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1.  Detecting the neuropathic pain component in the clinical setting: a study protocol for validation of screening instruments for the presence of a neuropathic pain component 
BMC Neurology  2014;14:94.
Background
The presence of nerve damage plays a key role in the development and prognosis of chronic pain states. Assessment of the presence and severity of a neuropathic pain component (NePC) is key in diagnosing chronic pain patients. Low back pain (LBP) and neck and shoulder pain (NSP) are highly prevalent and clinically important medical and societal problems in which a NePC is frequently present. The more severe the NePC, the worse the course of the pain, its prognosis and the results of treatment. Reliable and standardised diagnosis of the NePC remains difficult to achieve. Standardized and validated screening tools may help to reliably identify the NePC in individual chronic pain patients. The aim of this study is to validate the Dutch language versions of the PainDETECT Questionnaire (PDQ-Dlv) and the ‘Douleur Neuropathique 4 Questions’ (DN4-Dlv) for use in primary and specialist medical care settings to screen for a NePC in patients with chronic pain due to (1) LBP, (2) NSP or (3) known peripheral nerve damage (PND).
Methods/design
The study design is cross-sectional to assess the validity of the PDQ-Dlv and the DN4-Dlv with 2 weeks follow-up for test-retest reliability and 3 months follow-up for monitoring and prognosis. 438 patients with chronic pain due to (1) LBP, (2) NSP or (3) PND. will be included in this study. Based on the IASP definition of neuropathic pain, two physicians will independently assess whether the patient has a NEPC or not. This result will be compared with the outcome of the PDQ-Dlv & DN4-Dlv, the grading system for neuropathic pain, bed side examination and quantitative sensory testing. This study will further collect data regarding prevalence of NePC, general health status, mental health status, functioning, pain attribution and quality of life.
Discussion
The rationale for this study is to provide detailed information on the clinimetric quality of the PDQ-Dlv and DN4-Dlv in Dutch speaking countries. Our innovative multi-factorial approach should help achieve more reliable diagnosis and quantification of a NePC in patients with chronic pain.
Trial registration
The Netherlands National Trial Register (NTR3030).
doi:10.1186/1471-2377-14-94
PMCID: PMC4046010  PMID: 24885108
PainDETECT questionnaire; PDQ; DN4; Validation; Low back pain; Neck-shoulder pain; Peripheral nerve damage
2.  Depressive disorder in the last phase of life in patients with cardiovascular disease, cancer, and COPD: data from a 20-year follow-up period in general practice 
The British Journal of General Practice  2012;63(610):e303-e308.
Background
Depression is assumed to be common in chronically ill patients during their last phase of life and is associated with poorer outcomes. The prevalence of depression is widely varying in previous studies due to the use of different terminology, classification, and assessment methods.
Aim
To explore the reported incidence of depressive disorder, as registered in the last phase of life of patients who died from cardiovascular disease, cancer or COPD, in a sample of primary care patients.
Design and setting
A historic cohort study, using a 20-year period registration database of medical records in four Dutch general practices (a dynamic population based on the Continuous Morbidity Registration database).
Method
Medical history of the sample cohort was analysed for the diagnosis of a new episode of depressive disorder and descriptive statistics were used.
Results
In total 982 patients were included, and 19 patients (1.9%) were diagnosed with a new depressive disorder in the last year of their life. The lifetime prevalence of depressive disorder in this sample was 8.2%.
Conclusion
The incidence of depressive disorder in the last phase of life is remarkably low in this study. These data were derived from actual patient care in general practice. Psychiatric diagnoses were made by GPs in the context of both patient needs and delivered care. A broader concept of depression in general practice is recommended to improve the diagnosis and treatment of mood disorders in patients in the last phase of life.
doi:10.3399/bjgp13X667150
PMCID: PMC3635575  PMID: 23643227
cardiovascular disease; depression; epidemiology; cancer; COPD; palliative care; general practice; prevalence
3.  Primary health care: what role for occupational health? 
doi:10.3399/bjgp12X659141
PMCID: PMC3505386  PMID: 23211235
4.  Early identification of palliative care patients in general practice: development of RADboud indicators for PAlliative Care Needs (RADPAC) 
The British Journal of General Practice  2012;62(602):e625-e631.
