Family Medicine Network Research Articles

Which patients are at risk of developing symptom diagnoses that persist for more than a year in primary care? Development and external validation of a prediction model

ObjectivesTo train, test and externally validate a prediction model that supports General Practitioners (GPs) in early identification of patients at risk of developing symptom diagnoses that persist for more than a year. MethodsWe retrospectively collected and selected all patients having episodes of symptom diagnoses during the period 2008 and 2021 from the Family Medicine Network (FaMe-Net) database. From this group, we identified symptom diagnoses that last for less than a year and symptom diagnoses that persist for more than a year. Multivariable logistic regression analysis using a backward selection was used to assess which factors were most predictive for developing symptom diagnoses that persist for more than a year. Performance of the model was assessed using calibration and discrimination (AUC) measures. External validation was tested using data between 2018 and 2022 from AHON-registry, a primary care electronic health records data registry including 73 general practices from the north and east regions of the Netherlands and about 460,795 patients. ResultsFrom the included 47,870 patients with a symptom diagnosis in the FaMe-Net registry, 12,481 (26.1%) had a symptom diagnosis that persisted for more than a year. Older age (≥ 75 years: OR = 1.30, 95% CI [1.19, 1.42]), having more previous symptom diagnoses (≥ 3: 1.11, [1.05, 1.17]) and more contacts with the GP over the last 2 years (≥ 10 contacts: 5.32, [4.80, 5.89]) were predictive of symptom diagnoses that persist for more than a year with a marginally acceptable discrimination (AUC 0.70, 95% CI [0.69–0.70]). The external validation showed poor performance with an AUC of 0.64 ([0.63–0.64]). ConclusionA clinical prediction model based on age, number of previous symptom diagnoses and contacts might help the GP to early identify patients developing symptom diagnoses that persist for more than a year. However, the performance of the original model is limited. Hence, the model is not yet ready for a large-scale implementation.

25-year retrospective longitudinal study on seasonal allergic rhinitis associations with air temperature in general practice

Due to climate change, air temperature in the Netherlands has gradually increased. Higher temperatures lead to longer pollen seasons. Possible relations between air temperature and increased impact of seasonal allergic rhinitis (SAR) in general practice have not been investigated yet. We explored trends in timing of frequent seasonal allergic rhinitis presentation to general practitioners (GPs) over 25 years and explored associations with air temperature. We performed a retrospective exploratory longitudinal study with data from our Family Medicine Network (1995–2019), including all SAR patients and their GP-encounters per week. We determined patients’ GP-consultation frequency. Every year we identified seasonal periods with substantial increase in SAR related encounters: peak-periods. We determined start date and duration of the peak-period and assessed associations with air temperature in the beginning and throughout the year, respectively. The peak-period duration increased by a mean of 1.3 days (95% CI 0.23–2.45, P = 0.02) per year throughout the study period. Air temperature between February and July showed a statistically significant association with peak-period duration. We could not observe direct effects of warmer years on the start of peak-periods within distinct years (P = 0.06). SAR patients’ contact frequency slightly increased by 0.01 contacts per year (95% CI 0.002–0.017, P = 0.015). These longitudinal findings may help to facilitate further research on the impact of climate change, and raise awareness of the tangible impact of climate change in general practice.

Proposal to set up a College of Family Medicine in East, Central and Southern Africa.

Family Medicine training in Africa is constrained by limited postgraduate educational resources and opportunities. Specialist training programmes in surgery, anaesthetics, internal medicine, paediatrics and others have developed a range of trainers and assessors through colleges across East, Central and Southern Africa (ECSA). Each college has a single curriculum with standardised training and assessment in designated institutions, which run alongside and in collaboration with the Master’s in Medicine programmes in universities. Partnerships between colleges in Britain, Ireland and Canada and national specialist associations have led to joint training-of-trainer courses, e-learning platforms, improved regional coordination, better educational networking and research opportunities through regional conferences and joint publications. We propose the establishment of a regional college for specialist training of family physicians, similar to other specialist colleges in ECSA. Partnerships with family medicine programmes in South Africa, Canada and Australia, with support from international institutions such as the Primary Care and Family Medicine Network for Sub-Saharan Africa (PRIMAFAMED) and the World Organisation of Family Doctors (WONCA Africa), would be essential for its success. Improved health outcomes have been demonstrated with strong primary care systems and related to the number of family physicians in communities. A single regional college would make better use of resources available for training, assessment and accreditation and strengthen international and regional partnerships. Family medicine training in Africa could benefit from the experience of specialist colleges in the ECSA region to accelerate training of a critical mass of family physicians. This will raise the profile of family medicine in Africa and contribute to improved quality of primary care and clinical services in district hospitals.

