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BackgroundVitamin tests are increasingly ordered by GPs, but a clinical and evidence-based indication is often lacking. Harnessing technology (that is, decision support tools and redesigning request forms) have been shown to reduce vitamin requests.AimTo investigate whether the number of vitamin tests may be reduced by providing a multi-level intervention programme based on training, monitoring, and feedback.Design & settingThis was a cluster randomised intervention study performed in 26 primary care health centres (>195 000 patients) in the Netherlands. The relative reduction in ordered vitamin D and B12 tests was determined after introduction of two de-implementation strategies (1 May 2017 to 30 April 2018).MethodHealth centres randomised to de-implementation strategy 1 received education and benchmarking of their own vitamin test ordering behaviour every 3 months. Health centres in de-implementation strategy 2 received the same education and benchmarking, but supplemented with educational material for patients.ResultsThe number of vitamin D tests decreased by 23% compared to the 1-year pre-intervention period (1 May 2016 to 30 April 2017). For vitamin B12 tests an overall reduction of 20% was found. Provision of patient educational information showed additional value over training and benchmarking of GPs alone for vitamin D test ordering (10% extra reduction, odds ratio [OR] 0.88, 95% confidence interval [CI] = 0.83 to 0.92), but not for vitamin B12 ordering (4% extra reduction, OR 0.96, 95% CI = 0.91 to 1.02). Nationwide, this would result in over €3 200 000 in savings on healthcare expenditure a year.ConclusionA structured intervention programme, including training and benchmarking of GPs regarding their diagnostic test ordering, resulted in a significant reduction in ordered vitamin tests. Additional information provision to patients resulted in a small but still relevant additional reduction. If implemented on a national level, a substantial cost saving could be achieved.

Inleiding Verpleegkundig specialisten nemen steeds meer patiëntenzorg van de huisarts over, waaronder die voor kinderen met luchtweginfecties. Deze substitutie door geprotocolleerde zorg zou kunnen zorgen voor betere voorlichting aan de ouders en overbehandeling kunnen terugdringen. Doel van dit onderzoek was de kwaliteit van zorg zoals geleverd door de verpleegkundig specialist te vergelijken met die van zorg door de huisarts. Methode Retrospectief observationeel cohortonderzoek op basis van medische dossiers. De gegevens betroffen kinderen van 0 tot 6 jaar die tussen januari en december 2013 de huisartsenpraktijk bezochten wegens een luchtweginfectie. Primaire uitkomsten waren antibioticumvoorschriften en reconsultaties, waarbij werd gecorrigeerd voor mogelijke confounders. Resultaten In totaal 899 consulten werden beoordeeld (168 van de verpleegkundig specialist; 731 van huisartsen). Van deze consulten leidde 21% tot een antibioticumvoorschrift, zowel bij de verpleegkundig specialist als bij de huisarts (OR na correctie 1,40; 95%-BI 0,89 tot 2,22). Ziekte-ernst was hierbij een belangrijke confounder. Het percentage reconsultaties was bij de verpleegkundig specialist 30% en bij de huisarts 23% (OR na correctie 1,53; 95%-BI 1,01 tot 2,31). Hierbij was piepende ademhaling een confounder. De percentages complicaties en verwijzingen verschilden niet. Conclusie Voor kinderen met een luchtweginfectie leiden consulten bij een verpleegkundig specialist of bij een huisarts niet tot minder antibioticumvoorschriften, complicaties en verwijzingen. Huisartsen hebben een lager reconsultatiepercentage en zien meer ernstig zieke kinderen.

Van Vugt SF. Diagnostiek van pneumonie bij volwassenen. Huisarts Wet 2014;57(1):14-7. Pneumonie is een indicatie om antibiotica te starten bij een volwassen patient met hoestklachten, maar het is lastig om deze te onderscheiden van overige lage luchtweginfecties, waarbij de huisarts een afwachtend beleid kan voeren. In dit diagnostisch dilemma blijkt de klinische blik van de huisarts van meerwaarde voor het voorspellen van pneumonie. Een CRP-test (afkapwaarde 30 mg/ml) heeft toegevoegde waarde als deze wordt gebruikt in combinatie met anamnese en lichamelijk onderzoek. De toegevoegde waarde van de CRP-test is het grootst in de groep patienten bij wie de huisarts na anamnese en lichamelijk onderzoek nog niet goed kan beoordelen of er sprake is van pneumonie. Indien de huisarts kiest voor een thoraxfoto als aanvullende diagnostiek, is het percentage aan potentieel relevante toevalsbevindingen beperkt. Het diagnostisch proces bij volwassen patienten met lage luchtwegklachten blijft complex en zal ook in de toekomst een uitdaging blijven.

Pneumonia is often diagnosed and treated empirically. We set out to determine the diagnostic accuracy of clinical judgment based on signs and symptoms to detect radiographic pneumonia in patients presenting with acute cough in primary care. In 2810 European patients with acute cough, general practitioners (GPs) recorded whether they considered pneumonia to be present (yes or no) immediately after history and physical examination. Chest radiography was performed within 1 week by local radiologists blind to other patient characteristics. 140 patients had radiographic pneumonia (5%), of whom 41 (29%) had been diagnosed as such. 31 (1%) patients had a clinical diagnosis that was not confirmed by radiography (n=2670). In clinically suspected pneumonia, 57% of subjects were subsequently diagnosed with radiographic pneumonia. Negative predictive value (NPV), sensitivity and specificity of GPs clinical judgment were 96%, 29% and 99%, respectively. Compared to patients with a clinical diagnosis of pneumonia, less severe symptoms were found in radiographic pneumonia cases not suspected clinically (p