Background
According to the World Health Organization (WHO) definition, palliative care should be initiated in an early phase and not be restricted to terminal care. In the literature, no validated tools predicting the optimal timing for initiating palliative care have been determined.
Aim
The aim of this study was to systematically develop a tool for GPs with which they can identify patients with congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and cancer respectively, who could benefit from proactive palliative care.
Design
A three-step procedure, including a literature review, focus group interviews with input from the multidisciplinary field of palliative healthcare professionals, and a modified Rand Delphi process with GPs.
Method
The three-step procedure was used to develop sets of indicators for the early identification of CHF, COPD, and cancer patients who could benefit from palliative care.
Results
Three comprehensive sets of indicators were developed to support GPs in identifying patients with CHF, COPD, and cancer in need of palliative care. For CHF, seven indicators were found: for example, frequent hospital admissions. For COPD, six indicators were found: such as, Karnofsky score ≤50%. For cancer, eight indicators were found: for example, worse prognosis of the primary tumour.
Conclusion
The RADboud indicators for PAlliative Care Needs (RADPAC) is the first tool developed from a combination of scientific evidence and practice experience that can help GPs in the identification of patients with CHF, COPD, or cancer, in need of palliative care. Applying the RADPAC facilitates the start of proactive palliative care and aims to improve the quality of palliative care in general practice.
doi:10.3399/bjgp12X654597
PMCID: PMC3426601  PMID: 22947583
early identification; general practice; indicators; palliative care
5.  Generalist solutions to complex problems: generating practice-based evidence - the example of managing multi-morbidity 
BMC Family Practice  2013;14:112.
Background
A growing proportion of people are living with long term conditions. The majority have more than one. Dealing with multi-morbidity is a complex problem for health systems: for those designing and implementing healthcare as well as for those providing the evidence informing practice. Yet the concept of multi-morbidity (the presence of >2 diseases) is a product of the design of health care systems which define health care need on the basis of disease status. So does the solution lie in an alternative model of healthcare?
Discussion
Strengthening generalist practice has been proposed as part of the solution to tackling multi-morbidity. Generalism is a professional philosophy of practice, deeply known to many practitioners, and described as expertise in whole person medicine. But generalism lacks the evidence base needed by policy makers and planners to support service redesign. The challenge is to fill this practice-research gap in order to critically explore if and when generalist care offers a robust alternative to management of this complex problem.
We need practice-based evidence to fill this gap. By recognising generalist practice as a ‘complex intervention’ (intervening in a complex system), we outline an approach to evaluate impact using action-research principles. We highlight the implications for those who both commission and undertake research in order to tackle this problem.
Summary
Answers to the complex problem of multi-morbidity won’t come from doing more of the same. We need to change systems of care, and so the systems for generating evidence to support that care. This paper contributes to that work through outlining a process for generating practice-based evidence of generalist solutions to the complex problem of person-centred care for people with multi-morbidity.
doi:10.1186/1471-2296-14-112
PMCID: PMC3750615  PMID: 23919296
Generalism; Primary care; Action research; Multimorbidity
6.  A pharmacy medication alert system based on renal function in older patients 
The British Journal of General Practice  2012;62(601):e525-e529.
Background
Patients with diabetes or cardiovascular disease are at risk of reduced renal function and frequently use drugs that interact with renal function. GPs monitor renal function in these patients. Computerised prescription systems produce alerts in patients labelled as having chronic kidney disease, but alerts are often ignored. If pharmacists use a pharmacy medication alert system (PMAS) based on renal function, they can provide the GP with therapeutic advice to optimise the medication. The extent of this advice and the feasibility in the clinical context are unknown.
Aim
To assess the therapeutic advice formulated by pharmacists with help of a PMAS based on the renal function of patients aged ≥70 years with diabetes or cardiovascular disease.
Design and setting
Observational study in primary health care in the Netherlands.
Method
GPs provided pharmacists with the renal function of older patients with diabetes or cardiovascular disease who were using target drugs, that is, drugs requiring therapeutic advice in patients with reduced renal function. With the help of a PMAS, pharmacists assessed the actual medication. The GP weighed the advice in relation to the clinical context of the individual patient.
Results
Six hundred and fifty patients were prescribed 1333 target drugs. Pharmacists formulated 143 therapeutic recommendations (11% of target drugs) concerning 89 patients (13.7% of study population). In 71 recommendations in 52 patients (8.0% of study population), the GP agreed immediately.
