Henk van Weert

Detecting Somatoform Disorders in Primary Care With the PHQ-15

PURPOSE Because recognition and management of patients with somatoform disorders are difficult, we wanted to determine the specificity, sensitivity, and the test-retest reliability of the 15-symptom Patient Health Questionnaire (PHQ-15) for detection of somatoform disorders in a high-risk primary care population. METHODS We studied the performance of the PHQ-15 in comparison with the Structured Clinical Interview for the Diagnostic and Statistical Manual-IV Axis I disorders (SCID-I) as a reference standard. From January through September 2006, we approached patients for participation. This study was conducted in primary care settings in the Netherlands. Patients aged between 18 and 70 years were eligible if they belonged to 1 or more of the following groups: (1) patients with unexplained somatic complaints, (2) frequent attenders, and (3) patients with mental health problems. For the SCID-I interview we invited all patients with a PHQ-15 score of 6 or greater and a random sample of 30% of patients with a PHQ-15 score of less than 6. The primary study outcomes were the sensitivity and specificity for the validity and the κ coefficient for the test-retest reliability. RESULTS Of 2,147 eligible patients, 906 (42%) participated (mean age 48 years, 62% female). At a cutoff level of 3 or more severe somatic symptoms during the past 4 weeks, sensitivity was 78% and specificity 71%. The test-retest reliability was 0.60. CONCLUSIONS The PHQ-15 is a valid and moderately reliable questionnaire for the detection of patients in a primary care setting at risk for somatoform disorders.