PURPOSE: We sought to determine the prevalence of airway obstruction and bronchodilator responsiveness in adults consulting for acute cough in primary care. METHODS: Family physicians recruited 3,105 adult patients with acute cough (28 days or shorter) attending primary care practices in 12 European countries. After exclusion of patients with preexisting physician-diagnosed asthma or chronic obstructive pulmonary disease (COPD), we undertook complete case analysis of spirometry results (n = 1,947) 28 to 35 days after inclusion. Bronchodilator responsiveness was diagnosed if there were recurrent complaints of wheezing, cough, or dyspnea and an increase of the forced expiratory volume in 1 second (FEV(1)) of 12% or more after bronchodilation. Airway obstruction was diagnosed according to 2 thresholds for the (postbronchodilator) ratio of FEV(1) to forced vital capacity (FEV(1):FVC): less than 0.7 and less than the lower limit of normal. RESULTS: There were 240 participants who showed bronchodilator responsiveness (12%), 193 (10%) had a FEV(1)/FVC ratio of less than 0.7, and 126 (6%) had a ratio of less than the lower limit of normal. Spearman's correlation between the 2 definitions of obstruction was 0.71 (P

Moeheid is een veelvoorkomende klacht in de huisartsenpraktijk. 1 Een relatie tussen vitamine D-deficientie en moeheidsklachten wordt regelmatig gesuggereerd in lekenliteratuur, op internet en door uw vermoeide patienten. 2− 4 De Landelijke Eerstelijns Samenwerkingsafspraak (LESA) Rationeel aanvragen van laboratoriumdiagnostiek vermeldt in het hoofdstuk over vitamine D-deficientie dat moeheid geen indicatie is voor spiegelbepaling of suppletie van vitamine D. 5 Deze CAT komt tot dezelfde conclusie.

Aim To compare quality of care provided by nurse practitioners (NP) with care provided by general practitioners (GP) for children with respiratory tract infections (RTI) in the Netherlands. Background Nurse practitioners increasingly manage acute conditions in general practice, with opportunities for more protocolled care. Studies on quality of NPs' care for children with RTIs are limited to the US healthcare system and do not take into account baseline differences in illness severity. Design Retrospective observational cohort study. Methods Data were extracted from electronic healthcare records of children 0-6 years presenting with RTI between January-December 2013. Primary outcomes were antibiotic prescriptions and early return visits. Generalized estimating equations were used to correct for potential confounders. Results A total of 899 RTI consultations were assessed (168 seen by NP; 731 by GP). Baseline characteristics differed between these groups. Overall antibiotic prescription and early return visit rates were 21% and 24%, respectively. Adjusted odds ratio for antibiotic prescription after NP vs. GP delivered care was 1.40 (95% confidence interval 0.89-2.22) and for early return visits 1.53 (95% confidence interval 1.01-2.31). Important confounder for antibiotic prescription was illness severity. Presence of wheezing was a confounder for return visits. Complication and referral rates did not differ. Conclusion Antibiotic prescription, complication and referral rates for paediatric RTI consultations did not differ significantly between NP and GP consultations, after correction for potential confounders. General practitioners, however, see more severely ill children and have a lower return visit rate. A randomised controlled study is needed to determine whether NP care quality is truly noninferior.

Previously unknown or unexpected pathogens may be responsible for that proportion of respiratory diseases in which a causative agent cannot be identified. The application of broad-spectrum, sequence independent virus discovery techniques may be useful to reduce this proportion and widen our knowledge about respiratory pathogens. Thanks to the availability of high throughput sequencing (HTS) technology, it became today possible to detect viruses which are present at a very low load, but the clinical relevance of those viruses must be investigated. In this study we used VIDISCA-454, a restriction enzyme based virus discovery method that utilizes Roche 454 HTS system, on a nasal swab collected from a subject with respiratory complaints. A γ-papillomavirus was detected (complete genome: 7142 bp) and its role in disease was investigated. Respiratory samples collected both during the acute phase of the illness and two weeks after full recovery contained the virus. The patient presented antibodies directed against the virus but there was no difference between IgG levels in blood samples collected during the acute phase and two weeks after full recovery. We therefore concluded that the detected γ-papillomavirus is unlikely to be the causative agent of the respiratory complaints and its presence in the nose of the patient is not related to the disease. Although HTS based virus discovery techniques proved their great potential as a tool to clarify the aetiology of some infectious diseases, the obtained information must be subjected to cautious interpretations. This study underlines the crucial importance of performing careful investigations on viruses identified when applying sensitive virus discovery techniques, since the mere identification of a virus and its presence in a clinical sample are not satisfactory proofs to establish a causative link with a disease.

PURPOSE Imaging may produce unexpected or incidental fi ndings with conse- quences for patients and ordering of future investigations. Chest radiography in patients with acute cough is among the most common reasons for imaging in primary care, but data on associated incidental fi ndings are lacking. We set out to describe the type and prevalence of incidental chest radiography fi ndings in primary care patients with acute cough. METHODS We report on data from a cross-sectional study in 16 European pri- mary care networks on 3,105 patients with acute cough, all of whom were under- going chest radiography as part of a research study workup. Apart from assess- ment for specifi ed signs of pneumonia and acute bronchitis, local radiologists were asked to evaluate any additional fi nding on the radiographs. For the 2,823 participants with good-quality chest radiographs, these fi ndings were categorized according to clinical relevance based on previous research evidence and analyzed for type and prevalence by network, sex, age, and smoking status. RESULTS Incidental fi ndings were reported in 19% of all participants, and ranged from 0% to 25% by primary care network, with the network being an independent contributor (P