Conclusion
The use of a PMAS resulted in therapeutic advice in 11% of the target drugs. After weighing the clinical context, the GP agreed with half of the advice.
doi:10.3399/bjgp12X653561
PMCID: PMC3404329  PMID: 22867675
aged; medication alert systems; medication errors; primary health care; renal insufficiency
7.  Qualitative study about the ways teachers react to feedback from resident evaluations 
BMC Medical Education  2013;13:98.
Background
Currently, one of the main interventions that are widely expected to contribute to teachers’ professional development is confronting teachers with feedback from resident evaluations of their teaching performance. Receiving feedback, however, is a double edged sword. Teachers see themselves confronted with information about themselves and are, at the same time, expected to be role models in the way they respond to feedback. Knowledge about the teachers’ responses could be not only of benefit for their professional development, but also for supporting their role modeling. Therefore, research about professional development should include the way teachers respond to feedback.
Method
We designed a qualitative study with semi-structured individual conversations about feedback reports, gained from resident evaluations. Two researchers carried out a systematic analysis using qualitative research software. The analysis focused on what happened in the conversations and structured the data in three main themes: conversation process, acceptance and coping strategies.
Results
The result section describes the conversation patterns and atmosphere. Teachers accepted their results calmly, stating that, although they recognised some points of interest, they could not meet with every standard. Most used coping strategies were explaining the results from their personal beliefs about good teaching and attributing poor results to external factors and good results to themselves. However, some teachers admitted that they had poor results because of the fact that they were not “sharp enough” in their resident group, implying that they did not do their best.
Conclusions
Our study not only confirms that the effects of feedback depend first and foremost on the recipient but also enlightens the meaning and role of acceptance and being a role model. We think that the results justify the conclusion that teachers who are responsible for the day release programmes in the three departments tend to respond to the evaluation results just like human beings do and, at the time of the conversation, are initially not aware of the fact that they are role models in the way they respond to feedback.
doi:10.1186/1472-6920-13-98
PMCID: PMC3751067  PMID: 23866849
Teachers; Professional development; Feedback; Role modeling
8.  GPs' considerations in multimorbidity management: a qualitative study 
The British Journal of General Practice  2012;62(600):e503-e510.
Background
Scientific evidence on how to manage multimorbidity is limited, but GPs have extensive practical experience with multimorbidity management.
Aim
To explore GPs’ considerations and main objectives in the management of multimorbidity and to explore factors influencing their management of multimorbidity.
Design and setting
Focus group study of Dutch GPs; with heterogeneity in characteristics such as sex, age and urbanisation.
Method
The moderator used an interview guide in conducting the interviews. Two researchers performed the analysis as an iterative process, based on verbatim transcripts and by applying the technique of constant comparative analysis. Data collection proceeded until saturation was reached.
Results
Five focus groups were conducted with 25 participating GPs. The main themes concerning multimorbidity management were individualisation, applying an integrated approach, medical considerations placed in perspective, and sharing decision making and responsibility. A personal patient–doctor relationship was considered a major factor positively influencing the management of multimorbidity. Mental-health problems and interacting conditions were regarded as major barriers in this respect and participants experienced several practical problems. The concept of patient-centredness overarches the participants’ main objectives.
Conclusion
GPs’ main objective in multimorbidity management is applying a patient-centred approach. This approach is welcomed since it counteracts some potential pitfalls of multimorbidity. Further research should include a similar design in a different setting and should aim at developing best practice in multimorbidity management.
doi:10.3399/bjgp12X652373
PMCID: PMC3381276  PMID: 22781998
comorbidity; focus groups; multimorbidity; patient-centredness; primary care; qualitative research
9.  Measuring continuity of care: psychometric properties of the Nijmegen Continuity Questionnaire 
The British Journal of General Practice  2012;62(600):e949-e957.
Background
Recently, the Nijmegen Continuity Questionnaire (NCQ) was developed. It aims to measure continuity of care from the patient perspective across primary and secondary care settings. Initial pilot testing proved promising.
Aim
To further examine the validity, discriminative ability, and reliability of the NCQ.
Design
A prospective psychometric instrument validation study in primary and secondary care in the Netherlands.