Safely Ruling Out Deep Venous Thrombosis in Primary Care

Context Primary care physicians need office-based methods to rule out suspected deep venous thrombosis (DVT). Contribution The authors conducted a management trial of a prediction rule that uses clinical findings and a point-of-care d-dimer test to identify patients at very low risk for suspected DVT. They managed 1028 patients from approximately 300 primary care practices according to the rule, which identified nearly half (49%) to be at low enough risk to withhold imaging tests and anticoagulation treatment. In 3 months, 1.4% (95% CI, 0.6% to 2.9%) of low-risk patients had venous thromboembolism. Caution There was no control group. Authors relied on symptoms to detect subsequent venous thromboembolism. Implication Office-based methods can safely rule out DVT. The Editors Each year, more than 140000 persons in the United Kingdom present to their primary care physician with signs and symptoms suggestive of deep venous thrombosis (DVT) of the leg (1, 2). Because DVT is a potentially life-threatening disorder, current practice is to refer all patients for diagnostic testing services. These services are readily available, use noninvasive tests (such as, ultrasonography and d-dimer testing), and provide the referring physician with the assurance that DVT is not missed (3, 4). However, many studies have revealed that 80% to 90% of these referred patients do not have DVT (46). Therefore, it would be ideal to safely exclude DVT at initial presentation in a large proportion of these patients and thereby avoid referral. The recent introduction of rapid point-of-care d-dimer assays that can be included in a specific clinical decision rule makes it possible to do a diagnostic work-up in a primary care setting (79). We recently found that the use of a decision ruleinitially developed and validated in secondary carewas not accurate enough for primary care patients suspected of having DVT because the prevalence of thrombosis was still 2.9% among patients with a low probability (based on the Wells score and a normal quantitative d-dimer) compared with 0.9% reported in the original publication by Wells and colleagues (10, 11). Therefore, we developed and validated such a decision rule specifically for the primary care setting (10, 12) that included clinical items and the d-dimer assay result. A major difference between the rules, taking into account the additional use of d-dimer for low-probability patients in the Wells rule, is the replacement of the subjective phrase alternative diagnosis more likely with the more objective phrase absence of leg trauma. In primary care, the category of low probability based on the new rule had a 0.7% prevalence for thrombosis (13). However, as Reilly and Evans (14) recently outlined, development and validation studies should be followed by a prospective impact or management study demonstrating that the rule could be used by physicians to direct care before the rule is implemented in daily practice. Therefore, we conducted this study in a large series of consecutive patients in a primary care setting to evaluate the safety and efficiency of excluding DVT by using a clinical decision rule and a point-of-care d-dimer assay. In addition, we measured the yield of ultrasonography in the referred patients. Methods Study Overview In this prospective study in primary care, we managed patients suspected of having DVT by using a clinical decision rule that included a point-of-care d-dimer test. We did not refer patients with a low probability of DVT for further testing or administer treatment; we followed them for 3 months to record the incidence of venous thromboembolism (10, 12). Setting and Patients We invited the affiliated general practices of the 3 academic centers (who organized the study) to participate. Approximately 300 general practitioners agreed to participate. From March 2005 to January 2007, consecutive patients who presented with clinically suspected DVT were eligible for the study on the basis of the presence of at least 1 of 3 lower extremity symptoms: swelling, redness, or pain. We excluded patients if they were younger than 18 years, received anticoagulant treatment (that is, vitamin K antagonists or low-molecular-weight heparin) at presentation, or declined to participate. We obtained written informed consent, and the local institutional review boards approved the study. Diagnostic Strategy General practitioners applied a clinical decision rule, provided on a worksheet, to all study patients. This clinical decision rule was developed to safely exclude clinically suspected DVT in primary care patients. It included clinical items and a d-dimer assay result (Table 1) (10, 12). Table 1. Clinical Decision Rule Because we aimed to improve the management of patients suspected of having DVT in a primary care setting, we explicitly selected a rapid point-of-care d-dimer assay (Clearview Simplify d-dimer assay, Inverness Medical, Bedford, United Kingdom) (8, 15, 16). This allowed the general practitioner to use the decision rule outside of office hours and during house calls. We drew a capillary blood sample by using the finger-prick method (15). The test result was considered abnormal if, next to the control band, a second band appeared within 10 minutes (15). Participating physicians and their assistants received a single, brief instruction on how to use the d-dimer assay and the clinical rule. Physicians calculated the score for each patient by using the clinical decision rule (Table 1) (10, 12) and managed patients accordingly. Those with a score of 3 or less did not receive anticoagulant treatment or a referral for ultrasonography, but they were instructed to contact their general practitioner if symptoms became worse. Patients with a score of 4 or greater received a referral for ultrasonography. Deep venous thrombosis was considered present when 1 of the proximal veins of the lower extremities was noncompressible on ultrasonography (4). All patients visited their general practitioner between days 5 and 9 for reevaluation. Three months after entering the study, all patients received a questionnaire addressing signs and symptoms of (recurrent) venous thromboembolism. We contacted patients who did not respond (30%) through their general practitioners. If we had any suspicion of a (recurrent) venous thromboembolic event during the 3-month follow-up, based on the information presented in the questionnaire, we retrieved additional medical information of patients from their general practitioners, including letters from hospital specialists. Outcome Measure We defined the primary outcome as the incidence of symptomatic venous thromboembolism during 3-month follow-up. This included fatal pulmonary embolism, nonfatal pulmonary embolism, and DVT. An independent adjudication committee, unaware of the patients result of the clinical decision rule, evaluated all suspected venous thromboembolic events and deaths. A diagnosis of pulmonary embolism or DVT was based on a prioridefined and generally accepted criteria (Appendix Table) (17). Deaths were classified as caused by pulmonary embolism when autopsy was done if an objective test result was positive for pulmonary embolism before death or if pulmonary embolism could not be confidently excluded as the cause of death (17). Appendix Table. Adjudication Criteria Used for the AMUSE Study Statistical Analysis On the basis of an expected incidence of venous thromboembolism in 1% of patients (those with a score 3) during 3-month follow-up and the exclusion of a predetermined incidence of 4% or more, we calculated that 488 patients needed to be included in this low-risk group (type I error, 0.05; type II error, 0.2). The primary analysis was about the incidence (with exact 95% CI) of symptomatic venous thromboembolism during 3-month follow-up in the group of patients with a score of 3 or less who were not referred for further testing or treatment. In addition, we calculated the percentage of patients with a score of 3 or less. Furthermore, we calculated the probability of venous thromboembolism on leg ultrasonography at baseline or during follow-up, according to the results of the clinical decision rule without the d-dimer assay result, as well as the d-dimer assay result alone. For this purpose, a cutoff of 3 or less was also used because on the basis of this cutoff, patients with a negative d-dimer result should still receive a referral for ultrasonography. Role of the Funding Source The study was funded by the Netherlands Organization for Scientific Research. The funding source had no role in the design, conduct, or reporting of the study or in the decision to submit the manuscript for publication. Results Patients We assessed 1086 consecutive patients with clinically suspected DVT. We excluded 58 patients (5.3%) because of predefined exclusion criteria (Figure). Table 2 shows characteristics of the 1028 study patients, including the items of the clinical decision rule. The mean age was 58 years, and 37% were men. Suspicion of DVT that led to study inclusion was based most commonly on leg pain (87%) and leg swelling (78%). Figure. Study flow diagram. CDR = clinical decision rule; DVT = deep venous thrombosis; DVT+ = deep venous thrombosis confirmed by ultrasonography; DVT = deep venous thrombosis excluded by ultrasonography; LMWH = low-molecular-weight heparin; PE = pulmonary embolism; VTE = venous thromboembolism. * All patients were referred for ultrasonography on the day of presentation. No clinical events occurred in this group. Clearview Simplify d-dimer assay, Inverness Medical, Bedford, United Kingdom. Incidence of VTE, 1.4% (95% CI, 0.6% to 2.9%). If the 1 patient lost to follow-up had developed VTE, the percentage missed by the procedure would have been 1.6% instead of 1.4%. Table 2. Demographic and Clinical Characteristics of the Study Sample (n= 1028) Results of the Clinical Decision Rule In 500 of 1028 patients (49%), the score was 3 or les

