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BACKGROUND: Most diagnostic tests for acute uncomplicated urinary tract infections (UTIs) have been previously studied in so-called single-test evaluations. In practice, however, clinicians use more than one test in the diagnostic work-up. Since test results carry overlapping information, results from single-test studies may be confounded. The primary objective of the Amsterdam Cystitis/Urinary Tract Infection Study (ACUTIS) is to determine the (additional) diagnostic value of relevant tests from patient history and laboratory investigations, taking into account their mutual dependencies. Consequently, after suitable validation, an easy to use, multivariable diagnostic rule (clinical index) will be derived. METHODS: Women who contact their GP with painful and/or frequent micturition undergo a series of possibly relevant tests, consisting of patient history questions and laboratory investigations. Using urine culture as the reference standard, two multivariable models (diagnostic indices) will be generated: a model which assumes that patients attend the GP surgery and a model based on telephone contact only. Models will be made more robust using the bootstrap. Discrimination will be visualized in high resolution histograms of the posterior UTI probabilities and summarized as 5th, 10th, 25th 50th, 75th, 90th, and 95th centiles of these, Brier score and the area under the receiver operating characteristics curve (ROC) with 95% confidence intervals. Using the regression coefficients of the independent diagnostic indicators, a diagnostic rule will be derived, consisting of an efficient set of tests and their diagnostic values. The course of the presenting complaints is studied using 7-day patient diaries. To learn more about the natural history of UTIs, patients will be offered the opportunity to postpone the use of antibiotics. DISCUSSION: We expect that our diagnostic rule will allow efficient diagnosis of UTIs, necessitating the collection of diagnostic indicators with proven added value. GPs may use the rule (preferably after suitable validation) to estimate UTI probabilities for women with different combinations of test results. Finally, in a subcohort, an attempt is made to identify which indicators (including antibiotic treatment) are useful to prognosticate recovery from painful and/or frequent micturition. [ABSTRACT FROM AUTHOR] more...

Background: The rising prevalence estimates of multiple sclerosis (MS) globally underscore the imperative for up-to-date epidemiological data specific to the Netherlands., Methods: Data from two Dutch healthcare databases (Nivel Primary Care Database and Vektis Database) comprising both general practices and hospital electronic health records in 2019 were combined to assess age- and sex-standardized MS prevalence and incidence estimates. Differences in prevalence estimates based on latitude and between primary versus secondary care records were examined., Results: The age and sex-standardized prevalence estimate was 210.4 per 100,000 inhabitants. Incidence estimate of MS was 7.1 per 100,000 person-years within the year 2019. One-third of the MS cohort from primary care records was not documented in the hospital database over two consecutive years. Prevalence estimates were higher in northern areas versus southern areas (respectively 240.6 versus 208.3 per 100,000 inhabitants)., Conclusion: Aligning results from different global regions, prevalence estimates of MS in the Netherlands have increased significantly over the last decennia, while incidence estimates are stable. The discrepancy between MS records within the primary and secondary care setting could indicate that a substantial proportion of Dutch patients with MS are not under specialized neurological care., Competing Interests: Declaration of competing interest BMJU has received consultancy fees from Immunic Therapeutics. BdJ receives research funding from the Dutch MS Research Foundation, National MS Foundation, Dutch Multiple Sclerosis Association, Zorgverzekeraars Nederland (i.e. umbrella organization of health insurers in the Netherlands). The other authors declare no conflicts of interest relevant to the manuscript., (Copyright © 2024. Published by Elsevier B.V.) more...

