Off-label use of antipsychotic medication in people with intellectual disabilities:adherence to guidelines, long-term effectiveness, and effects on quality of life

People with intellectual disabilities often use antipsychotic drugs long-term to reduce challenging behaviours. This thesis discusses the prescription practice, the relationship between long-term use of antipsychotics and quality of life, and the effects of discontinuation of risperidone. A survey of medical records showed insufficient adherence to guideline recommendations. Only a minority of the surveyed clients receives, in addition to an antipsychotic, a psychological treatment. The annual monitoring of side-effects is infrequent and does not take place for all clients, while only half of the clients attempted to discontinue the medication. Physicians and psychologists suggested that guideline recommendations should be further incorporated into organization-specific treatment policies of organizations to improve adherence. When people with intellectual disabilities use antipsychotics long-term, their quality of life is often lowered. Also, their mental well-being is often reduced, which is linked with the presence of challenging behaviours. Side-effects, such as parkinsonism and lowered bladder control, can affect physical well-being. Discontinuation of antipsychotics has a positive effect on physical well-being and only resulted in a temporary lowering of mental well-being. A placebo-controlled discontinuation study showed that withdrawal from risperidone is often possible without a worsening in challenging behaviours, except for a possible increase in stereotypical behaviour. The withdrawal of risperidone has a positive effect on physical health, due to a decrease in weight, waist circumference and an improvement of certain blood levels (prolactin and testosterone). Reducing antipsychotic drug use by people with intellectual disabilities is an important recommendation for clinical practice

The use of out-of-hours primary care during the first year of the COVID-19 pandemic

BACKGROUND: In the Netherlands, General Practitioners (GP) are usually the first point of contact with a health professional for most health problems. Out-of-hours (OOH) primary care is provided by regional OOH services. Changes in consultation rates at OOH services may be regarded as a warning system for failures elsewhere in the healthcare system. Therefore in this study, we investigated how the COVID-19 pandemic changed the use of primary care OOH services during the first year of the pandemic. METHODS: Routine electronic health records data were used from 60% of OOH services in the Netherlands, collected by the Nivel Primary Care Database. We compared consultation rates per week (2020) for COVID-19-like symptoms and other health problems (e.g. small traumas, urinary tract infections), for different age groups, the proportion of remote consultations, and different levels of urgency during the pandemic compared to the same period in 2019. RESULTS: The number of consultations for COVID-19-like symptoms peaked at the start of the COVID-19 pandemic, while consultations for other health problems decreased. These changes in consultation rates differed between age groups. Remote consultations took place more frequently for all health problems, while the proportion of non-urgent health problems increased. CONCLUSION: There were significant changes in the number of consultations and the proportion that were remote for COVID-19-like symptoms and other health problems. Especially care for babies and young children decreased, while the number of consultations for older adults remained stable. The continued use of OOH services by older adults suggests there were unmet care needs elsewhere in our healthcare system. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12913-022-08096-x

Patient experiences during the COVID-19 pandemic:A qualitative study in Dutch primary care

Background Changes in primary care provision during the COVID-19 pandemic could have affected patient experience of primary care both positively and negatively. Aim To assess the experiences of patients in primary care during the COVID-19 pandemic. Design & setting A qualitative study of patients from regions with high and low COVID-19 prevalence in the Netherlands. Method A qualitative study using a phenomenological framework was performed among purposively sampled patients. Individual semi-structured interviews were performed and transcribed. Data were thematically analysed by means of an inductive approach. Results Twenty-eight patients were interviewed (13 men and 15 women, aged 27–91 years). After thematic analysis, two main themes emerged: accessibility and continuity of primary care. Changes considered positive during the pandemic regarding accessibility and continuity of primary care included having a quieter practice, having more time for consultations, and the use of remote care for problems with low complexity. However, patients also experienced decreases in both care accessibility and continuity, such as feeling unwelcome, the GP postponing chronic care, seeing unfamiliar doctors, and care being segregated. Conclusion Despite bringing several benefits, patients indicated that the changes to primary care provision during the COVID-19 pandemic could have threatened care accessibility and continuity, which are core values of primary care. These insights can guide primary care provision not only in this and future pandemics, but also when implementing permanent changes to care provision in primary care

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

What can we learn from experiences in general practice during the COVID-19 pandemic?:A qualitative study

Background: Experiences with organizational changes in daytime general practices and out-of-hours (OOH) services during the COVID-19 pandemic may help to address the challenges in general practice care that were already a concern before the crisis. This study aimed to describe these experiences and the potential usefulness of the organizational changes for future general practice care and any future pandemics.Methods: Semi-structured interviews were performed among 11 directors of OOH services, and 19 (locum) general practitioners (GPs) or practice managers, who were purposively sampled. Video or telephone interviews were performed in two rounds: between November 2020 and January 2021 and between May 2021 and August 2021. The data were analyzed using thematic analysis methods.Results: Three themes emerged from the data: (1) Changes in the triage procedures; in GP practices and OOH services, stricter triage criteria were implemented, and GPs were more actively involved in the triage process. These measures helped to reduce the number of ‘low urgency’ face-to-face consultations. (2) Changes in GP care; there was a shift towards video and telephone consultations, allowing GPs to spend more time with patients during the remaining face-to-face consultations. For chronic patients, the shift towards telemonitoring appeared to encourage self-care, and postponing face-to-face consultations for regular checkups appeared to be unproblematic for stable patients. (3) Coordination of GP care and information communication flow during the COVID-19 pandemic; OOH directors perceived a lack of consistency in the information from various governmental and non-governmental parties on containment measures and guidelines related to COVID-19, making it difficult to act on them. The COVID-19 pandemic intensified collaboration between GPs, OOH services, and other healthcare professionals.Conclusions: The results of this study indicate that some of the organizational changes, such as stricter triage, remote consultations, and changes in managed care of chronic patients, may help in tackling the pre-existing challenges in GP care from before the COVID-19 pandemic. However, more extensive research and continuous monitoring are necessary to establish the effects on patients and their health outcomes. To navigate future pandemics, the intensified collaboration between health professionals should be maintained, while there is considerable room for improvement in the provision of unambiguous information.</p