Accuracy of Monofilament Testing to Diagnose Peripheral Neuropathy: A Systematic Review

PURPOSE We wanted to summarize evidence about the diagnostic accuracy of the 5.07/10-g monofilament test in peripheral neuropathy. METHODS We conducted a systematic review of studies in which the accuracy of the 5.07/10-g monofilament was evaluated to detect peripheral neuropathy of any cause using nerve conduction as reference standard. Methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool. RESULTS We reviewed 173 titles and abstracts of articles to identify 54 potentially eligible studies, of which 3 were finally selected for data synthesis. All studies were limited to patients with diabetes mellitus and showed limitations according to the QUADAS tool. Sensitivity ranged from 41% to 93% and specificity ranged from 68% to 100%. Because of the heterogenous nature of the studies, a meta-analysis could not be accomplished. CONCLUSIONS Despite the frequent use of monofilament testing, little can be said about the test accuracy for detecting neuropathy in feet without visible ulcers. Optimal test application and defining a threshold should have priority in evaluating monofilament testing, as this test is advocated in many clinical guidelines. Accordingly, we do not recommend the sole use of monofilament testing to diagnose peripheral neuropathy.

Predicting bacterial cause in infectious conjunctivitis: cohort study on informativeness of combinations of signs and symptoms

Abstract Objective To find an efficient set of diagnostic indicators that are optimally informative in the diagnosis of a bacterial origin of acute infectious conjunctivitis. Design Cohort study involving consecutive patients. Results of index tests and reference standard were collected independently from each other. Setting 25 Dutch health centres. Participants 184 adults presenting with a red eye and either (muco)purulent discharge or glued eyelid(s), not wearing contact lenses. Main outcome measures Probability of a positive bacterial culture, given different combinations of index test results; area under receiver operating characteristics curve. Results Logistic regression analysis showed optimal diagnostic discrimination for the combination of early morning glued eye(s), itch, and a history of conjunctivitis. The first of these indicators increased the likelihood of a bacterial cause, whereas the other two decreased it. The area under the receiver operating characteristics curve for this combination of symptoms was 0.74 (95% confidence interval 0.63 to 0.80). The overall prevalence of bacterial involvement of 32% could be lowered to 4% or raised to 77%, depending on the pattern of index test results. Conclusion A bacterial origin of complaints indicative of acute infectious conjunctivitis can be made much more likely or unlikely by the answers to three simple questions posed during clinical history taking (possibly by telephone). These results may have consequences for more targeted prescription of ocular antibiotics.

Safe exclusion of pulmonary embolism using the Wells rule and qualitative D-dimer testing in primary care: prospective cohort study

Objective To validate the use of the Wells clinical decision rule combined with a point of care D-dimer test to safely exclude pulmonary embolism in primary care. Design Prospective cohort study. Setting Primary care across three different regions of the Netherlands (Amsterdam, Maastricht, and Utrecht). Participants 598 adults with suspected pulmonary embolism in primary care. Interventions Doctors scored patients according to the seven variables of the Wells rule and carried out a qualitative point of care D-dimer test. All patients were referred to secondary care and diagnosed according to local protocols. Pulmonary embolism was confirmed or refuted on the basis of a composite reference standard, including spiral computed tomography and three months’ follow-up. Main outcome measures Diagnostic accuracy (sensitivity and specificity), proportion of patients at low risk (efficiency), number of missed patients with pulmonary embolism in low risk category (false negative rate), and the presence of symptomatic venous thromboembolism, based on the composite reference standard, including events during the follow-up period of three months. Results Pulmonary embolism was present in 73 patients (prevalence 12.2%). On the basis of a threshold Wells score of ≤4 and a negative qualitative D-dimer test result, 272 of 598 patients were classified as low risk (efficiency 45.5%). Four cases of pulmonary embolism were observed in these 272 patients (false negative rate 1.5%, 95% confidence interval 0.4% to 3.7%). The sensitivity and specificity of this combined diagnostic approach was 94.5% (86.6% to 98.5%) and 51.0% (46.7% to 55.4%), respectively. Conclusion A Wells score of ≤4 combined with a negative qualitative D-dimer test result can safely and efficiently exclude pulmonary embolism in primary care.

