incontinence could lead to important health gains in patients and caregivers. Management of incontinence is currently suboptimal, especially in elderly patients. To optimise the provision of incontinence care a global optimum continence service specification (OCSS) was developed. The current study evaluates the costs and effects of implementing this OCSS for community-dwelling patients older than 65 years with four or more chronic diseases in the Netherlands. #### Method A decision analytic model was developed comparing the current care pathway for urinary incontinence in the Netherlands with the pathway as described in the OCSS. The new care strategy was operationalised as the appointment of a continence nurse specialist (NS) located with the general practitioner (GP). This was assumed to increase case detection and to include initial assessment and treatment by the NS. The analysis used a societal perspective, including medical costs, containment products (out-of-pocket and paid by insurer), home care, informal care, and implementation costs. #### Results With the new care strategy a QALY gain of 0.005 per patient is achieved while saving €402 per patient over a 3 year period from a societal perspective. In interpreting these findings it is important to realise that many patients are undetected, even in the new care situation (36%), or receive care for containment only. In both of these groups no health gains were achieved. #### Conclusion Implementing the OCSS in the Netherlands by locating a NS in the GP practice is likely to reduce incontinence, improve quality of life, and reduce costs. Furth

Preventie in de huisartsenpraktijk anno 2008: de vroege opsporing van hart- en vaatziekten, diabetes mellitus en nierziekten.

Ongeveer een kwart van de huisartsen zegt patiënten actief op te roepen voor preventieve metingen voor hart- en vaatziekten, diabetes en nierziekte. En bijna alle huisartsen doen dit soort metingen als mensen met een groot risico, door erfelijke aanleg, overgewicht en roken, op het spreekuur komen. Huisartsen zijn ín voor preventie: het preventieconsult komt eraan. APK bij de huisarts Preventie is hot. We willen ziekten niet meer alleen genezen, maar liever voorkomen of uitstellen. Commerciële bedrijven adverteren met Total body scans of een Lichaams-APK en ook de overheid heeft preventie door maatregelen voor leefstijl, voeding en beweging hoog op de agenda staan. Omdat de drempel naar de huisarts laag is, kan deze een belangrijke rol spelen in preventie. De huisartsenorganisaties NHG en LHV werken daarvoor samen met de Nederlandse Hartstichting, het Diabetes Fonds, en Nierstichting Nederland. Deze drie organisaties hebben een cardiometabole module laten ontwikkelen om mensen met een verhoogd risico op hart- en vaatziekten, diabetes en chronische nierziekten op te sporen. Deze module is een belangrijk onderdeel van het preventieconsult dat wordt ingevoerd in de huisartsenpraktijk. Risicofactoren Met subsidie van deze drie gezondheidsfondsen onderzocht het NIVEL de houding van huisartsen in Nederland ten opzichte van preventie en het preventieconsult. Huisartsen staan vooral positief tegenover preventie van hart- en vaatziekten, diabetes en chronische nierziekten, blijkt uit het onderzoek. Voor preventie van kanker en psychische problemen is nog wat minder belangstelling. Huisartsen doen vooral preventieve metingen naar aanleiding van leeftijd en risicofactoren zoals erfelijke aanleg, overgewicht en roken. Praktijkondersteuner Bij preventie houden huisartsen nog wel veel in eigen hand. Ze hoeven niet alles zelf te doen. Veel preventieve taken kunnen worden overgenomen door een praktijkondersteuner en huisartsen kunnen patiënten ook doorverwijzen naar de fysiotherapeut of bijvoorbeeld voor het stoppen met roken naar de GGD. Onderzoeksmethode Voor het onderzoek stuurden de onderzoekers een vragenlijst aan 1100 huisartsen. De gegevens zijn gebaseerd op 330 vragenlijsten die ingevuld zijn teruggestuurd. De respondenten vormen een goede afspiegeling van alle huisartsen in Nederland

Atopic children and use of prescribed medication: a comprehensive study in general practice

These datasets contain information about children aged 0-18 years listed in the NIVEL Primary Care Database in 2014 diagnosed with atopic disorders (atopic eczema, asthma, allergic rhinitis or all three diseases) and matched controls (not diagnosed with any of these disorders) within the same general practice on age and gender. In this study we studied the associations between having an atopic disorder and prescribed medication by the GP

Evaluatie campagne 'Stop beginnende nierziekte'.

