Kees van Boven

Do unexplained symptoms predict anxiety or depression? Ten-year data from a practice-based research network

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.

Why the ‘reason for encounter’ should be incorporated in the analysis of outcome of care

In the traditional medical model, the diagnosis takes a central stage in the delineation of treatment and care. The diagnosis as the determinant of the response to patients1 has been the general line of medical education,2 is at the core of most evidence-based guidelines and protocols,3 and shapes the payment of physicians’ performance.4 Since its renaissance in the 1960s, general practice has questioned the narrow focus on the diagnosis as the single determinant of professional performance and pursued a person-centred, holistic approach of health care;5,6 diseases do not come in isolation but occur in the context of an individual with the disease, and it is to this broader context that health care has to respond. Yet, despite the growing international support of people at the centre of health care, professional performance is mainly regulated and awarded in relation to the diagnosis, disregarding the broader individual and social context of diseases, even in countries with a long and strong primary care tradition.3,7 Person-centredness should be part of every consultation. Clarifying the patient perspective parallel to the health problem can be a practical way of achieving this. In this article we call on the discipline of general practice to clarify patients’ perspectives in a systematic way, in patient care and research. We argue that patients’ reasons to seek medical care reflect their personal needs and expectations, and we illustrate how the use of the International Classification of Primary Care (ICPC)8 can help better understand the process and outcome of care. ICPC was a major step in the development of health informatics for primary care, by incorporating different aspects alongside the classification of health problems.9 For this …

Dementia incidence trend over 1992-2014 in the Netherlands: analysis of primary care data

Background Recent reports have suggested declining age-specific incidence rates of dementia in high-income countries over time. Improved education and cardiovascular health in early age have been suggested to be bringing about this effect. The aim of this study was to estimate the age-specific dementia incidence trend in primary care records from a large population in the Netherlands. Methods and findings A dynamic cohort representative of the Dutch population was composed using primary care records from general practice registration networks (GPRNs) across the country. Data regarding dementia incidence were obtained using general-practitioner-recorded diagnosis of dementia within the electronic health records. Age-specific dementia incidence rates were calculated for all persons aged 60 y and over; negative binomial regression analysis was used to estimate the time trend. Nine out of eleven GPRNs provided data on more than 800,000 older people for the years 1992 to 2014, corresponding to over 4 million person-years and 23,186 incident dementia cases. The annual growth in dementia incidence rate was estimated to be 2.1% (95% CI 0.5% to 3.8%), and incidence rates were 1.08 (95% CI 1.04 to 1.13) times higher for women compared to men. Despite their relatively low numbers of person-years, the highest age groups contributed most to the increasing trend. There was no significant overall change in incidence rates since the start of a national dementia program in 2003 (−0.025; 95% CI −0.062 to 0.011). Increased awareness of dementia by patients and doctors in more recent years may have influenced dementia diagnosis by general practitioners in electronic health records, and needs to be taken into account when interpreting the data. Conclusions Within the clinical records of a large, representative sample of the Dutch population, we found no evidence for a declining incidence trend of dementia in the Netherlands. This could indicate true stability in incidence rates, or a balance between increased detection and a true reduction. Irrespective of the exact rates and mechanisms underlying these findings, they illustrate that the burden of work for physicians and nurses in general practice associated with newly diagnosed dementia has not been subject to substantial change in the past two decades. Hence, with the ageing of Western societies, we still need to anticipate a dramatic absolute increase in dementia occurrence over the years to come.

An international comparative family medicine study of the Transition Project data from the Netherlands, Malta, Japan and Serbia. An analysis of diagnostic odds ratios aggregated across age bands, years of observation and individual practices

INTRODUCTION This is a study of the process of diagnosis in family medicine (FM) in four practice populations from the Netherlands, Malta, Serbia and Japan. Diagnostic odds ratios (ORs) for common reasons for encounter (RfEs) and episode titles are used to study the process of diagnosis in international FM and to test the assumption that data can be aggregated across different age bands, practices and years of observation. METHODOLOGY Participating family doctors (FDs) recorded details of all their patient contacts in an episode of care (EoC) structure using the International Classification of Primary Care (ICPC). RfEs presented by the patient and the diagnostic labels (EoC titles) recorded for each encounter were classified with ICPC. The relationships between RfEs and episode titles were expressed as ORs using Bayesian probability analysis to calculate the posterior (post-test) odds of an episode title given an RfE, at the start of a new EoC. RESULTS The distributions of diagnostic ORs from the four population databases are tabled across age groups, years of observation and practices. CONCLUSIONS There is a lot of congruence in diagnostic process and concepts between populations, across age groups, years of observation and FD practices, despite differences in the strength of such diagnostic associations. There is particularly little variability of diagnostic ORs across years of observation and between individual FD practices. Given our findings, it makes sense to aggregate diagnostic data from different FD practices and years of observation. Our findings support the existence of common core diagnostic concepts in international FM.

Comorbidities Among Women With Vulvovaginal Complaints in Family Practice.

