Evaluation of practice nurses' management of paediatric psychosocial problems in general practice

Background Child mental health services are under major pressure worldwide. In the Netherlands, Youth Mental Health Practice Nurses (YMHPNs) have been introduced in general practice to improve access to care. In this study, we evaluated care delivered by YMHPNs.Methods We used medical records of a population-based cohort (21 717 children, 0-17 years). Characteristics of children consulting a YMHPN, type of problem, care delivered by YMHPNs and referrals were assessed using quantitative content analysis.Results Records of 375 children (mean age 12.9 years, 59.2% girl) were analysed. These children were often in their adolescence (57.3% was between 13 and 17 years), and more often female than male (59.2% vs 40.8%). YMHPNs had a median of four consultations (IQR 2-7) with the child. YMHPNs managed a variety of psychosocial problems. YMHPNs managed 22.4% of children without need of referral, 52.0% were eventually referred for additional care. 13.3% of children dropped out during the treatment trajectory. In the remaining 12.3% of children, the treatment trajectory was stopped because the child was already attending specialized services, the treatment trajectory was still ongoing or the medical record was inconclusive.Conclusions YMHPNs successfully managed one in four children with psychosocial problems without need for referral. Nevertheless, most children were eventually referred for additional care

The prevalence, incidence and management of low back pain with radiating leg pain in Dutch general practice:A population-based cohort study in the Rijnmond Primary Care Database

BACKGROUND: Radiating leg pain is common in patients with low back pain (LBP). In this study, we aimed to determine the prevalence and incidence of LBP with radiating leg pain in Dutch general practice, and to describe the prescribed medications and requested imaging diagnostics.METHODS: The Rijnmond Primary Care Database containing over 500,000 primary care patients was used to select patients ≥18 years with LBP with radiating leg pain between 2013 and 2021. Data on patient characteristics, LBP episodes, prescribed medication and requested imaging in the first 3 months of an episode was extracted. Descriptive statistics were used to present patient characteristics and diagnostic/therapeutic interventions.RESULTS: A total of 27,695 patients were included. The total number of LBP with radiating leg pain episodes in these patients was 36,268. In 2021, the incidence and prevalence were 19.1 and 25.7 per 1000 patient years, respectively. In 60% of patients, the episode duration was shorter than 1 month. In 62% of the episodes, patients visited the general practitioner (GP) one to two times. In 59% of the episodes, at least one medication was prescribed, non-steroidal anti-inflammatory drugs (NSAIDs) being the most common one (45%). In approximately 11% of the episodes, additional diagnostic imaging was requested.CONCLUSION: LBP with radiating leg pain is common in Dutch general practice patients. About 2/3rd were prescribed pain medications. Dutch request few to none diagnostic imaging for these patients which is in line with clinical practice guidelines.SIGNIFICANCE: In this new study, we have gained insights into the incidence and prevalence of LBP with radiating leg pain in Dutch general practice. Both remained fairly stable over the study period of 9 years (2013-2021). Overall, the care burden regarding seeking contact with the GPs and the requested diagnostics seem not to be that high. In 62% of the care episodes, there were one or two consultations with the GP, and in 11% of the episodes a diagnostic imaging was requested. Pain medications frequently prescribed (i.e. 2/3rd of the episodes), with NSAIDs being the most common ones.</p

Children and young people's consultation rates for psychosocial problems between 2016 and 2021 in the Netherlands

Background: Worldwide, there are concerns about declining mental health of children and young people (CYP).Objectives: To examine trends in GP consultation rates for psychosocial problems and the impact of the COVID-19 pandemic.Methods: We performed a population-based cohort study using electronic GP records of CYP (0-24 years) living in the Rotterdam metropolitan area between 2016 and 2021. We calculated monthly consultation rates for psychosocial problems, stratified by age group and sex. We used negative binomial models to model the pre-COVID-19 trend, and estimate expected rates post-COVID-19 onset. We modelled the effect of COVID-19 infection rate and school closure on consultation rates per sex and age group.Results: The cohort increased from 64801 to 92093 CYP between January 2016 and December 2021. Median age was 12.5 years and 49.3% was female. Monthly consultation rates increased from 2,443 to 4,542 consultations per 100,000 patient months over the six years. This trend (RR 1.009, 95%CI 1.008-1.011) started well before the COVID-19 pandemic. Consultation rates of adolescent girls and young women increased most strongly. Between March and May 2020, there was a temporary reduction in consultation rates, whereupon these returned to expected levels. COVID-19 infection rate and school closures showed small but significant associations with consultation rates for psychosocial problems but this did not affect the overall trend. Although consultation rates for psychosocial problems increased, this increment was stable over the entire study period.Conclusion: The COVID-19 pandemic did not significantly increase consultation rates for psychosocial problems in CYP. The consultation rates increased, especially in adolescent girls and young women