Sex differences in the trajectories to diagnosis of patients presenting with common somatic symptoms in primary care: an observational cohort study

ObjectiveLittle insight exists into sex differences in diagnostic trajectories for common somatic symptoms. This study aims to quantify sex differences in the provided primary care diagnostic interventions for common somatic symptoms, as well as the consequences hereof for final diagnoses. MethodsIn this observational cohort study, we used real-world clinical data from the Dutch Family Medicine Network (N = 34,268 episodes of care related to common somatic symptoms; 61,4% female). The association between patients' sex on the one hand, and diagnostic interventions and disease diagnoses on the other hand, were assessed using multilevel multiple logistic regression analyses. Structural equation modelling was used to estimate a mediation model with multiple parallel mediators to assess whether the fewer disease diagnoses given to female patients were mediated by the fewer diagnostic interventions female patients receive, compared to male patients. ResultsWomen received fewer physical examinations (OR = 0.84, 95%CI = 0.79–0.89), diagnostic imaging (OR = 0.92, 95%CI = 0.84–0.99) and specialist referrals (OR = 0.85, 95%CI = 0.79–0.91) than men, but more laboratory diagnostics (OR = 1.27, 95%CI = 1.19–1.35). Women received disease diagnoses less often than men for their common somatic symptoms (OR = 0.94, 95%CI = 0.89–0.98). Mediation analysis showed that the fewer disease diagnosis in female patients were mediated by the fewer diagnostic interventions conducted in women compared to men. ConclusionThis study shows that sex inequalities are present in primary care diagnostic trajectories of patients with common somatic symptoms and that these lead to unequal health outcomes in terms of diagnoses between women and men. FPs have to be aware of these inequalities to ensure equal high-quality care for all patients.

AB0634 BELIEFS ABOUT URATE LOWERING THERAPY DIFFER BETWEEN GENERAL PRACTITIONERS AND RHEUMATOLOGISTS

Background:Uric acid lowering therapy (ULT) can be effective in gout if taken correctly (1), but non-adherence is a known problem (2). Although patients’ adherence barriers regarding ULT, such as lack of knowledge on disease and therapy, and beliefs, have been widely studied (3), less is known physicians’ beliefs.Objectives:To investigate the physicians’ beliefs on ULT treatment in both primary and secondary care in the Netherlands.Methods:Cross-sectional study among all rheumatologists of the Sint Maartenskliniek and to all General Practitioners (GPs) of 17 practices, participating in the practice-based research network Family Medicine Network Nijmegen, Netherlands. All participants filled out the beliefs about medication questionnaire (BMQ), adjusted for physicians; in addition data were collected on physician characteristics including working experience in total and gout consultations. The BMQ consists of two parts, a specific part with 10 questions about beliefs on necessity (N=5) and concerns (N=5) regarding ULT and a general part with 8 questions about beliefs on harms (N=4) and overuse (N=4) regarding medication in general. Each question is scored on a Likert-scale from 1-5, a higher score corresponds to higher beliefs on that category. Sum scores for all four categories were calculated. With the total scores on the specific BMQ including necessity and concerns beliefs, physicians were classified in four different categories (Table 1)(4).Results:In total 112 physicians received the questionnaire, 28 of 37 rheumatologists (76%) and 45 of 75 GPs (60%) responded. Rheumatologists had less years of experience than GPs (median 8.5 years (IQR 3 – 14) versus (vs) 13 years (IQR 8-20)) and less hours of patient contact per week (15 hours (IQR 8.5 – 20) vs 24 hours (IQR 20 – 30)). Rheumatologists reported more consultations for gout per week than GPs: median 4 (IQR 1 – 6.6) vs 1 (IQR 0.2– 1).Rheumatologists scored higher on the BMQ necessity scale, 17.5 (95% CI 16.6 – 18.5) compared to GPs 16.1 (95% CI 15.1 – 17.1). GPs scored higher on BMQ concern scale, 12.1 (95% CI 11.4 – 12.7) compared to rheumatologists, 10.4 (95% CI 9.7 – 11.2). On medication in general, GPs scored higher on both overuse and harms scales compared to rheumatologists, 11.3 (95% CI 10.7 – 12) versus 9.9 (95% CI 9 – 10.7)and 8.3 (95% CI 7.9 – 8.7) vs 7.1 (95% CI 6.5 – 7.7), respectively. Table 1 shows classification according to the BMQ specific for both groups.Table 1.Classification based on the adapted BMQRheumatologists (N=28)GPs (N=45)Acceptant (%)19 (67.9)16 (35.6)Ambivalent (%)08 (17.8)Sceptic (%)1 (3.6)5 (11.1)Indifferent (%)8 (28.6)16 (35.6)Conclusion:For the majority of rheumatologist the necessity beliefs outweighs concern beliefs towards the use of ULT outweighs concern beliefs. GPs show a more heterogenic profile, including acceptant, indifferent and ambivalent beliefs towards ULT use. GPs also show higher harm and overuse concerns regarding medication in general. Next step is to investigate possible associations with actual ULT use and disease outcome.