BACKGROUND The lifetime prevalence of women suffering from provoked vestibulodynia (PVD) is estimated to be approximately 15%. The etiology of PVD is not yet clear. Recent studies approach PVD as a chronic multifactorial sexual pain disorder. PVD is associated with pain syndromes, genital infections, and mental disorders, which are common diseases in family practice. PVD, however, is not included in the International Classification of Primary Care. Hence, the vulvovaginal symptoms, which could be suggestive of PVD, are likely to be missed. AIM To explore the relationship between specific vulvovaginal symptoms that could be suggestive of PVD (genital pain, painful intercourse, other symptoms/complaints related to the vagina/vulva), and related diseases such as pain syndromes, psychological symptom diagnoses, and genital infections in family practice. METHODS A retrospective analysis of all episodes from 1995 to 2008 in 784 women between 15 and 49 years were used to determine the posterior probability of a selected diagnosis in the presence of specific vulvovaginal symptoms suggestive of PVD expressed in an odds ratio. Selected comorbidities were pain syndromes (muscle pain, general weakness, irritable bowel syndrome [IBS]), psychological symptom diagnoses (anxiety, depression, insomnia), vulvovaginal candidiasis, and sexual and physical abuse. RESULTS Women with symptoms suggestive of PVD were 4 to 7 times more likely to be diagnosed with vulvovaginal candidiasis and 2 to 4 times more likely to be diagnosed with IBS. Some symptoms suggestive of PVD were 1 to 3 times more likely to be diagnosed with complaints of muscle pain, general weakness, insomnia, depressive disorder, and feeling anxious. CONCLUSION Data from daily family practice showed a clear relationship between symptoms suggestive of PVD and the diagnoses of vulvovaginal candidiasis and IBS in premenopausal women. Possibly, family doctors make a diagnosis of vulvovaginal candidiasis or IBS based only on clinical manifestations in many women in whom a diagnosis of PVD would be more appropriate.

Psychosocial, musculoskeletal and somatoform comorbidity in patients with chronic low back pain: original results from the Dutch Transition Project

BACKGROUND Better insight into frequent comorbidities in patients with chronic (≥ 3 months) low back pain (LBP) may help general practitioners when planning comprehensive care for these patients. OBJECTIVE To prospectively study the prevalence of psychological, social, musculoskeletal and somatoform disorders in patients presenting with chronic non-specific LBP to general practitioners, in comparison to a contrast group of patients consulting in the same setting. METHODS This case-control study is embedded in a historical cohort, based on a primary care practice-based research network. All the health problems presented by the patients were prospectively coded according to the international classification of primary care between 1996 and 2013. The prevalence of psychological, social, musculoskeletal and somatoform disorders presented by the adult patients from 1 year before the onset of chronic LBP to 2 years after onset was compared to that of matched patients consulting without LBP, using conditional logistic regressions. RESULTS The 1511 patients with chronic LBP more often presented musculoskeletal disorders than the contrast group during the year before the onset of LBP and during the second year after it, with odds ratios (95%confidence intervals) of 1.39 (1.20-1.61) and 1.56 (1.35-1.81), respectively. They did not more often present psychological, social or non-musculoskeletal somatoform disorders. CONCLUSIONS General practitioners should consider all the musculoskeletal symptoms when caring for patients with chronic LBP. Rather than systematically screening for specific psychological, social or somatoform disorders, they should consider with the patient how LBP and any type of potential comorbidity interfere with his/her daily functioning.

Estimating incidence and prevalence rates of chronic diseases using disease modeling

BackgroundMorbidity estimates between different GP registration networks show large, unexplained variations. This research explores the potential of modeling differences between networks in distinguishing new (incident) cases from existing (prevalent) cases in obtaining more reliable estimates.MethodsData from five Dutch GP registration networks and data on four chronic diseases (chronic obstructive pulmonary disease [COPD], diabetes, heart failure, and osteoarthritis of the knee) were used. A joint model (DisMod model) was fitted using all information on morbidity (incidence and prevalence) and mortality in each network, including a factor for misclassification of prevalent cases as incident cases.ResultsThe observed estimates vary considerably between networks. Using disease modeling including a misclassification term improved the consistency between prevalence and incidence rates, but did not systematically decrease the variation between networks. Osteoarthritis of the knee showed large modeled misclassifications, especially in episode of care-based registries.ConclusionRegistries that code episodes of care rather than disease generally provide lower estimates of the prevalence of chronic diseases requiring low levels of health care such as osteoarthritis. For other diseases, modeling misclassification rates does not systematically decrease the variation between registration networks. Using disease modeling provides insight in the reliability of estimates.

Spoedzorg in de huisartsenpraktijk.