The accuracy of Patient Health Questionnaire-9 in detecting depression and measuring depression severity in high-risk groups in primary care.

OBJECTIVE Only half of patients with depressive disorder are diagnosed by their family physicians. Screening in high-risk groups might reduce this hidden morbidity. This study aims to determine the accuracy of the Patient Health Questionnaire-9 (PHQ-9) in (a) screening for depressive disorder, (b) diagnosing depressive disorder and (c) measuring the severity of depressive disorder in groups that are at high risk for depressive disorder. METHOD We compared the performance of the PHQ-9 as a screening instrument and as a diagnostic instrument to that of the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) interview, which we used as reference standard. Three high-risk groups of patients were selected: (a) frequent attenders, (b) patients with mental health problems and (c) patients with unexplained complaints. Patients completed the PHQ-9. Next, patients who were at risk for depression (based on PHQ scores) and a random sample of 20% of patients who were not at risk were selected for a second PHQ-9 and the reference standard (SCID-I). We assessed the adequacy of the PHQ-9 as a tool for severity measurement by comparing PHQ-9 scores with scores on the 17-item Hamilton Depression Rating Scale (HDRS-17) in patients diagnosed with a depressive disorder. RESULTS Among 440 patients, both PHQ-9 and SCID-I were analyzed. The test characteristics for screening were sensitivity=0.93 and specificity=0.85; those for diagnosing were sensitivity=0.68 and specificity=0.95. The positive likelihood ratio for diagnosing was 14.2. The HDRS-17 was administered in 49 patients with depressive disorder. The Pearson correlation coefficient of the PHQ-9 to the HDRS-17 was r=.52 (P<.01). CONCLUSION The PHQ-9 performs well as a screening instrument, but in diagnosing depressive disorder, a formal diagnostic process following the PHQ-9 remains imperative. The PHQ-9 does not seem adequate for measuring severity.

Current and future use of point-of-care tests in primary care: an international survey in Australia, Belgium, The Netherlands, the UK and the USA

Objective Despite the growing number of point-of-care (POC) tests available, little research has assessed primary care clinician need for such tests. We therefore aimed to determine which POC tests they actually use or would like to use (if not currently available in their practice). Design Cross-sectional survey. Setting Primary care in Australia, Belgium (Flanders region only), the Netherlands, the UK and the USA. Participants Primary care doctors (general practitioners, family physicians). Main measures We asked respondents to (1) identify conditions for which a POC test could help inform diagnosis, (2) from a list of tests provided: evaluate which POC tests they currently use (and how frequently) and (3) determine which tests (from that same list) they would like to use in the future (and how frequently). Results 2770 primary care clinicians across five countries responded. Respondents in all countries wanted POC tests to help them diagnose acute conditions (infections, acute cardiac disease, pulmonary embolism/deep vein thrombosis), and some chronic conditions (diabetes, anaemia). Based on the list of POC tests provided, the most common tests currently used were: urine pregnancy, urine leucocytes or nitrite and blood glucose. The most commonly reported tests respondents expressed a wish to use in the future were: D-dimer, troponin and chlamydia. The UK and the USA reported a higher actual and desired use for POC tests than Australia, Belgium and the Netherlands. Our limited data suggest (but do not confirm) representativeness. Conclusions Primary care clinicians in all five countries expressed a desire for POC tests to help them diagnose a range of acute and chronic conditions. Rates of current reported use and desired future use were generally high for a small selection of POC tests, but varied across countries. Future research is warranted to explore how specific POC tests might improve primary care.