Method
The NCQ was administered to patients with a chronic disease recruited from general practice (n = 145) and hospital outpatient departments (n = 123) (response rate 76%). A principal component analysis was performed to confirm three subscales that had been found previously. Construct validity was tested by correlating the NCQ score to scores of other scales measuring quality of care, continuity, trust, and satisfaction. Discriminative ability was tested by investigating differences in continuity subscores of different subgroups. Test–retest reliability was analysed in 172 patients.
Results
Principal factor analysis confirmed the previously found three continuity subscales — personal continuity, care provider knows me; personal continuity, care provider shows commitment; and team/cross-boundary continuity. Construct validity was demonstrated through expected correlations with other variables and discriminative ability through expected differences in continuity subscores of different subgroups. Test–retest reliability was high (the intraclass correlation coefficient varied between 0.71 and 0.82).
Conclusion
This study provides evidence for the validity, discriminative ability, and reliability of the NCQ. The NCQ can be of value to identify problems in continuity of care.
doi:10.3399/bjgp12X652364
PMCID: PMC3381279  PMID: 22782001
continuity of patient care; factor analysis, statistical; healthcare surveys; questionnaires; reproducibility of results
10.  Context factors in general practitioner - patient encounters and their impact on assessing communication skills - an exploratory study 
BMC Family Practice  2013;14:65.
Background
Assessment of medical communication performance usually focuses on rating generically applicable, well-defined communication skills. However, in daily practice, communication is determined by (specific) context factors, such as acquaintance with the patient, or the presented problem. Merely valuing the presence of generic skills may not do justice to the doctor’s proficiency.
Our aim was to perform an exploratory study on how assessment of general practitioner (GP) communication performance changes if context factors are explicitly taken into account.
Methods
We used a mixed method design to explore how ratings would change. A random sample of 40 everyday GP consultations was used to see if previously identified context factors could be observed again. The sample was rated twice using a widely used assessment instrument (the MAAS-Global), first in the standard way and secondly after context factors were explicitly taken into account, by using a context-specific rating protocol to assess communication performance in the workplace. In between first and second rating, the presence of context factors was established. Item score differences were calculated using paired sample t-tests.
Results
In 38 out of 40 consultations, context factors prompted application of the context-specific rating protocol. Mean overall score on the 7-point MAAS-Global scale increased from 2.98 in standard to 3.66 in the context-specific rating (p < 0.00); the effect size for the total mean score was 0.84. In earlier research the minimum standard score for adequate communication was set at 3.17.
Conclusions
Applying the protocol, the mean overall score rose above the level set in an earlier study for the MAAS-Global scores to represent ‘adequate GP communication behaviour’. Our findings indicate that incorporating context factors in communication assessment thus makes a meaningful difference and shows that context factors should be considered as ‘signal’ instead of ‘noise’ in GP communication assessment. Explicating context factors leads to a more deliberate and transparent rating of GP communication performance.
doi:10.1186/1471-2296-14-65
PMCID: PMC3688246  PMID: 23697479
Communication and Interviewing skills; Continuing Medical Education; Graduate Medical Education; Assessment of Learner Performance
11.  Prescribing ANtiDepressants Appropriately (PANDA): a cluster randomized controlled trial in primary care 
BMC Family Practice  2013;14:6.
Background
Inappropriate use of antidepressants (AD), defined as either continuation in the absence of a proper indication or continuation despite the lack of therapeutic efficacy, applies to approximately half of all long term AD users.
Methods/design
We have designed a cluster randomized controlled clinical trial to assess the (cost-) effectiveness of an antidepressant cessation advice in the absence of a proper indication for maintenance treatment with antidepressants in primary care.
We will select all patients using antidepressants for over 9 months from 45 general practices. Patients will be diagnosed using the Composite International Diagnostic Interview (CIDI) version 3.0, extended with questions about the psychiatric history and previous treatment strategies. General practices will be randomized to either the intervention or the control group. In case of overtreatment, defined as the absence of a proper indication according to current guidelines, a cessation advice is given to the general practitioner. In the control groups no specific information is given. The primary outcome measure will be the proportion of patients that successfully discontinue their antidepressants at one-year follow-up. Secondary outcomes are dimensional measures of psychopathology and costs.
Discussion
This study protocol provides a detailed overview of the design of the trial. Study results will be of importance for refining current guidelines. If the intervention is effective it can be used in managed care programs.
