Sibo Oskam

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.

Once tired, always tired? Limitations in function over time of tired patients in Dutch general practice

Objective: To gain insight into limitations in function over time of general-practice patients who presented and were diagnosed with “tiredness”. Methods: In a routine family-practice electronic register based on use of the International Classification of Primary Care (ICPC), 684 patients were identified who presented (in 1997 or 1998) with the complaint tiredness, who were given the same symptom diagnosis, and who still had this diagnosis on 1 August 1999. A questionnaire (WONCA/COOP charts, HAD Scale, recent medical care, tiredness and attribution) was sent to these 684 “cases” and 858 controls. In a logistic regression analysis (16 dichotomous variables), we constructed five models for optimizing sensitivity and specificity for the detection of patients with an episode of care for “tiredness”. Results: We received 385 fully completed questionnaires of cases, on average 19 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31 months after the start of their episode of care for “tiredness”. The results of the 1997 and 1998 cases were similar. Cases did considerably worse than did the 385 optimally matched controls: e.g., seriously limited by tiredness: 52% of cases vs 32% of controls; poor overall health: 35% of cases vs 20% of controls; HAD Scale scores indicating anxiety or depression: about 20% of cases vs about 10% of controls. Highest sensitivity (70%) was reached by including poor overall health, recent medical care and HAD Scale depression score >10 in the model; and highest specificity (65%) by including poor overall health and a HAD Scale anxiety score >7. Conclusion: Patients who present with tiredness and receive the same diagnosis have a high probability of suffering from substantial limitations in function in the years following diagnosis. Their limitations are more serious than those of controls, but no indication is found for a specific limitation. The indicators are strongly related and concentrate around “poor overall health”.

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.

The Diagnostic Value of the Patient’s Reason for Encounter for Diagnosing Cancer in Primary Care

Purpose: Family physicians (FPs) have to recognize alarm symptoms and estimate the probability of cancer to manage these symptoms correctly. Mostly, patients start the consultation with a spontaneous statement on why they visit the doctor. This is also called the reason for encounter (RFE). It precedes the interaction and interpretation by FPs and patients. The aim of this study is to investigate the predictive value of alarm symptoms as the RFE for diagnosing cancer in primary care. Design and setting: Retrospective cohort study in a Dutch practice-based research network (Family Medicine Network). Method: We analyzed all patients >45 years of age listed in the practice-based research network, FaMe-net, in the period 1995 to 2014 (118.219 patient years). We focused on a selection of alarm symptoms as defined by the Dutch Cancer Society and Cancer Research UK. We calculated the positive predictive value (PPV) of alarm symptoms, spontaneously mentioned in the beginning of the consultation by the patient (RFE), for diagnosing cancer. Results: The highest PPVs were found for patients spontaneously mentioning a breast lump (PPV 14.8%), postmenopausal bleeding (PPV 3.9%), hemoptysis (PPV 2.7%), rectal bleeding (PPV 2.6%), hematuria (PPV 2.2%) and change in bowel movements (PPV 1.8%). Conclusion: Patients think about going to their physician and think about their first uttered statements during the consultation. In the case of cancer, the diagnostic workup during the consultation on alarm symptoms will add to the predictive value of these reasons for encounter. However, it is important to realize that the statement made by the patient entering the consultation room has a significant predictive value in itself.

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.