No Added Value of Duloxetine in Patients With Chronic Pain due to Hip or Knee Osteoarthritis:A Cluster-Randomized Trial

OBJECTIVE: To assess the effectiveness of duloxetine in addition to usual care in patients with chronic osteoarthritis (OA) pain. The cost‐effectiveness and whether the presence of symptoms of centralized pain alters the response to duloxetine were secondary objectives. METHODS: We conducted an open‐label, cluster‐randomized trial. Patients with chronic hip or knee OA pain who had an insufficient response to acetaminophen and nonsteroidal antiinflammatory drugs were included. Randomization took place at the general practice level, and patients received duloxetine (60 mg/day) in addition to usual care or usual care alone. The presence of centralized pain was defined as a modified PainDETECT Questionnaire score >12. The primary outcome measure was Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain scores (scale 0–20) at 3 months after the initiation of treatment. Our aim was to detect a difference between the groups of a clinically relevant effect of 1.9 points (effect size 0.4). We used a linear mixed model with repeated measurements to analyze the data. RESULTS: In total, 133 patients were included, and 132 patients were randomized into treatment groups. A total of 66 patients (at 31 practices) were randomized to receive duloxetine in addition to usual care, and 66 patients (at 35 practices) were randomized to receive usual care alone. We found no differences in WOMAC pain scores between the groups at 3 months (adjusted difference –0.58 [95% confidence interval (95% CI) –1.80, 0.63]) or at 12 months (adjusted difference –0.26 [95% CI –1.86, 1.34]). In the subgroup of patients with centralized pain symptoms, we also found no effect of duloxetine compared to usual care alone (adjusted difference –0.32 [95% CI –2.32, 1.67]). CONCLUSION: We found no effect of duloxetine added to usual care compared to usual care alone in patients with chronic knee or hip OA pain. Another trial including patients with centralized pain symptoms should be conducted to validate our results

The prevalence, incidence and management of low back pain with radiating leg pain in Dutch general practice:A population-based cohort study in the Rijnmond Primary Care Database

BACKGROUND: Radiating leg pain is common in patients with low back pain (LBP). In this study, we aimed to determine the prevalence and incidence of LBP with radiating leg pain in Dutch general practice, and to describe the prescribed medications and requested imaging diagnostics.METHODS: The Rijnmond Primary Care Database containing over 500,000 primary care patients was used to select patients ≥18 years with LBP with radiating leg pain between 2013 and 2021. Data on patient characteristics, LBP episodes, prescribed medication and requested imaging in the first 3 months of an episode was extracted. Descriptive statistics were used to present patient characteristics and diagnostic/therapeutic interventions.RESULTS: A total of 27,695 patients were included. The total number of LBP with radiating leg pain episodes in these patients was 36,268. In 2021, the incidence and prevalence were 19.1 and 25.7 per 1000 patient years, respectively. In 60% of patients, the episode duration was shorter than 1 month. In 62% of the episodes, patients visited the general practitioner (GP) one to two times. In 59% of the episodes, at least one medication was prescribed, non-steroidal anti-inflammatory drugs (NSAIDs) being the most common one (45%). In approximately 11% of the episodes, additional diagnostic imaging was requested.CONCLUSION: LBP with radiating leg pain is common in Dutch general practice patients. About 2/3rd were prescribed pain medications. Dutch request few to none diagnostic imaging for these patients which is in line with clinical practice guidelines.SIGNIFICANCE: In this new study, we have gained insights into the incidence and prevalence of LBP with radiating leg pain in Dutch general practice. Both remained fairly stable over the study period of 9 years (2013-2021). Overall, the care burden regarding seeking contact with the GPs and the requested diagnostics seem not to be that high. In 62% of the care episodes, there were one or two consultations with the GP, and in 11% of the episodes a diagnostic imaging was requested. Pain medications frequently prescribed (i.e. 2/3rd of the episodes), with NSAIDs being the most common ones.</p

Changes in the Diagnosis of Stroke and Cardiovascular Conditions in Primary Care During First 2 COVID-19 Waves in the Netherlands