Trial registration
NTR2032
doi:10.1186/1471-2296-14-6
PMCID: PMC3544619  PMID: 23297810
Depression; Anxiety; Composite International Diagnostic Interview (CIDI); Randomized controlled trial; General practice; Depressive disorder; Anxiety disorders
12.  Reforming primary care: innovation or destruction? 
doi:10.3399/bjgp12X616463
PMCID: PMC3252531  PMID: 22520679
14.  Prevalence and incidence density rates of chronic comorbidity in type 2 diabetes patients: an exploratory cohort study 
BMC Medicine  2012;10:128.
Background
Evidence-based diabetes guidelines generally neglect comorbidity, which may interfere with diabetes management. The prevalence of comorbidity described in patients with type 2 diabetes (T2D) shows a wide range depending on the population selected and the comorbid diseases studied. This exploratory study aimed to establish comorbidity rates in an unselected primary-care population of patients with T2D.
Methods
This was a cohort study of 714 adult patients with newly diagnosed T2D within the study period (1985-2007) in a practice-based research network in the Netherlands. The main outcome measures were prevalence and incidence density rates of chronic comorbid diseases and disease clusters. All chronic disease episodes registered in the practice-based research network were considered as comorbidities. We categorised comorbidity into 'concordant' (that is, shared aetiology, risk factors, and management plans with diabetes) and 'discordant' comorbidity. Prevalence and incidence density were assessed for both categories of comorbidity.
Results
The mean observation period was 17.3 years. At the time of diabetes diagnosis, 84.6% of the patients had one or more chronic comorbid disease of 'any type', 70.6% had one or more discordant comorbid disease, and 48.6% and 27.2% had three or more chronic comorbid diseases of 'any type' or of 'discordant only', respectively. A quarter of those without any comorbid disease at the time of their diabetes diagnosis developed at least one comorbid disease in the first year afterwards. Cardiovascular diseases (considered concordant comorbidity) were the most common, but there were also high rates of musculoskeletal and mental disease. Discordant comorbid diseases outnumbered concordant diseases.
Conclusions
We found high prevalence and incidence density rates for both concordant and discordant comorbidity. The latter may interfere with diabetes management, thus future research and clinical practice should take discordant comorbidity in patients with T2D into account.
doi:10.1186/1741-7015-10-128
PMCID: PMC3523042  PMID: 23106808
type 2 diabetes; comorbidity; primary care; prevalence; incidence
15.  Thirty-minute compared to standardised office blood pressure measurement in general practice 
The British Journal of General Practice  2011;61(590):e590-e597.
Background
Although blood pressure measurement is one of the most frequently performed measurements in clinical practice, there are concerns about its reliability. Serial, automated oscillometric blood pressure measurement has the potential to reduce measurement bias and white-coat effect'
Aim
To study agreement of 30-minute office blood pressure measurement (OBPM) with standardised OBPM, and to compare repeatability
Design and setting
Method comparison study in two general practices in the Netherlands
Method
Thirty-minute and standardised OBPM was carried out with the same, validated device in 83 adult patients, and the procedure was repeated after 2 weeks. During 30-minute OBPM, blood pressure was measured automatically every 3 minutes, with the patient in a sitting position, alone in a quiet room. Agreement between 30-minute and standardised OBPM was assessed by Bland–Altman analysis. Repeatability of the blood pressure measurement methods after 2 weeks was expressed as the mean difference in combination with the standard deviation of difference (SDD)
Results
Mean 30-minute OBPM readings were 7.6/2.5 mmHg (95% confidence interval [CI] = 6.1 to 9.1/1.5 to 3.4 mmHg) lower than standardised OBPM readings. The mean difference and SDD between repeated 30-minute OBPMs (mean difference = 3/1 mmHg, 95% CI = 1 to 5/0 to 2 mmHg; SDD 9.5/5.3 mmHg) were lower than those of standardised OBPMs (mean difference = 6/2 mmHg, 95% CI = 4 to 8/1 to 4 mmHg; SDD 10.9/6.3 mmHg).
Conclusion
Thirty-minute OBPM resulted in lower readings than standardised OBPM and had a better repeatability. These results suggest that 30-minute OBPM better reflects the patient's true blood pressure than standardised OBPM does.
doi:10.3399/bjgp11X593875
PMCID: PMC3162182  PMID: 22152748
blood pressure; general practice; reproducibility of results
16.  PELICAN: A quality of life instrument for childhood asthma: Study Protocol of two Randomized Controlled Trials in Primary and Specialized Care in the Netherlands 
BMC Pediatrics  2012;12:137.