Ruim een miljoen De Nierstichting begon in september 2006 de campagne ‘Stop beginnende nierziekte’. Met als doel mensen met een beginnende nierziekte op te sporen, waardoor de ziekte eerder kan worden behandeld. Via televisie en kranten werden Nederlanders van 18 jaar en ouder opgeroepen de gratis Niercheck uit te voeren, een test die eiwit in de urine opspoort. 1,2 miljoen Nederlanders deden de Niercheck. NIVEL-onderzoeker Robert Verheij: “Dat is veel, meer dan we hadden verwacht.” Campagne Het NIVEL evalueerde de campagne voor de Nierstichting. Twintig procent van de mensen die de Niercheck deden had een ongunstige (positieve) uitslag: 19% zwak positief en 1% sterk positief. Onder de mensen met een zwak positieve uitslag zaten er waarschijnlijk veel met een ‘fout-positieve’ test. Dit betekent dat ze wel een positieve test-uitslag hadden, terwijl er bij hen geen sprake was van teveel eiwit in de urine. Voor het onderzoek vulden 100.000 mensen die de Niercheck uitvoerden een vragenlijst in. Bij 17 van hen werd een nierziekte ontdekt, bij 269 mensen werd geconstateerd dat zij inderdaad teveel eiwit in de urine hadden. Bij 140 van hen werd een hoge bloeddruk ontdekt en bij 27 suikerziekte. Met enige voorzichtigheid kunnen we deze cijfers omslaan naar de 1,2 miljoen mensen die de Niercheck deden. Het effect van de Niercheck ligt dan in de volgende orde van grootte: 200 ontdekte mensen met een nierziekte, van rond de 3200 mensen staat vast dat ze teveel eiwit in hun urine hebben, rond de 1600 ontdekte mensen met hoge bloeddruk en rond de 300 met diabetes. Niet gealarmeerd Verrassend is dat slechts één op de vier mensen met een positieve testuitslag de huisarts bezocht. Kennelijk maakte de Nederlander zich niet al te druk om een positieve testuitslag. Verheij: “In onze optiek is de Niercheck te vrijblijvend. De Niercheck moet nog worden verbeterd. Het is allereerst belangrijk dat het aantal fout-positieven fors afneemt. Nu krijgen teveel mensen een positieve testuitslag, terwijl er niets aan de hand is. Dat zou beter moeten.” Daarnaast is het belangrijk ervoor te zorgen dat mensen met een positieve testuitslag wel naar hun huisarts gaan, zodat deze kan nagaan wat er aan de hand is. Eén manier om die vrijblijvendheid te bestrijden is de campagne in te bedden in de bestaande gezondheidszorg, bijvoorbeeld in de huisartsenzorg. Dit soort verbeteringen maken de Niercheck een effectiever en efficiënter instrument. Het onderzoek Het onderzoek werd uitgevoerd onder de eerste 1 miljoen aanvragers van de Niercheck. Inmiddels is het aantal aanvragers van de Niercheck opgelopen tot 1,2 miljoen. Ongeveer 100.000 van de eerste aanvragers vulden ook een internetvragenlijst in. Daarin werd onder meer gevraagd naar de uitslag van de test en eventuele vervolgacties. Daarnaast is er een schriftelijke vragenlijst afgenomen bij 840 deelnemers aan het Consumentenpanel Gezondheidszorg van het NIVEL, en een telefonische vragenlijst bij een steekproef van 171 huisartsen