BACKGROUND AND OBJECTIVES: Although there is evidence of disruption in acute cerebrovascular and cardiovascular care during the coronavirus disease 2019 (COVID-19) pandemic, its downstream effect in primary care is less clear. We investigated how the pandemic affected utilization of cerebrovascular and cardiovascular care in general practices (GPs) and determined changes in GP-recorded diagnoses of selected cerebrovascular and cardiovascular outcomes. METHODS: From electronic health records of 166,929 primary care patients aged 30 or over within the Rotterdam region, the Netherlands, we extracted the number of consultations related to cerebrovascular and cardiovascular care, and first diagnoses of selected cerebrovascular and cardiovascular risk factors (hypertension, diabetes, lipid disorders), conditions, and events (angina, atrial fibrillation, TIA, myocardial infarction, stroke). We quantified changes in those outcomes during the first COVID-19 wave (March–May 2020) and thereafter (June–December 2020) by comparing them to the same period in 2016–2019. We also estimated the number of potentially missed diagnoses for each outcome. RESULTS: The number of GP consultations related to cerebrovascular and cardiovascular care declined by 38% (0.62, 95% confidence interval 0.56–0.68) during the first wave, as compared to expected counts based on prepandemic levels. Substantial declines in the number of new diagnoses were observed for cerebrovascular events: 37% for TIA (0.63, 0.41–0.96) and 29% for stroke (0.71, 0.59–0.84), while no significant changes were observed for cardiovascular events (myocardial infarction [0.91, 0.74–1.14], angina [0.77, 0.48–1.25]). The counts across individual diagnoses recovered following June 2020, but the number of GP consultations related to cerebrovascular and cardiovascular care remained lower than expected throughout the June to December period (0.93, 0.88–0.98). DISCUSSION: While new diagnoses of acute cardiovascular events remained stable during the COVID-19 pandemic, diagnoses of cerebrovascular events declined substantially compared to prepandemic levels, possibly due to incorrect perception of risk by patients. These findings emphasize the need to improve symptom recognition of cerebrovascular events among the general public and to encourage urgent presentation despite any physical distancing measures

Demographic characteristics and quality of life of patients with unexplained complaints: a descriptive study in general practice

OBJECTIVE: About 13% of GPs' consultations involve unexplained complaints (UCs). These complaints can progress to chronic conditions like medically unexplained symptoms, chronic functional symptoms or somatoform disorders. Little is known about the demographic characteristics and quality of life of patients with early stage UCs. Our study objective was to describe these characteristics. Additionally we compared them with other patient groups to serve as a frame of reference. METHODS: Descriptive study in general practices. Patients with early stage UCs who had not had elaborate diagnostic investigations were included. Demographic characteristics were compared to a Dutch general practice population. Quality of life scores were measured with the RAND-36 and compared to another Dutch general practice population and to depressed patients. RESULTS: Data of 466 patients were available for analysis. Mean age was 44 years and 74% were females, mostly higher educated. Of the patients, 63% presented with unexplained fatigue. On average, quality of life was poor (mean RAND-36 domain scores 37-73), also in comparison with other groups. CONCLUSION: General practice patients presenting with UCs have a remarkably poor quality of life. Future research should explore how early identification of patients at risk of developing chronicity can take place. Awareness of potential poor quality of life may influence GPs' medical decision makin

Dizziness reported by elderly patients in family practice: prevalence, incidence, and clinical characteristics

Background: Although dizziness in elderly patients is very common in family practice, most prevalence studies on dizziness are community-based and include a study population that is not representative of family practice. The aim of this study was to investigate the prevalence and incidence of dizziness reported by elderly patients in family practice, to describe their final diagnoses as recorded by the family physician, and to compare the clinical characteristics of dizzy patients with those of non-dizzy patients. Methods: Data were obtained from the Second Dutch National Survey of General Practice, a prospective registration study which took place over a 12-month period in 2001. We developed a search strategy consisting of 15 truncated search terms (based on Dutch synonyms for dizziness), and identified all patients aged 65 or older who visited their family physician because of dizziness (N=3,990). We used the mid-time population as denominator to calculate the prevalence and incidence, and for group comparisons we used the Student's t and Chi-square test, and logistic regression analysis. Results: The one-year prevalence of dizziness in family practice in patients aged 65 or older was 8.3%, it was higher in women than in men, and it increased with age. In patients aged 85 or older the prevalence was similar for men and women. The incidence of dizziness was 47.1 per 1000 person-years. For 39% of the dizzy patients the family physicians did not specify a diagnosis, and recorded a symptom diagnosis as the final diagnosis. Living alone, lower level of education, pre-existing cerebrovascular disease, and pre-existing hypertension were independently associated with dizziness. Conclusions: Dizziness in family practice patients increases with age. It is more common in women than in men, but this gender difference disappears in the very old. Because a large proportion of dizzy elderly patients in family practice remains undiagnosed, it would be worthwhile to carry out more diagnostic research on dizziness in a family practice setting

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