SamenvattingInleiding Huisartsen zijn verantwoordelijk voor de spoedzorg, op de huisartsenpost (HAP) maar ook in hun eigen praktijk. Hoeveel spoedzorgcontacten ze hebben in de dagpraktijk is echter niet bekend. We onderzochten de frequentie van die spoedzorgcontacten en om welke patiënten en zorgverlening het ging. Ook gingen we na hoeveel patienten zich tijdens kantooruren op de Spoedeisende Hulp (SEH) melden buiten hun huisarts om.Methode Retrospectief transversaal onderzoek waarin we in zeven huisartsenpraktijken verspreid over Nederland alle patiëntcontacten analyseerden die in week 42 van 2016 geregistreerd werden. Bij de contacten die naar voren kwamen als spoedcontacten beoordeelden we de kenmerken van de patiënt en de verleende zorg. Daarnaast analyseerden we alle SEH-brieven die de praktijken tijdens de onderzoeksweek hadden ontvangen.Resultaten Van de 2520 patiëntcontacten waren er 108 (4,3%) urgent. Van de 108 spoedcontacten was 74% een praktijkconsult en 23% een visite. Respiratoire klachten kwamen het meest voor (29%). Bij 23% van de contacten werd aanvullend onderzoek verricht, bij 48% werd medicatie voorgeschreven; slechts eenmaal (1%) was spoedmedicatie noodzakelijk. In 18% werd de patiënt verwezen naar het ziekenhuis. Dertien patiënten bezochten de SEH op eigen initiatief of na een 112-melding, drie van hen kwamen daar per ambulance, bij twee was er geen noodzaak voor specialistische zorg.Conclusie Spoedcontacten vormen slechts 4 à 5% van alle contacten in de huisartsenpraktijk, maar met 2,9 miljoen spoedcontacten per jaar hebben de huisartsenpraktijken een zeer groot aandeel in de spoedzorg in Nederland. Het aantal zelfverwijzers naar de SEH is tijdens kantooruren verhoudingsgewijs gering. Abstract Van der Maas J, Rutten M, Smits M, Van Boven K, Giesen P. Emergency care in general practice. Huisarts Wet 2018;61(2):36-43. DOI:10.1007/s12445--018-0003-9.Background General practitioners are responsible for providing emergency care, be it at an out-of-hours service or in their own practice; however, it is not known how many practice visits are for emergency care. We investigated the frequency of emergency care visits, for which patients, and the care provided. We also investigated the number of patients who went to an accident and emergency (A&E) department, without GP referral, during office hours.Method In this retrospective, transverse study, we analysed all patient contacts in seven general practices spread throughout the Netherlands in week 42 in 2016. The type of patient and care provided were assessed for patients requiring emergency care. The number of letters received from A&E departments was also counted.Results Of 2520 patient contacts, 108 (4.3%) were for emergency care. Of these, 74% occurred during a practice visit and 23% during a home visit. Respiratory disorders were the most common problem (29%). In 23% of the cases additional investigations were ordered, in 48% medicine was prescribed; in only 1% was emergency medication required. Overall, in 18% of cases the patient was referred to hospital. Thirteen patients visited an A&E department on their own initiative or after phoning 112; 3 came by ambulance and 2 did not require specialist care.Conclusion Although emergency care contacts accounted for only 4–5% of all patient contacts in general practice, with 2.9 million of such contacts annually general practice provides a substantial amount of emergency care in the Netherlands. Relatively few people go to an A&E department on their own initiative during office hours.

Alarmsymptomen voor kanker als reden van komst

SamenvattingInleiding Huisartsen moeten alarmsymptomen voor kanker niet alleen kunnen herkennen, maar ook kunnen inschatten hoe groot de kans is dat het echt om kanker gaat. De spontaan genoemde klacht of wens van een patiënt bij de huisarts noemt men de ‘reden van komst’ oftewel de reason for encounter (RFE). Sommige RFE’s zijn een alarmsymptoom voor kanker. Wij onderzochten de voorspellende waarde van deze RFE’s.Methode Wij voerden een retrospectief cohortonderzoek uit in het eerstelijns registratienetwerk Family Medicine Network. We selecteerden patiënten ouder dan 45 jaar die tussen 1995 en 2014 (118.219 patiëntjaren) bij de huisarts kwamen met als RFE een van de alarmsymptomen die gedefinieerd zijn door KWF Kankerbestrijding en UK Cancer Research. We berekenden de positief voorspellende waarde (PVW) van deze RFE’s voor de diagnose ‘kanker’.Resultaten Een knobbel in de borst had de hoogste PVW (14,8%), gevolgd door postmenopauzale bloeding (3,9%), hemoptoë (2,7%), rectaal bloedverlies (2,6%), hematurie (2,2%) en verandering in de stoelgang (1,8%).Conclusie Alarmsymptomen voor kanker die de patiënt bij binnenkomst spontaan noemt, hebben op zichzelf een voorspellende waarde, al wordt het beleid natuurlijk vooral bepaald door anamnese en lichamelijk onderzoek. De positief voorspellende waarde van zulke alarmsymptomen, die ook gecommuniceerd worden in publiekscampagnes, is een factor om rekening mee te houden.