René Wolters

Lower urinary tract symptoms: social influence is more important than symptoms in seeking medical care

Objective  To determine associations among lower urinary tract symptoms (LUTS), symptom severity, subjective beliefs and social influences when seeking primary medical care in men aged ≥ 50 years.

Harm caused by adverse events in primary care: a clinical observational study

RATIONALE, AIMS AND OBJECTIVES Patient safety in primary care is important, but not well studied. The aim of our study was to determine the actual and potential harm caused by adverse events in primary care. METHOD Observational study in two general practices, including the patients of five doctors. Two methods were used to identify adverse events; (1) a prospective registration of adverse events by the general practitioner and (2) a retrospective audit of medical records. Actual harm was registered and a clinical analysis was made to estimate potential harm. RESULTS A total of 31 adverse events were collected and analysed. The adverse events were spread over different adverse event categories. About half of the events did not have health consequences, but a third led to worsening of symptoms and a few resulted in unplanned hospital admission. Potential negative health consequences were likely in three-quarters of the events. CONCLUSIONS The identified adverse events had some impact on health outcomes, but a risk for harm existed in a majority of the events. Patient safety programmes in primary care should focus on adverse events and not just on harm.

Management of children's urinary tract infections in Dutch family practice: a cohort study

BackgroundOptimal clinical management of childhood urinary tract infections (UTI) potentiates long-term positive health effects. Insight into the quality of care in Dutch family practices for UTIs was limited, particularly regarding observation periods of more than a year. Our aim was to describe the clinical management of young childrens UTIs in Dutch primary care and to compare this to the national guideline recommendations.MethodsIn this cohort study, all 0 to 6-year-old children with a diagnosed UTI in 2001 were identified within the Netherlands Information Network of General Practitioners (LINH), which comprises 120 practices. From the Dutch guideline on urinary tract infections, seven indicators were derived, on prescription, follow-up, and referral.ResultsOf the 284 children with UTI who could be followed for three years, 183 (64%) were registered to have had one cystitis episode, 52 (18%) had two episodes, and 43 (15%) had three or more episodes. Another six children were registered to have had one or two episodes of acute pyelonephritis. Overall, antibiotics were prescribed for 66% of the children having had ≤ 3 cystitis episodes, two-thirds of whom received the antibiotics of first choice. About 30% of all episodes were followed up in general practice. Thirty-eight children were referred (14%), mostly to a paediatrician (76%). Less than one-third of the children who should have been referred was actually referred.ConclusionTreatment of childhood UTIs in Dutch family practice should be improved with respect to prescription, follow-up, and referral. Quality improvement should address the low incidence of urinary tract infections in children in family practice.

Management of Childhood Urinary Tract Infections: An Economic Modeling Study

UNLABELLED Childhood urinary tract infections (UTIs) can lead to renal scarring and ultimately to terminal renal failure, which has a high impact on quality of life, survival, and health-care costs. Variation in the treatment of UTIs between practices is high. OBJECTIVE To assess the cost-effectiveness of a maximum care model for UTIs in children, implying more testing and antibiotic treatment, compared with current practice in primary care in The Netherlands. METHODS We performed a probabilistic modeling study using Markov models. Figures used in the model were derived from a systematic review of the research literature. Multidimensional Monte Carlo simulation was used for the probabilistic analyses. RESULTS Maximum care gained 0.00102 (males) and 0.00219 (girls) QALYs (quality-adjusted life-years) and saved 42.70 euro (boys) and 77.81 euro (girls) in 30 years compared with current care, and was thus dominant. Net monetary benefit of maximum care ranged from 20 euro to 200 euro for a willingness to pay for a QALY ranging from 0 euro to 80,000 euro, respectively. Maximum care was also dominant over improved current care, although less dominant than to current care. CONCLUSIONS This study suggested that maximum care for childhood UTI was dominant in the long run to current care, meaning that it delivered more quality of life at lower costs. Nevertheless, making firm conclusions is not possible, given the limitations of the input data.

Shared care and the management of lower urinary tract symptoms

To investigate associations between the level of shared care and the clinical management of patients with uncomplicated lower urinary tract symptoms (LUTS).

How do Dutch general practitioners diagnose children's urinary tract infections?

OBJECTIVE To study which tests general practitioners used to diagnose a urinary tract infection (UTI) in children and which patient characteristics were associated with test choice. DESIGN Retrospective chart review on the diagnosis of UTIs in children in Dutch general practices who were diagnosed as having a UTI. A total of 49 general practices participated in the study, and provided information on 148 children aged 0-12 years old. RESULTS The nitrite test, which is recommended as first step, was performed in 87% of the children during the first contact. Less than 30% of the children had a dipslide and 37% a cultured urine. About half of all children with a UTI diagnosis had a follow-up contact in general practice, and an average of 83% of these children had their urine tested. The recommended test, a dipslide, was performed in 26% of the children with a follow-up contact. Patient age and UTI history were associated with choice of test. CONCLUSIONS The diagnostic procedures for UTIs in children in general practices could be improved, with focus on the importance of an accurate UTI diagnosis in all children, and explaining which tests should be performed and what the test results mean.

Improving initial management of lower urinary tract symptoms in primary care: costs and patient outcomes.

Objective. Guidelines for primary care management of lower urinary tract symptoms in older men recommend shared decision making regarding the choice of treatment. In this study we aimed to determine the costs and patient outcomes of an implementation strategy designed to enhance uptake of these guidelines. Material and methods. The intervention comprised a distance learning programme for general practitioners, comprising evidence-based information, assessment of learning needs, a knowledge test and patient education materials. The control group only received the written guidelines. A cluster randomized trial in 187 older male patients compared costs and outcomes in the two study groups. A healthcare perspective was taken in the economic evaluation, with a 3-month time horizon. The primary health outcome was patient-reported urinary symptoms at 3 months. Costs relating to the distance learning package and the healthcare provided were considered, using undiscounted standardized prices. Results. Patient-reported urinary symptoms at 3 months did not differ between the study groups: 66% and 61% with moderate symptoms and 7% and 11% with severe symptoms in the intervention and control groups, respectively. The mean total costs per patient were €28.15 lower in the intervention group (€93.11) compared to the control group (€121.26), mainly because of a lower number of referrals to the urologist. A bootstrap analysis showed an incremental cost-effectiveness ratio of €111.98 (95% CI –€423 to +€329). Conclusions. The distance learning programme did not change health outcomes, but it reduced costs in the first 3 months after an initial consultation compared to written guidelines. Studies with a longer follow-up period are needed.