Purpose: Global prevalence of tinnitus (15%) is rising, indicating an increase in patients seeking help for this common symptom and potentially affecting the accessibility of care. The aim of this retrospective study is twofold; describing the morbidity trends and healthcare utilization among patients with recorded tinnitus at Dutch general practices (GP), and comparing overall healthcare utilization before and after tinnitus to similar patients without recorded tinnitus., Patients and Methods: Routine electronic health records data from general practices participating in Nivel Primary Care Database were used to describe trends in age- and sex-specific incidence, contact prevalence and healthcare utilization (contacts, prescriptions, and referrals to secondary care) for tinnitus from 2012 to 2021. Patients with tinnitus were matched (on sex, age, general practice) to patients without tinnitus (1:2). Healthcare use one year before and after a first GP contact for tinnitus (period) was analyzed with negative binominal (number of contacts) and logistic regression (prescriptions or referrals)., Results: Between 2012 and 2021, tinnitus incidence increased by 33% (3.3 to 4.4 per 1000 person-years). The largest increase was observed among 20-44-years (2.6 to 3.8 per 1000 person-years). One year after the first GP contact for tinnitus, patients with tinnitus utilized healthcare more frequently than patients without tinnitus. The referral rate increased the most (OR 1.99, 95%CI 1.83-2.16). The year before tinnitus at the GP, patients with tinnitus had more often GP consultations (IRR 1.16, 95%CI 1.12-1.19) and referrals (OR 1.09, 95%CI 1.01-1.18) than patients without tinnitus., Conclusion: Although GPs saw an increased number of patients with tinnitus, absolute numbers of patients remained low. Patients' healthcare use increased after the first tinnitus complaint at the GP, mainly for secondary care. Yet, they already used healthcare services more frequently than similar patients without tinnitus. Insight into possible explanations for these health disparities could contribute to targeted prevention., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Bes et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.) more...

Background: The post-COVID syndrome (PCS) has a large impact on an individual's daily life. The wide variety of symptoms in PCS patients and the fact that it is still relatively new makes it difficult for general practitioners (GPs) to recognize, diagnose and treat patients with PCS, leading to difficulties in assessing and fulfilling healthcare needs. It is largely unknown what the experiences of Dutch patients and GPs are with PCS and, therefore, we gained insight into the different aspects of living with PCS and the associated healthcare needs., Methods: Semi-structured interviews were performed with 13 self-reported PCS patients (varying in sex, age, education, and health literacy) and 6 GPs (varying in gender, age, and type of practice) between January-July 2022. Patients and GPs were most likely unrelated (not in the same practices). The data have been analysed using the Thematic Analysis method., Results: Experiences appeared to vary between two types of PCS patients that emerged during the interviews: (1) individuals with good pre-existing health status (PEHS) who are severely affected by PCS and have difficulty recovering and (2) individuals with poorer PEHS whose health became even poorer after COVID-19 infection. The interviews with PCS patients and GPs revealed two main themes, in which the types of patients differed: (1) aspects of living with PCS; individuals with good PEHS mainly experience symptoms when overstimulated, while individuals with poorer PEHS generally feel exhausted continuously. (2) Healthcare experiences; GPs emphasized that individuals with good PEHS seem to benefit from support in distributing their energy by careful planning of daily activities, whereas individuals with poorer PEHS require support in activation. Patients and GPs emphasised the importance of taking patients seriously and acknowledging their symptoms. Finally, the patients interviewed indicated that some GPs doubted the existence of PCS, resulting in insufficient recognition., Conclusion: Awareness of the differences in needs and experiences of the two types of PCS patients could contribute to more appropriate care. Acknowledgement of PCS by GPs as a real syndrome is important for patients and plays an important role in coping with or recovering from PCS. A multidisciplinary person-centred approach is important and can be coordinated by a GP., (© 2024. The Author(s).) more...

Background: Healthcare systems around the world are facing significant challenges because higher costs and an increase in demand for care has not been matched by a corresponding growth in the health workforce. Without reform, healthcare systems are unsustainable. Relocating care, such as from hospitals to general practices, is expected to make a key contribution to ensuring healthcare remains sustainable. Relocating care has a significant impact upon general practitioners (GPs). Therefore, we investigated which care, according to GPs, could be relocated and under which conditions., Method: GPs were recruited through Nivel's GPs network on eHealth and innovation, located in the Netherlands. One exploratory focus group and 12 in-depth interviews were conducted. Interview transcripts were analyzed using the qualitative research principles of thematic analysis., Results: According to the participants, some diagnostic and follow-up care could be relocated from hospitals to GPs once certain prerequisites are fulfilled. An important condition of relocating care from the hospital to the GP is that GPs have sufficient time to take over these tasks. The types of care that can be relocated from the GP to other settings are those questions where the medical knowledge of the GP can offer nothing extra or where problems in navigating the health system cause patients to either turn to, or stay with, their GP., Conclusion: Care should first be relocated from the GP to other settings before attempting to organize the relocation of care from the hospital to the GP. When this, and other conditions are met, some diagnostic and follow-up care can be relocated from the hospital to the GP., (© 2024. The Author(s).) more...

