Expectations and Perceptions of Dutch Pharmacy Staff Regarding a New Framework for Continence Care:A Focus Group Study

Based on complaints that patients with urinary incontinence were not receiving the correct medical aids, the Dutch Ministry of Health, Wellbeing, and Sports requested further exploration. This resulted in a new framework based on considering individual activities of daily living when providing continence products. We aimed to explore the expectations of pharmacy staff regarding this new framework for continence care in the Netherlands and to establish the facilitators and barriers associated with that care. In total, 15 participants from 7 different pharmacies participated in 2 focus groups. Data analysis was by thematic content analysis. Pharmacy employees were positive about the idea of considering individual daily activities when providing continence products in the new framework, but they did have some reservations about the feasibility of implementation in daily practice. Barriers to optimal continence care included low reimbursement for patients with incontinence, especially with non-standard needs, and poor communication between the various stakeholders in continence care. Efforts must be extended to review the current reimbursement system and to change the policies and information provided by stakeholders in continence care, before the new framework will make a real impact in clinical practice

Evaluation of the First Year(s) of Physicians Collaboration on an Interdisciplinary Electronic Consultation Platform in the Netherlands:Mixed Methods Observational Study

BACKGROUND: Complexity of health problems and aging of the population create an ongoing burden on the health care system with the general practitioner (GP) being the gatekeeper in primary care. In GPs daily practice, collaboration with specialists and exchange of knowledge from the secondary care play a crucial role in this system. Communication between primary and secondary care has shortcomings for health care workers that want to practice sustainable patient-centered health care. Therefore, a new digital interactive platform was developed: Prisma. OBJECTIVE: This study aims to describe the development of a digital consultation platform (Prisma) to connect GPs with hospital specialists via the Siilo application and to evaluate the first year of use, including consultations, topic diversity, and number of participating physicians. METHODS: We conducted a mixed methods observational study, analyzing qualitative and quantitative data for cases posted on the platform between June 2018 and May 2020. Any GP can post questions to an interdisciplinary group of secondary care specialists, with the platform designed to facilitate discussion and knowledge exchange for all users. RESULTS: In total, 3674 cases were posted by 424 GPs across 16 specialisms. Most questions and answers concerned diagnosis, nonmedical treatment, and medication. Mean response time was 76 minutes (range 44-252). An average of 3 users engaged with each case (up to 7 specialists). Almost half of the internal medicine cases received responses from at least two specialisms in secondary care, contrasting with about one-fifth for dermatology. Of note, the growth in consultations was steepest for dermatology. CONCLUSIONS: Digital consultations offer the possibility for GPs to receive quick responses when seeking advice. The interdisciplinary approach of Prisma creates opportunities for digital patient-centered networking

Effectiveness of a newly developed online self-management program for male patients with uncomplicated lower urinary tract symptoms

AIMS: To explore the effect of an online self-management program in secondary care for men with lower urinary tract symptoms (LUTS). METHODS: We performed a prospective nonrandomized double-cohort pilot study of consecutive adult men referred with uncomplicated LUTS to three urology outpatient departments. Men in both cohorts received care as usual from a urologist, but men in the intervention cohort also had access to an online self-management program. Outcomes were assessed after 6 and 12 weeks: LUTS severity was assessed with the International Prostate Symptom Score (IPSS), the Overactive Bladder Questionnaire (OABq), and the Perceived Global Impression of Improvement (PGI-I). The main outcome of interest was a clear improvement in the PGI-I scores ("much better" or "very much better"). RESULTS: Age, symptom severity, and quality of life scores were comparable between the intervention (n = 113) and standard care (n = 54) cohorts. Clear improvement in the PGI-I scores was reported after 12 weeks in 19.4% and 26.1% of men in the intervention and standard care cohorts, respectively. However, logistic regression analysis indicated that the difference between cohorts was not significant. Multivariable linear regression analysis also indicated no significant differences between cohorts for the IPSS or the OABq score at either assessment point. Notably, the uptake of the intervention was low (53%). CONCLUSIONS: We found no significant benefit from adding an online self-management program to standard care for men with LUTS, probably due to the low uptake of the intervention that may have resulted from the timing in the care pathway

Evidence-based Urology:Understanding Heterogeneity in Systematic Reviews

Variability in the results of randomized trials presents challenges to the interpretation and application of the evidence to patient care. Understanding how systematic reviews deal with this problem of "heterogeneity" will help clinicians in applying results in their patient management. This manuscript offers a review of heterogeneity from the clinical urological perspective.  PATIENT SUMMARY: Systematic reviews of the literature are necessary to accurately summarize the available evidence to inform clinical decisions. In this mini-review, we explain how to understand and deal with the differences between studies-which we call heterogeneity-included in these types of reviews

Determining the minimal important differences in the International Prostate Symptom Score and Overactive Bladder Questionnaire:results from an observational cohort study in Dutch primary care