Causes of Persistent Dizziness in Elderly Patients in Primary Care

PURPOSE Although dizzy patients are predominantly seen in primary care, most diagnostic studies on dizziness have been performed among patients in secondary or tertiary care. Our objective was to describe subtypes of dizziness in elderly patients in primary care and to assess contributory causes of dizziness. METHODS We performed a cross-sectional diagnostic study among elderly patients in the Netherlands consulting their family physician for persistent dizziness. All patients underwent a comprehensive evaluation according to a set of diagnostic tests that were developed during an international Delphi procedure. Data for each patient were independently reviewed by a panel consisting of a family physician, a geriatrician, and a nursing home physician, which resulted in major and minor contributory causes of dizziness. RESULTS From June 2006 to January 2008, we included 417 patients aged 65 to 95 years. Presyncope was the most common dizziness subtype (69%). Forty-four percent of the patients were assigned more than 1 dizziness subtype. Cardiovascular disease was considered to be the most common major contributory cause of dizziness (57%), followed by peripheral vestibular disease (14%), and psychiatric illness (10%). An adverse drug effect was considered to be the most common minor contributory cause of dizziness (23%). Sixty-two percent of the patients were assigned more than 1 contributory cause of dizziness. CONCLUSIONS Contrary to most previous studies, cardiovascular disease was found to be the most common major cause of dizziness in elderly patients in primary care. In one-quarter of all patients an adverse drug effect was considered to be a contributory cause of dizziness, which is much higher than reported in previous studies.

Teledermatologic consultation and reduction in referrals to dermatologists: a cluster randomized controlled trial.

OBJECTIVE To determine whether teledermatologic consultations can reduce referrals to a dermatologist by general practitioners (GPs). DESIGN Multicenter cluster randomized controlled trial. SETTING AND PARTICIPANTS We recruited 85 GPs from 35 general practices in 2 regions in the Netherlands (Almere and Zeist); 5 dermatologists from 2 nonacademic hospitals were also included in the study. Interventions The GPs randomized to the intervention used a teledermatologic consultation system to confer with a dermatologist, whereas those in the control group referred their patients according to usual practice. All patients, regardless of their condition, were seen in the office by a dermatologist after approximately 1 month. OUTCOME MEASURES The main outcome measure was the proportion of office visits prevented by teledermatologic consultation, as determined by dermatologists at approximately the 1-month office visit. The secondary outcome measure was patient satisfaction, measured using the Patient Satisfaction Questionnaire III developed by Ware et al. RESULTS The 85 study GPs enrolled 631 patients (46 intervention GPs, 327 patients; 39 control GPs, 304 patients). The 5 dermatologists considered a consultation preventable for 39.0% of patients who received teledermatologic consultation and 18.3% of 169 control patients, a difference of 20.7% (95% confidence interval, 8.5%-32.9%). At the 1-month dermatologist visit, 20.0% of patients who received teledermatologic consultation had recovered compared with 4.1% of control patients. No significant differences in patient satisfaction were found between groups. CONCLUSIONS Teledermatologic consultation offers the promise of reducing referrals to a dermatologist by 20.7%. Providing teledermatologic consultation by GPs with more extended knowledge of dermatology may further reduce the need for dermatologist referrals. Trial Registration Current Controlled Trials No. ISRCTN57478950.

Dizziness reported by elderly patients in family practice: prevalence, incidence, and clinical characteristics

BackgroundAlthough dizziness in elderly patients is very common in family practice, most prevalence studies on dizziness are community-based and include a study population that is not representative of family practice. The aim of this study was to investigate the prevalence and incidence of dizziness reported by elderly patients in family practice, to describe their final diagnoses as recorded by the family physician, and to compare the clinical characteristics of dizzy patients with those of non-dizzy patients.MethodsData were obtained from the Second Dutch National Survey of General Practice, a prospective registration study which took place over a 12-month period in 2001. We developed a search strategy consisting of 15 truncated search terms (based on Dutch synonyms for dizziness), and identified all patients aged 65 or older who visited their family physician because of dizziness (N = 3,990). We used the mid-time population as denominator to calculate the prevalence and incidence, and for group comparisons we used the Students t and Chi-square test, and logistic regression analysis.ResultsThe one-year prevalence of dizziness in family practice in patients aged 65 or older was 8.3%, it was higher in women than in men, and it increased with age. In patients aged 85 or older the prevalence was similar for men and women. The incidence of dizziness was 47.1 per 1000 person-years. For 39% of the dizzy patients the family physicians did not specify a diagnosis, and recorded a symptom diagnosis as the final diagnosis. Living alone, lower level of education, pre-existing cerebrovascular disease, and pre-existing hypertension were independently associated with dizziness.ConclusionsDizziness in family practice patients increases with age. It is more common in women than in men, but this gender difference disappears in the very old. Because a large proportion of dizzy elderly patients in family practice remains undiagnosed, it would be worthwhile to carry out more diagnostic research on dizziness in a family practice setting.