Background: Healthcare systems around the world are facing large challenges. There are increasing demands and costs while at the same time a diminishing health workforce. Without reform, healthcare systems are unsustainable. Relocating care, for example, from hospitals to sites closer to patients' homes, is expected to make a key contribution to keeping healthcare sustainable. Given the significant impact of this initiative on citizens, we conducted a scoping review to provide insight into the factors that influence citizens' attitudes towards relocating care., Method: A scoping review was conducted. The search was performed in the following databases: Pubmed, Embase, Cinahl, and Scopus. Articles had to include relocating healthcare and citizens' perspectives on this topic and the articles had to be about a European country with a strong primary care system. After applying the inclusion and exclusion criteria, 70 articles remained., Results: Factors positively influencing citizens' attitudes towards relocating care included: convenience, familiarity, accessibility, patients having more control over their disease, and privacy. Factors influencing negative attitudes included: concerns about the quality of care, familiarity, the lack of physical examination, contact with others, convenience, and privacy. Furthermore, in general, most citizens preferred to relocate care in the studies we found, especially from the hospital to care provided at home., Conclusion: Several factors influencing the attitude of citizens towards relocating care were found. These factors are very important when determining citizens' preferences for the location of their healthcare. The majority of studies in this review reported that citizens are in favour of relocating care. In general citizens' perspectives on relocating care are very often missing in articles. It was significant that very few studies on relocation from the hospital to the general practitioner were identified., (© 2024. The Author(s).) more...

Purpose: We aimed to assess participant-reported factors associated with non-follow-up with colonoscopy in colorectal cancer (CRC) screening., Methods: In May 2019, we distributed a nationwide cross-sectional questionnaire (n = 4,009) to participants in the Dutch CRC screening program who received a positive fecal immunochemical test (FIT). Among respondents who reported no colonoscopy, we assessed the presence of a contraindication, and those without were compared with those who reported colonoscopy by logistic regression analysis., Results: Of 2,225 respondents (56% response rate), 730 (33%) reported no colonoscopy. A contraindication was reported by 55% (n = 404). Decisional difficulties (odds ratio [OR] = 0.29; 95% CI, 0.18-0.47), lacking the opportunity to discuss the FIT outcome (OR = 0.45; 95% CI, 0.28-0.72), and a low estimated risk of CRC (OR = 0.45; 95% CI, 0.26-0.76) were negatively associated with follow-up. Knowledge items negatively associated with follow-up included having an alternative explanation for the positive FIT (OR = 0.3; 95% CI, 0.21-0.43), having trust in the ability to self-detect CRC (OR = 0.42; 95% CI, 0.27-0.65), and thinking that polyp removal is ineffective (OR = 0.59; 95% CI, 0.43-0.82). The belief that the family physician would support colonoscopy showed the strongest positive association with follow-up (OR = 2.84; 95% CI, 2.01-4.02) CONCLUSIONS: Because decisional difficulties and certain convictions regarding CRC and screening are associated with non-follow-up, personalized screening counseling might be an intervention worth exploring as a means of improving follow-up in the Dutch CRC screening program. Involving family physicians might also prove beneficial., (© 2022 Annals of Family Medicine, Inc.) more...