OBJECTIVES: To determine the minimal important difference (MID) of the International Prostate Symptom Score (IPSS) and the Overactive Bladder Questionnaire short form (OAB-q SF) assessed in primary care among patients treated for lower urinary tract symptoms (LUTS).DESIGN: Single-arm, open-label observational cohort study with a 6-week follow-up.SETTING: Twenty-two pharmacies in the Netherlands.PARTICIPANTS: We enrolled Dutch men with uncomplicated LUTS who received a new alpha-blocker prescription from their general practitioner or urologist.PRIMARY AND SECONDARY OUTCOMES: The IPSS and OAB-q SF were completed before and after 6 weeks of therapy. At 6 weeks, men also completed the Patient Global Impression of Improvement (PGI-I). The mean change scores of the IPSS and OAB-q SF were calculated for each PGI-I outcome category, with the category 'a little better' used to determine the MID. The SE of measurement (SEM) was calculated for each questionnaire.RESULTS: In total, 165 men completed follow-up. The MID was 5.2 points (95% CI 3.9 to 6.4; SEM 3.6) for the IPSS and 11.0 points (95% CI 7.1 to 14.9; SEM 9.7) for the OAB-q SF. For both questionnaires, CIs showed an overlap with the no-change categories. However, the MID for the IPSS was higher in men with severe baseline symptoms (7.1; 95% CI 5.3 to 9.0) than in men with moderate baseline symptoms (3.2; 95% CI 1.7 to 4.8).CONCLUSION: In this study, the MID for the IPSS was considerably higher than the MID of 3.1 reported in the only other study on this topic, but may be due to methodological differences. Interpretation of the MID for the OAB-q SF is hampered by the overlap with the SEM. Future studies are needed to confirm our results because correlations between the PGI-I and symptom questionnaires were suboptimal.</p

Discontinuation of alpha-blocker therapy in men with lower urinary tract symptoms:a systematic review and meta-analysis

OBJECTIVES: We aimed to synthesise the available data for the effect of stopping alpha-blocker therapy among men with lower urinary tract symptoms. The focus was on symptom, uroflowmetry and quality of life outcomes, but we also reviewed the adverse events (AEs) and the number of patients who restarted therapy.DATA SOURCES: We searched MEDLINE/PubMed, EMBASE/Ovid and The Cochrane Central Register of Controlled Trials from inception to May 2018.ELIGIBILITY CRITERIA: We selected studies regardless of study design in which men were treated with an alpha-blocker for at least 3 months and in which the effects of alpha-blocker discontinuation were subsequently studied. Only controlled trials were used for the primary objective.DATA EXTRACTION AND SYNTHESIS: Two reviewers independently extracted data and assessed the risk of bias for the controlled studies only using the Cochrane Collaboration's tool for assessing risk of bias. Data were pooled using random-effects meta-analyses.RESULTS: We identified 10 studies (1081 participants) assessing the primary objective. Six studies (733 participants) assessed differences in AEs between continuation and discontinuation, and six studies (501 participants) reported the numbers of subjects that restarted treatment after discontinuation. No studies in primary care were identified. After discontinuing monotherapy, symptom scores increased and peak flow rates decreased at 3 and 6 months, but not at 12 months; however, neither parameter changed when alpha-blockers were stopped during combination therapy. Small differences in post-void residual volumes and quality of life scores were considered clinically irrelevant. We also found that 0%-49% of patients restarted after stopping alpha-blocker therapy and that AEs did not increase with discontinuation.CONCLUSIONS: Discontinuing alpha-blocker monotherapy leads to a worsening compared with continuing therapy. Discontinuing the alpha-blocker after combination therapy had no significant effects on outcomes in either the short or long term. Discontinuation may be appropriate for the frail, elderly or those with concomitant illness or polypharmacy. However, studies in primary care are lacking.PROSPERO REGISTRATION NUMBER: CRD42016032648.</p

Impact of digital interdisciplinary consultation on secondary care referrals by general practitioners:a protocol for a stepped-wedge cluster randomised controlled trial