Background
Asthma is one of the major chronic health problems in children in the Netherlands. The Pelican is a paediatric asthma-related quality of life instrument for children with asthma from 6–11 years old, which is suitable for clinical practice in primary and specialized care. Based on this instrument, we developed a self-management treatment to improve asthma-related quality of life. The Pelican intervention will be investigated in different health care settings. Results of intervention studies are often extrapolated to other health care settings than originally investigated. Because of differences in organization, disease severity, patient characteristics and care provision between health care settings, extrapolating research results could lead to unnecessary health costs without the desired health care achievements. Therefore, interventions have to be investigated in different health care settings when possible. This study is an example of an intervention study in different health care settings. In this article, we will present the study protocol of the Pelican study in primary and specialized care.
Method/design
This study consists of two randomized controlled trials to assess the effectiveness of the Pelican intervention in primary and specialized care. The trial in primary care is a multilevel design with 170 children with asthma in 16 general practices. All children in one general practices are allocated to the same treatment group. The trial in specialized care is a multicentre trial with 100 children with asthma. Children in one outpatient clinic are randomly allocated to the intervention or usual care group. In both trials, children will visit the care provider four times during a follow-up of nine months. This study is registered and ethically approved.
Discussion
This article describes the study protocol of the Pelican study in different health care settings. If the Pelican intervention proves to be effective and efficient, implementation in primary and specialized care for paediatric asthma in the Netherlands will be recommended.
Trial registration
This study is registered by clinicaltrial.gov (NCT01109745)
doi:10.1186/1471-2431-12-137
PMCID: PMC3512535  PMID: 22935133
Asthma; Quality of life; Children; Primary care; Specialized care; Self-management; Randomized controlled trial (RCT)
17.  Implementation of an innovative web-based conference table for community-dwelling frail older people, their informal caregivers and professionals: a process evaluation 
Background
Due to fragmentation of care, continuity of care is often limited in the care provided to frail older people. Further, frail older people are not always enabled to become involved in their own care. Therefore, we developed the Health and Welfare Information Portal (ZWIP), a shared Electronic Health Record combined with a communication tool for community-dwelling frail older people and primary care professionals. This article describes the process evaluation of its implementation, and aims to establish (1) the outcomes of the implementation process, (2) which implementation strategies and barriers and facilitators contributed to these outcomes, and (3) how its future implementation could be improved.
Methods
Mixed methods study, consisting of (1) a survey among professionals (n = 118) and monitoring the use of the ZWIP by frail older people and professionals, followed by (2) semi-structured interviews with purposively selected professionals (n = 12).
Results
290 frail older people and 169 professionals participated in the ZWIP. At the end of the implementation period, 55% of frail older people and informal caregivers, and 84% of professionals had logged on to their ZWIP at least once. For professionals, the exposure to the implementation strategies was generally as planned, they considered the interprofessional educational program and the helpdesk very important strategies. However, frail older people’s exposure to the implementation strategies was less than intended. Facilitators for the ZWIP were the perceived need to enhance interprofessional collaboration and the ZWIP application being user-friendly. Barriers included the low computer-literacy of frail older people, a preference for personal communication and limited use of the ZWIP by other professionals and frail older people. Interviewees recommended using the ZWIP for other target populations as well and adding further strategies that may help frail older people to feel more comfortable with computers and the ZWIP.
Conclusions
This study describes the implementation process of an innovative e-health intervention for community-dwelling frail older people, informal caregivers and primary care professionals. As e-health is an important medium for overcoming fragmentation of healthcare and facilitating patient involvement, but its adoption in everyday practice remains a challenge, the positive results of this implementation are promising.
doi:10.1186/1472-6963-12-251
PMCID: PMC3470954  PMID: 22894654
E-health; Implementation; Process evaluation; Frail older people; Primary care
18.  Do unexplained symptoms predict anxiety or depression? Ten-year data from a practice-based research network 
The British Journal of General Practice  2011;61(587):e316-e325.
Background
Unexplained symptoms are associated with depression and anxiety. This association is largely based on cross-sectional research of symptoms experienced by patients but not of symptoms presented to the GP.