Background: There is increasing attention on machine learning (ML)-based clinical decision support systems (CDSS), but their added value and pitfalls are very rarely evaluated in clinical practice. We implemented a CDSS to aid general practitioners (GPs) in treating patients with urinary tract infections (UTIs), which are a significant health burden worldwide., Objective: This study aims to prospectively assess the impact of this CDSS on treatment success and change in antibiotic prescription behavior of the physician. In doing so, we hope to identify drivers and obstacles that positively impact the quality of health care practice with ML., Methods: The CDSS was developed by Pacmed, Nivel, and Leiden University Medical Center (LUMC). The CDSS presents the expected outcomes of treatments, using interpretable decision trees as ML classifiers. Treatment success was defined as a subsequent period of 28 days during which no new antibiotic treatment for UTI was needed. In this prospective observational study, 36 primary care practices used the software for 4 months. Furthermore, 29 control practices were identified using propensity score-matching. All analyses were performed using electronic health records from the Nivel Primary Care Database. Patients for whom the software was used were identified in the Nivel database by sequential matching using CDSS use data. We compared the proportion of successful treatments before and during the study within the treatment arm. The same analysis was performed for the control practices and the patient subgroup the software was definitely used for. All analyses, including that of physicians' prescription behavior, were statistically tested using 2-sided z tests with an α level of .05., Results: In the treatment practices, 4998 observations were included before and 3422 observations (of 2423 unique patients) were included during the implementation period. In the control practices, 5044 observations were included before and 3360 observations were included during the implementation period. The proportion of successful treatments increased significantly from 75% to 80% in treatment practices (z=5.47, P<.001). No significant difference was detected in control practices (76% before and 76% during the pilot, z=0.02; P=.98). Of the 2423 patients, we identified 734 (30.29%) in the CDSS use database in the Nivel database. For these patients, the proportion of successful treatments during the study was 83%-a statistically significant difference, with 75% of successful treatments before the study in the treatment practices (z=4.95; P<.001)., Conclusions: The introduction of the CDSS as an intervention in the 36 treatment practices was associated with a statistically significant improvement in treatment success. We excluded temporal effects and validated the results with the subgroup analysis in patients for whom we were certain that the software was used. This study shows important strengths and points of attention for the development and implementation of an ML-based CDSS in clinical practice., Trial Registration: ClinicalTrials.gov NCT04408976; https://clinicaltrials.gov/ct2/show/NCT04408976., (©Willem Ernst Herter, Janine Khuc, Giovanni Cinà, Bart J Knottnerus, Mattijs E Numans, Maryse A Wiewel, Tobias N Bonten, Daan P de Bruin, Thamar van Esch, Niels H Chavannes, Robert A Verheij. Originally published in JMIR Medical Informatics (https://medinform.jmir.org), 04.05.2022.) more...

Background: Opinions differ about the extent to which intervention research should and can directly assess the main patient-important health outcomes, what role surrogate endpoints can play, and which requirements should then apply to the scientific underpinning of clinical and policy decisions., Method: In a commentary we elaborate on this and provide guidance for dealing with related dilemmas., Conclusions: Ethical, methodological and practical reasons for decision making based on surrogate endpoints can be that (1) reaching the intended patient-important health outcome would take too long to await direct RCT-based evidence, (2) experimental conditions have limited sustainability over time; and (3) the plausibility of an intervention's clinical efficacy, given the already available evidence regarding surrogate endpoints, goes beyond equipoise. Given an expected increase of interventions with a long term patient-important health outcome perspective, dealing with surrogate endpoints will remain an important challenge. Appropriately dealing with a surrogate endpoint includes (1) the assessment of its predictive value for the intended patient-important outcome, where GRADE guidelines for assessing 'indirectness' and 'causal chain analysis' can be helpful; (2) transparency of (absence of) evidence; (3) adequately updating the 'knowledge mosaic'; (4) weighing different perspectives and values, and (5) monitoring whether adjustments need to be made. The remaining level of uncertainty must be balanced against the urgency of clinical or societal decision making and the disadvantages of postponing this. Criteria for using surrogate endpoints are suggested. Patients, citizens and policy makers can be involved in agreeing upon these criteria., (Copyright © 2022 Elsevier Inc. All rights reserved.) more...

This is a commentary on the article of Van der Spek et al. on the workload, diagnostic work-up and treatment of urinary tract infections in adults during out-of-hours primary care. Despite a well-established Dutch guideline on urinary tract infections, correctly diagnosing and prescribing antibiotics for urinary tract infections is a challenge that needs major improvement, especially during out-of-hours GP care. more...

