Impact of Individual Risk Assessment on Prostate Cancer Diagnosis

Current prostate-specific antigen screening practice leads to two important unwanted side effects; first of all screening induces many unnecessary prostate biopsies and secondly it leads to overdiagnosis and overtreatment of prostate cancer. The large amount of unnecessary prostate biopsies, as well as the overdiagnosis and overtreatment might be reduced by using prediction models. These models, using individual risk estimations, support the identification of men at increased risk for prostate cancer and the identification of potentially indolent disease after a prostate cancer diagnosis. Traditionally, urologists have not used prediction models in their standard practice. The aim of this thesis was testing a decision aid for men considering prostate-specific antigen testing and applying risk-based strategies. The data of the studies described in this thesis are the result of an active implementation of these tools

Association between person and disease related factors and the planned diabetes care in people who receive person-centered type 2 diabetes care : An implementation study

AIMS: To assess the planned diabetes care for the coming year and its associated factors in patients with Type 2 diabetes who have a person-centered annual consultation. METHODS: Implementation study of a new consultation model in 47 general practices (primary care) and 6 outpatient clinics (secondary care); 1200 patients from primary and 166 from secondary care participated. Data collection took place between November 2015 and February 2017. Outcomes: preferred monitoring frequency; referral to other health care provider(s); medication change. One measurement at the end of the consultation. We performed logistic regression analyses. Differences between primary and secondary care were analyzed. RESULTS: Many patients arranged a monitoring frequency <4 times per year (general practices 19.5%, outpatient clinics 40%, p < .001). Type of provider (physician/nurse, OR 3.83, p < .001), baseline HbA1c (OR 1.02, p = .017), glucose lowering medication; and setting treatment goals (OR .65, p = .048) were associated with the chosen frequency. Independently associated with a referral were age (OR .99, p = .039), baseline glucose lowering medication and patients' goal setting (OR 1.52, p = .016). Medication change was associated with type of provider, baseline HbA1c, blood glucose lowering medication, quality of life (OR .80, p = .037) and setting treatment goals (OR 2.64, p = .001). CONCLUSIONS: Not only disease but also person related factors, especially setting treatment goals, are independently associated with planned care use in person-centered diabetes care

Implementatie van het diabetes-jaargesprek

Inleiding Steeds breder wordt erkend dat een persoonsgerichte aanpak en gedeelde besluitvorming onontbeerlijk zijn in de diabeteszorg. De Nederlandse Diabetes Federatie ontwikkelde een model voor een diabetes-jaargesprek ter vervanging van de jaarcontrole, wij onderzochten de toepassing, bruikbaarheid en toegevoegde waarde. Methode In Nederlandse huisartsenpraktijken en ziekenhuizen rekruteerden we zorgverleners en patiënten met diabetes type 1 en type 2. De zorgverleners kregen twee gesprekstrainingen van elk twee uur. Patiënten en zorgverleners vulden bij ieder gesprek vragenlijsten in, biomedische gegevens haalden we uit de dossiers. We vergeleken de antwoorden van patiënten in de eerste en de tweede lijn, en analyseerden verschillen tussen gesprekken die gevoerd werden door een arts dan wel een praktijkondersteuner of diabetesverpleegkundige. Resultaten Onder de deelnemers waren 57 huisartsen, 23 praktijkondersteuners, 17 internisten, 8 diabetesverpleegkundigen en 1366 patiënten met diabetes type 2. De meeste gesprekken (72%) duurden korter dan 25 minuten. Zorgverleners vonden het diabetes-jaargesprek goed toepasbaar (artsen iets minder vaak dan praktijkondersteuners en diabetesverpleegkundigen). Acht op de tien gesprekken mondden uit in een gezamenlijke beslissing, in negen op de tien gesprekken kwamen persoonsgebonden factoren aan de orde, vier op de tien patiënten voelden zich meer dan voorheen betrokken bij behandelbeslissingen en de helft van de patiënten vond het gesprek prettiger dan voorheen. Conclusie Het gespreksmodel is goed toepasbaar. Uit de gesprekken blijkt dat persoonsgebonden factoren grote invloed hebben op persoonlijke doelen en daarmee op de behandeling van diabetes. Een korte training volstaat en het is dus goed mogelijk het model snel op nationale schaal te implementeren

Implementation of a Structured Diabetes Consultation Model to Facilitate a Person-Centered Approach: Results From a Nationwide Dutch Study

OBJECTIVE: We assessed both from a patient and provider perspective the usefulness and added value of a consultation model that facilitates person-centered diabetes care. RESEARCH DESIGN AND METHODS: The model consists of 1) inventory of disease and patient-related factors; 2) setting personal goals; 3) choosing treatment; and 4) determination of required care. It was implemented in 47 general practices and 6 hospital outpatient clinics. Providers were trained, and patients were recommended to prepare their visit. All filled out a questionnaire after every consultation. Differences between primary and secondary care practices and between physician-led and nurse-led consultations were analyzed. RESULTS: Seventy-four physicians and thirty-one nurses participated, reporting on 1,366 consultations with type 2 diabetes patients. According to providers, the model was applicable in 72.4% (nurses 79.3% vs. physicians 68.5%, P < 0.001). Physicians more often had a consultation time <25 min (80.4% vs. 56.9%, P < 0.001). According to providers, two of three patients spoke more than half of the consultation time (outpatient clinics 75.2% vs. general practices 66.6%, P = 0.002; nurses 73.2% vs. physicians 64.4%, P = 0.001). Providers stated that person-related factors often determined treatment goals. Almost all patients (94.4%) reported that they made shared decisions; they felt more involved than before (with physicians 45.1% vs. with nurses 33.6%, P < 0.001) and rated the consultation 8.6 of 10. After physician-led consultations, 52.5% reported that the consultation was better than before (nurse visit 33.7%, P < 0.001). CONCLUSIONS: A consultation model to facilitate person-centered care seems well applicable and results in more patient involvement, including shared decision making, and is appreciated by a substantial number of patients