Aim
To investigate whether unexplained symptoms as presented to the GP predict mental disorders.
Design and setting
Cross-sectional and longitudinal analysis of data from a practice-based research network of GPs, the Transition Project, in the Netherlands.
Method
All data about contacts between patients (n = 16 000) and GPs (n = 10) from 1997 to 2008 were used. The relation between unexplained symptoms episodes and depression and anxiety was calculated and compared with the relation between somatic symptoms episodes and depression and anxiety. The predictive value of unexplained symptoms episodes for depression and anxiety was determined.
Results
All somatoform symptom episodes and most somatic symptom episodes are significantly associated with depression and anxiety. Presenting two or more symptoms episodes gives a five-fold increase of the risk of anxiety or depression. The positive predictive value of all symptom episodes for anxiety and depression was very limited. There was little difference between somatoform and somatic symptom episodes with respect to the prediction of anxiety or depression.
Conclusion
Somatoform symptom episodes have a statistically significant relation with anxiety and depression. The same was true for somatic symptom episodes. Despite the significant odds ratios, the predictive value of symptom episodes for anxiety and depression is low. Consequently, screening for these mental health problems in patients presenting unexplained symptom episodes is not justified in primary care.
doi:10.3399/bjgp11X577981
PMCID: PMC3103694  PMID: 21801510
anxiety; depression; mental health; primary care; somatisation; symptoms, unexplained
19.  Seeking ethical approval for an international study in primary care patient safety 
The British Journal of General Practice  2011;61(585):e197-e204.
Seeking ethics committee approval for research can be challenging even for relatively simple studies occurring in single settings. Complicating factors such as multicentre studies and/or contentious research issues can challenge review processes, and conducting such studies internationally adds a further layer of complexity. This paper draws on the experiences of the LINNAEUS Collaboration, an international group of primary care researchers, in obtaining ethics approval to conduct an international study investigating medical error in general practice in six countries. It describes the ethics review processes applied to exactly the same research protocol for a study run in Australia, Canada, England, the Netherlands, New Zealand, and the US. Wide variation in ethics review responses to the research proposal occurred, from no approval being deemed necessary to the study plan narrowly avoiding rejection. The authors' experiences demonstrated that ethics committees operate in their own historical and cultural context, which can lead to radically different subjective interpretations of commonly-held ethical principles, and raised further issues such as ‘what is research?’. This first LINNAEUS study started when patient safety was a particularly sensitive subject. Although it is now a respectable area of inquiry, patient safety is still a topic that can excite emotions and prejudices. The LINNAEUS Collaboration now extends to more countries and continues to pursue an international research agenda, so reflection on the influences of history, social context, and structure of each country's ethical review processes is timely.
doi:10.3399/bjgp11X567144
PMCID: PMC3063049  PMID: 21439178
ethics; patient safety; primary care; regulation
20.  Lung function decline in relation to diagnostic criteria for airflow obstruction in respiratory symptomatic subjects 
Background
Current COPD guidelines advocate a fixed < 0.70 FEV1/FVC cutpoint to define airflow obstruction. We compared rate of lung function decline in respiratory symptomatic 40+ subjects who were 'obstructive' or 'non-obstructive' according to the fixed and/or age and gender specific lower limit of normal (LLN) FEV1/FVC cutpoints.
Methods
We studied 3,324 respiratory symptomatic subjects referred to primary care diagnostic centres for spirometry. The cohort was subdivided into four categories based on presence or absence of obstruction according to the fixed and LLN FEV1/FVC cutpoints. Postbronchodilator FEV1 decline served as primary outcome to compare subjects between the respective categories.
Results
918 subjects were obstructive according to the fixed FEV1/FVC cutpoint; 389 (42%) of them were non-obstructive according to the LLN cutpoint. In smokers, postbronchodilator FEV1 decline was 21 (SE 3) ml/year in those non-obstructive according to both cutpoints, 21 (7) ml/year in those obstructive according to the fixed but not according to the LLN cutpoint, and 50 (5) ml/year in those obstructive according to both cutpoints (p = 0.004).