Background: Uncomplicated Urinary Tract Infections (UTIs) are common in primary care resulting in substantial costs. Since antimicrobial resistance against antibiotics for UTIs is rising, accurate diagnosis is needed in settings with low rates of multidrug-resistant bacteria., Objective: To compare the cost-effectiveness of different strategies to diagnose UTIs in women who contacted their general practitioner (GP) with painful and/or frequent micturition between 2006 and 2008 in and around Amsterdam, The Netherlands., Methods: This is a model-based cost-effectiveness analysis using data from 196 women who underwent four tests: history, urine stick, sediment, dipslide, and the gold standard, a urine culture. Decision trees were constructed reflecting 15 diagnostic strategies comprising different parallel and sequential combinations of the four tests. Using the decision trees, for each strategy the costs and the proportion of women with a correct positive or negative diagnosis were estimated. Probabilistic sensitivity analysis was used to estimate uncertainty surrounding costs and effects. Uncertainty was presented using cost-effectiveness planes and acceptability curves., Results: Most sequential testing strategies resulted in higher proportions of correctly classified women and lower costs than parallel testing strategies. For different willingness to pay thresholds, the most cost-effective strategies were: 1) performing a dipstick after a positive history for thresholds below €10 per additional correctly classified patient, 2) performing both a history and dipstick for thresholds between €10 and €17 per additional correctly classified patient, 3) performing a dipstick if history was negative, followed by a sediment if the dipstick was negative for thresholds between €17 and €118 per additional correctly classified patient, 4) performing a dipstick if history was negative, followed by a dipslide if the dipstick was negative for thresholds above €118 per additional correctly classified patient., Conclusion: Depending on decision makers' willingness to pay for one additional correctly classified woman, the strategy consisting of performing a history and dipstick simultaneously (ceiling ratios between €10 and €17) or performing a sediment if history and subsequent dipstick are negative (ceiling ratios between €17 and €118) are the most cost-effective strategies to diagnose a UTI. more...

In the cancer screening debate, arguments for and against screening are often based on statistics, whereas for individuals personal, non-statistical factors are at least as important when deciding whether to participate in screening. Health care professionals have a responsibility in helping individuals navigate in this complex field by identifying and clarifying the individuals' beliefs, fears and preferences while being aware of their own. Moreover, researchers should explore beliefs and motives that matter for individuals and not only report numbers that can be interpreted in different ways., (© 2017 John Wiley & Sons Ltd.) more...

Purpose: Whereas a diagnosis of acute uncomplicated urinary tract infection (UTI) in clinical practice comprises a battery of several diagnostic tests, these tests are often studied separately (in isolation from other test results). We wanted to determine the value of history and urine tests for diagnosis of uncomplicated UTIs, taking into account their mutual dependencies and information from preceding tests., Methods: Women with painful and/or frequent micturition answered questions about their signs and symptoms (history) of UTIs and underwent urine tests. A culture was the reference standard (10(3) colony-forming units per milliliter). A diagnostic index was derived using logistic regression with bootstrapped backward selection and parameter-wise shrinkage. Risk thresholds for UTI of 30% and 70% were used to analyze discriminative properties. Six models were compared: (1) history only, (2) history+ urine dipstick, (3) history+ urine dipstick + urinary sediment, (4) history+ urine dipstick+ dipslide, and (5) history+ urine dipstick+ urinary sediment+ dipslide; we then added (6) a test only for patients with an intermediate risk (between 30% and 70%) after the preceding test., Results: One hundred ninety-six women were included (UTI prevalence 61%). Seven variables were selected from history (3), dipstick (2), sediment (1), and dipslide (1). History correctly classified 56% of patients as having a UTI risk of either <30% or >70%. History and urine dipstick raised this to 73%. The 3 models with the addition of urinary sediment and dipslide, separately and in combination, performed hardly better. The sixth model, in which those at intermediate risk after history and received an additional test, correctly classified 83%. The patient's suspicion of a UTI and a positive nitrite test were the strongest indicators of a UTI., Conclusions: Most women with painful and/or frequent micturition can be correctly classified as having either a low or a high risk of UTI by asking 3 questions: Does the patient think she has a UTI? Is there at least considerable pain on micturition? Is there vaginal irritation? Other women require additional urine dipstick investigation. Sediment and dipslide have little added value. External validation of these recommendations is required before they are implemented in practice. more...