Patient activation in individuals with type 2 diabetes mellitus : Associated factors and the role of insulin

Aim: This study explored the relationship between insulin use and patient activation (a person’s internal readiness and capabilities to undertake health-promoting actions) in individuals with type 2 diabetes mellitus and aimed to identify demographic, clinical and psychosocial factors involved in patient activation. Methods: In this cross-sectional study, baseline data from a Dutch nationwide study were analyzed. Patient activation was assessed with the Patient Activation Measure 13. A linear mixed model was used to take clustering into account. Results: In total, 1,189 persons were included (310 of whom were on insulin), enrolled via 47 general practices and six hospitals. Their mean Patient Activation Measure 13 score was 59±12. We found no association between insulin therapy and patient activation. In the multivariable analysis, individuals with a better health status, very good or very poor social support (vs good social support), individuals who felt they had greater control over their illness and those with a better subjective understanding of their illness showed higher patient activation. Individuals with a lower educational level and those who expected their illness to continue showed a lower activation level. Conclusion: Patient activation does not differ between individuals with type 2 diabetes mellitus on insulin therapy and those on other therapies

Prediction of Prostate Cancer Risk: The Role of Prostate Volume and Digital Rectal Examination in the ERSPC Risk Calculators

Background: The European Randomized Study of Screening for Prostate Cancer (ERSPC) risk calculators (RCs) are validated tools for prostate cancer (PCa) risk assessment and include prostate volume (PV) data from transrectal ultrasound (TRUS). Objective: Develop and validate an RC based on digital rectal examination (DRE) that circumvents the need for TRUS but still includes information on PV. Design, setting, and participants: For development of the DRE-based RC, we studied the original ERSPC Rotterdam RC population including 3624 men (885 PCa cases) and 2896 men (547 PCa cases) detected at first and repeat screening 4 yr later, respectively. A validation cohort consisted of 322 men, screened in 2010-2011 as participants in ERSPC Rotterdam. Measurements: Data on TRUS-assessed PV in the development cohorts were re-coded into three categories (25, 40, and 60 cm(3)) to assess the loss of information by categorization of volume information. New RCs including PSA, DRE, and PV categories (DRE-based RC) were developed for men with and without a previous negative biopsy to predict overall and clinically significant PCa (high-grade [HG] PCa) defined as T stage >T2b and/or Gleason score >= 7. Predictive accuracy was quantified by the area under the receiver operating curve. We compared performance with the Prostate Cancer Prevention Trial (PCPT) RC in the validation study. Results and limitations: Areas under the curve (AUC) of prostate-specific antigen (PSA) alone, PSA and DRE, the DRE-based RC, and the original ERSPC RC to predict PCa at initial biopsy were 0.69, 0.73, 0.77, and 0.79, respectively. The corresponding AUCs for predicting HG PCa were higher (0.74, 0.82, 0.85, and 0.86). Similar results were seen in men previously biopsied and in the validation cohort. The DRE-based RC outperformed the PCPT RC (AUC 0.69 vs 0.59; p = 0.0001) and a model based on PSA and DRE only (AUC 0.69 vs 0.63; p = 0.0075) in the relatively small validation cohort. Further validation is required. Conclusions: An RC should contain volume estimates based either on TRUS or DRE. Replacing TRUS measurements by DRE estimates may enhance implementation in the daily practice of urologists and general practitioners. (C) 2011 European Association of Urology. Published by Elsevier B. V. All rights reserved

Disease insight and treatment perception of men on active surveillance for early prostate cancer

OBJECTIVE To investigate the levels of knowledge of prostate cancer and the perception of active surveillance (AS) in men on AS, as AS for early prostate cancer instead of radical treatment might partly solve the over-treatment dilemma in this disease, but might be experienced as a complex and contradictory strategy by patients. PATIENTS AND METHODS In all, 150 Dutch men recently diagnosed with early prostate cancer participating in a prospective protocol-based AS programme (PRIAS study) received questionnaires, including a 15-item measure on their general knowledge of prostate cancer, and open-ended questions on the most important disadvantages and advantages of AS, and on the specific perception of AS. We assessed knowledge scores and explored potentially associated factors, the stated (dis)advantages and specific perceptions. RESULTS The questionnaire response rate was 86% (129/150). Participants provided correct answers to a median (interquartile range) of 13 (12-14) of 15 (87%) knowledge items. Younger and higher educated men had higher knowledge scores. In line with a priori hypotheses, the most frequently reported advantage and disadvantage of AS were the delay of side-effects and the risk of disease progression, respectively. Specific negative experiences included the feeling of losing control over treatment decisions, distress at follow-up visits, and the desire for a more active participation in disease management. No conceptually wrong understandings or expectations of AS were identified. CONCLUSIONS We found adequate knowledge of prostate cancer levels and realistic perceptions of the AS strategy in patients with early prostate cancer and on AS. These findings suggest adequate counselling by the physician or patient self-educatio