Conclusion
This study showed that respiratory symptomatic 40+ smokers and non-smokers who show FEV1/FVC values below the fixed 0.70 cutpoint but above their age/gender specific LLN value did not show accelerated FEV1 decline, in contrast with those showing FEV1/FVC values below their LLN cutpoint.
doi:10.1186/1471-2466-12-12
PMCID: PMC3355014  PMID: 22439763
Airflow obstruction; Chronic obstructive pulmonary disease; Diagnosis; Lung function decline; Primary care; Spirometry
21.  Identifying context factors explaining physician's low performance in communication assessment: an explorative study in general practice 
BMC Family Practice  2011;12:138.
Background
Communication is a key competence for health care professionals. Analysis of registrar and GP communication performance in daily practice, however, suggests a suboptimal application of communication skills. The influence of context factors could reveal why communication performance levels, on average, do not appear adequate. The context of daily practice may require different skills or specific ways of handling these skills, whereas communication skills are mostly treated as generic. So far no empirical analysis of the context has been made. Our aim was to identify context factors that could be related to GP communication.
Methods
A purposive sample of real-life videotaped GP consultations was analyzed (N = 17). As a frame of reference we chose the MAAS-Global, a widely used assessment instrument for medical communication. By inductive reasoning, we analyzed the GP behaviour in the consultation leading to poor item scores on the MAAS-Global. In these cases we looked for the presence of an intervening context factor, and how this might explain the actual GP communication behaviour.
Results
We reached saturation after having viewed 17 consultations. We identified 19 context factors that could potentially explain the deviation from generic recommendations on communication skills. These context factors can be categorized into doctor-related, patient-related, and consultation-related factors.
Conclusions
Several context factors seem to influence doctor-patient communication, requiring the GP to apply communication skills differently from recommendations on communication. From this study we conclude that there is a need to explicitly account for context factors in the assessment of GP (and GP registrar) communication performance. The next step is to validate our findings.
doi:10.1186/1471-2296-12-138
PMCID: PMC3262758  PMID: 22166064
22.  Improving nutritional management within high-risk groups 
The current pitfalls and future possibilities of nutritional management are discussed by two patients with tongue cancer who have suffered from substantial weight loss. Their nutritional problems are illustrative of those among other (cancer) patient groups. The main concerns are the lack of early case finding and dietary treatment, and insufficient nutritional information transfer through referral letters. The GP as a central and longitudinal caretaker faces challenges in improving nutritional management.
doi:10.3399/bjgp09X453819
PMCID: PMC2714783  PMID: 22751235
cachexia; chronic disease; family practice; neoplasms; weight loss
23.  Getting a grip on guidelines: how to make them more relevant for practice 
The British Journal of General Practice  2009;59(562):e143-e144.
doi:10.3399/bjgp09X420554
PMCID: PMC2673179  PMID: 19401005
25.  Predictive value and utility of oral steroid testing for treatment of COPD in primary care: the COOPT study 
Background
The oral prednisolone test is widely used to distinguish chronic obstructive pulmonary disease (COPD) patients who might benefit from inhaled steroid treatment. Previous studies used selected patient groups that did not represent the large COPD population in primary care.
Methods
The study included smokers and exsmokers with chronic bronchitis or COPD from primary care, who underwent prednisolone testing (30 mg for 14 days) before randomization in a three-year follow-up randomized controlled trial (COOPT Study). Spirometry was performed before and after the test. Responders and nonresponders were classified according to international criteria. Effectiveness of inhaled fluticasone relative to placebo was compared in terms of health status (Chronic Respiratory Disease Questionnaire), exacerbations, and postbronchodilator forced expiratory volume in one second (FEV1), using repeated measurement analysis.
Results
Two hundred eighty-six patients recruited from 44 primary care practices were randomized. Nine percent to 16% of the COPD population was classified as responder, depending on the international guideline criteria used. On average, responders did not reach the minimum clinically important difference in health status (0.29 points/year, P = 0.05), although a borderline significant effect of inhaled fluticasone was noted. Possible clinically relevant reductions in exacerbation rate (rate ratio 0.67) and FEV1 decline (39 mL/year) occurred in responders, but did not reach statistical significance.
Conclusions
Oral steroid testing identifies a limited proportion of COPD patients, but does not reveal any clinically relevant benefit from inhaled steroid treatment on health status. No significant effects on exacerbation rate and lung function decline occurred.
PMCID: PMC2793071  PMID: 20037682
COPD; primary care; oral steroid testing; prednisolone test

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