Background: Women presenting with symptoms of acute uncomplicated urinary tract infection (UTI) are often prescribed antibiotics. However, in 25 to 50% of symptomatic women not taking antibiotics, symptoms recover spontaneously within one week. It is not known how many women are prepared to delay antibiotic treatment. We investigated how many women presenting with UTI symptoms were willing to delay antibiotic treatment when asked by their general practitioner (GP)., Methods: From 18 April 2006 until 8 October 2008, in a prospective cohort study, patients were recruited in 20 GP practices in and around Amsterdam, the Netherlands. Healthy, non-pregnant women who contacted their GP with painful and/or frequent micturition for no longer than seven days registered their symptoms and collected urine for urinalysis and culture. GPs were requested to ask all patients if they were willing to delay antibiotic treatment, without knowing the result of the culture at that moment. After seven days, patients reported whether their symptoms had improved and whether they had used any antibiotics., Results: Of 176 women, 137 were asked by their GP to delay antibiotic treatment, of whom 37% (51/137) were willing to delay. After one week, 55% (28/51) of delaying women had not used antibiotics, of whom 71% (20/28) reported clinical improvement or cure. None of the participating women developed pyelonephritis., Conclusions: More than a third of women with UTI symptoms are willing to delay antibiotic treatment when asked by their GP. The majority of delaying women report spontaneous symptom improvement after one week. more...

The Dutch College of General Practitioners (NHG) practice guideline 'Urinary tract infections' intended for primary health care and the Dutch Working Party on Antibiotic Policy (SWAB) practice guideline 'Antimicrobial therapy in complicated urinary tract infections' intended for specialists in secondary care, were reviewed together. - In the NHG guideline the differentiation between 'complicated' and 'uncomplicated' urinary tract infections has been replaced by categorisation into age, sex, risk group and the presence of fever, or invasion of tissues.- If urinary tract infection has been diagnosed, a dip slide test can be used to determine resistance.- The guidelines recommend the most narrow-spectrum antibiotic to reduce further increase in antimicrobial resistance.- A chapter about women with recurrent urinary tract infections has been added to the SWAB guideline. Amongst other things, the chapter provides information on the prescription of prophylactic lactobacillus in secondary care. more...

Background: Uncomplicated urinary tract infections (UTIs) are common among female patients. According to the national guidelines of the Dutch College of General Practitioners (GPs), the drugs of first and second choice as therapy for UTIs are nitrofurantoin and trimethoprim with resistance percentages of 2% and 23%, respectively. The third choice is fosfomycin tromethamine for which no current resistance data from The Netherlands are available. The aim of this study was to determine these resistance percentages., Methods: During 2003-04, urine samples were collected from a representative sample of 21 general practices spread over The Netherlands, the Sentinel Stations of The Netherlands Institute for Health Services Research (NIVEL). Escherichia coli isolated from female patients visiting their GP with symptoms of an acute, uncomplicated UTI were used. Fosfomycin tromethamine susceptibility was determined by Etests. An MIC of fosfomycin tromethamine of 64 mg/L or lower was considered to indicate susceptibility, and MIC values of 96 mg/L or higher were considered to indicate resistance. E. coli ATCC 25922 was used as a reference strain., Results: In total, 1705 E. coli strains were tested, of which 11 (0.65%) were resistant to fosfomycin tromethamine. The MIC(50) and MIC(90) values for this population were 1 and 4 mg/L, respectively. Within the inhibition zone of 162 susceptible E. coli, resistant mutant colonies were observed, of which after repetition of the susceptibility testing 68 were resistant. In total, 79 (5%) strains were resistant to fosfomycin tromethamine. There was no cross-resistance observed between fosfomycin tromethamine and other antimicrobial agents tested previously., Conclusions: The high in vitro susceptibility to fosfomycin tromethamine in this population and the lack of cross-resistance between fosfomycin tromethamine and other agents together with the extensive global clinical experience support the choice of the national guidelines of the Dutch College of GPs to include fosfomycin tromethamine as a therapeutic option in general practice for uncomplicated UTIs. more...