INTRODUCTION: Optimal collaboration between general practice and hospital care is crucial to maintain affordable and sustainable access to healthcare for the entire population. General practitioners (GPs) are the gatekeepers to specialist care and patients will visit hospitals mostly only after referral. However, a substantial part of these referrals may be inappropriate, as communication between GPs and medical specialists can be challenging and referring patients may be the most obvious action for a GP to perform.A new digital platform (Prisma) connects GPs and specialists in interdisciplinary groups and facilitates asynchronous, accessible and fast teleconsultation within the group. No previous research has been done to evaluate the impact of this new platform on the referral rates to the hospital. METHODS AND ANALYSIS: A stepped-wedge randomised controlled trial (RCT) will be performed in Zwolle region in the Netherlands to analyse the effect of introduction of the platform on rate of inappropriate referrals to orthopaedic surgery. In four steps, GPs in the region will be given access to the platform. GPs will be part of the control condition until randomisation to the intervention. According to our sample size calculation, we need to include 18 practices with 1008 patients presenting with hip and knee symptoms. Routine care data of hospital registrations will be analysed to calculate the rate of inappropriate referrals (primary outcome). Secondary outcome are costs, primary and secondary care workload, posted cases and user satisfaction. Alongside this quantitative analysis, we will evaluate patient experience, facilitators and barriers for use of the platform. ETHICS AND DISSEMINATION: The medical ethics review board of University Medical Center Groningen (UMCG), the Netherlands (METc-number: 2021/288) has confirmed that the Medical Research Involving Human Subjects Act (WMO) does not apply to the process evaluation because the study does not involve randomisation of patients or different medical treatments (letter number: M21.275351). TRIAL REGISTRATION NUMBER: NL9704

Recruitment through media and general practitioners resulted in comparable samples in an RCT on incontinence

Objectives: The objective of the study was to assess the impact of recruitment strategy on the baseline characteristics of patients recruited in a randomized controlled trial for treating women with urinary incontinence. Study Design and Setting: We conducted a cross-sectional analysis of baseline data from an earlier trial. Women were recruited through the media (including social media) or from participating general practices. Baseline characteristics were compared by univariate testing. Logistic regression analysis was performed to study the association between recruitment type and multiple baseline characteristics. Results: The only differences between recruitment methods were in patient age, with those recruited through the media being significantly older than those recruited through general practice. The mean age difference was 5.0 years (95% confidence interval: 2.2–7.9). Conclusion: Samples recruited through the media and through case identification were largely comparable. Therefore, recruitment through the media may be a viable alternative to recruitment through primary care. This may be especially relevant for research on eHealth treatment for conditions with which patients experience barriers when seeking health care

Identifying women's preferences for treatment of urinary tract infection:a discrete choice experiment

OBJECTIVE: To identify the preferences of women regarding management of urinary tract infections (UTIs). DESIGN: A discrete choice experiment of the preferences for certain treatment attributes was conducted by survey. Attributes included treatment duration, time to complaint resolution, complication risk, side effect risk and contribution to antimicrobial resistance. SETTING: General population in the Netherlands, recruited via social media. PARTICIPANTS: Women aged 18 years or older. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was the relative importance of the attributes for treatment choice, using a conditional logit model. The secondary outcome was the heterogeneity in these preferences. RESULTS: The discrete choice experiment was completed by 833 women. Most attributes were important to decisions for UTI treatment. Women were willing to accept management with, for example, a higher chance of complications or longer time to resolution, if it could help avoid antimicrobial resistance. However, there was heterogeneity in the preferences. Women who had one previous UTI had a stronger preference for faster symptom resolution compared with those who had no previous UTI. Younger women also preferred faster symptom resolution. Finally, women with a low or middle education level gave less importance to preventing antimicrobial resistance than women with a high education level. CONCLUSIONS: The current study indicated that a considerable part of women valued alternatives to antimicrobial treatment and were prepared to tolerate management that was less optimal in certain respects to avoid antimicrobial treatment

Perspective of Dutch healthcare professionals on care for female urinary incontinence:A mixed-methods study

Introduction and hypothesis : Health care professionals (HCP) can reveal practical recommendations to improve processes and address challenges in the care of women with urinary incontinence (UI) in the Netherlands.Methods : We conducted an exploratory, sequential, mixed-methods study among HCPs, using the outcomes of six focus group sessions (30 HCPs) to inform a subsequent survey. HCPs included general practitioners (GPs), practice assistants (PAs), pelvic physiotherapists (PPTs), and urologists and gynecologists (UGs).Results : The main themes arising from the six focus group sessions (with 6 GPs, 7 PAs, 6 (resident) UGs, 8 PPTs, and 7 PPTs) were “identification of UI,” “current state of care,” and “guiding patients through the healthcare system.” The survey respondents included 351 PAs, 124 GPs, 75 PPTs, and 183 UGs. Of these 741 respondents, 72.8% (strongly) agreed that the identification of UI in general practice required improvement and 60% confirmed the need for further education on this topic. Most HCPs (83.1%) found it useful to offer women a patient information leaflet when buying incontinence products, but less useful to ask about UI routinely in specific scenarios, and most (75%) agreed that a multidisciplinary guideline could improve healthcare. Interestingly, 86% of PPTs and 21% of UGs advocated referral to a PPT before referral to a specialist, while 87% of PPTs wanted primary care services to offer a UI consultation hour and 36% of the GPs (strongly) disagreed.Conclusion : Poor UI identification in primary care and a lack of patient guidance through the health care system hamper continence care provision