Preventing acute kidney injury in high-risk patients by temporarily discontinuing medication \u2013 an observational study in general practice

BackgroundElderly, patients with chronic kidney disease (CKD) and patients with heart failure who continue using renin-angiotensin-aldosterone-system (RAAS) inhibitors, diuretics, or non-steroidal-anti-inflammatory drugs (NSAIDs) during times of fluid loss have a high risk of developing complications like acute kidney injury (AKI). The aim of this study was to assess how often advice to discontinue high-risk medication was offered to high-risk patients consulting the general practitioner (GP) with increased fluid loss. Furthermore, we assessed the number and nature of the complications that occurred after GP consultation.MethodsWe performed a cross-sectional study with patients from seven Dutch general practices participating in the Family Medicine Network between 1 and 6-2013 and 1-7-2018. We included patients who used RAAS-inhibitors, diuretics, or NSAIDs, and had at least one of the following risk factors: age ≥ 70 years, CKD, or heart failure. From this population, we selected patients with a ‘dehydration-risk’ episode (vomiting, diarrhoea, fever, chills, or gastrointestinal infection). We manually checked their electronic patient files and assessed the percentage of episodes in which advice to discontinue the high-risk medication was offered and whether a complication occurred in 3 months after the ‘dehydration-risk’ episode.ResultsWe included 3607 high-risk patients from a total of 44.675 patients (8.1%). We found that patients were advised to discontinue the high-risk medication in 38 (4.6%) of 816 ‘dehydration-risk’ episodes. In 59 of 816 episodes (7.1%) complications (mainly AKI) occurred.ConclusionsDutch GPs do not frequently advise high-risk patients to discontinue high-risk medication during ‘dehydration-risk’ episodes. Complications occur frequently. Timely discontinuation of high-risk medication needs attention.

Early diagnosis and psychocorrection of mental and behavioral disorders in patients who use alcohol with harmful effects in family medicine network

Background. Currently, issues of early diagnosis and psychological correction of mental and behavioral disorders in primary care to patients who consume alcohol with harmful consequences remain relevant. Presently, Ukraine has not defined a system of psychosocial arrangements that will allow society to adapt part of the cohort of somatic patients who consume alcohol with harmful consequences, the volume and effectiveness of their complex psychosocial treatment and rehabilitation have been insufficiently analyzed. Prophylactic work in our country to prevent the use of alcohol by patients with somatic disorders is undoubtedly being carried out, but its scale and organizational features do not provide the proper effect. Therefore, it is extremely important to diagnose disorders in time, as a result of alcohol use with harmful consequences in patients who have somatic complaints in family medicine network.
 Objective – to develop a differentiated approach to the early diagnosis and psycho-correction of mental and behavioral disorders due to harmful use of alcohol in patients who have somatic complaints in family medicine network, taking into account the characteristics of socio-demographic indicators and characteristic differences in the course of the disease.
 Materials and methods. A comprehensive survey of 240 thematic patients who had fi led somatic complaints to general outpatient care facilities aged from 18 to 60 years was conducted. Research methods – clinical and anamnestic, socio-demographic, psychological, clinical and psychopathological.
 Results. We studied the distribution of patients by somatic pathology, gender, age, marital status, educational backgrounds. The social and personal factors provoking the use of alcohol are revealed. The question of the initiating agent of alcohol use has been investigated, the mental state of the respondents has been analyzed. Mental and behavioral disorders of varying severity have been revealed in a significant part of the subjects, which requires their timely recognition and adequate psychocorrection, psychoprophylaxis and therapy. The results of indicators of clinical and psychopathological methods have been analyzed after providing patients with a general group of psychocorrectional and psychotherapeutic measures.
 Conclusions. It was revealed that mental and behavioral disorders, resulting from alcohol, significantly worsen the course of the patient’s somatic illness and require additional psychocorrection by the family doctor. Risk factors in the use of alcohol are neuro-psychological instability, accentuation of nature, the peculiarity of behavioral responses to a stressful situation (the use of sedatives, denial, behavioral withdrawal from the problem and others). Significant psycho-emotional stress of a general and personal nature encourages patients to use alcohol in order to compensate for their negative state. It was revealed that after psychocorrectional measures that were provided to patients of the general group, their results had higher indicators in all parameters than in the comparative group. A differentiated approach to the early diagnosis and psycho-correction of mental and behavioral disorders due to harmful use of alcohol in patients who have somatic complaints in family medicine network have developed, taking into account the characteristics of socio-demographic indicators and characteristic differences in the course of the disease.

Investigación aplicada al territorio desde la Medicina Familiar

En el contexto la VII Cumbre Iberoamericana de Medicina Familiar, efectuada en Cali, Colombia el 13 y 14 de Marzo de 2018, el grupo de investigación y la Red Iberoamericana de Medicina Familiar (IBIMEFA) con el objetivo de Identificar las percepciones de médicos familiares graduados y en proceso de formación de Iberoamérica, sobre las condiciones que tienen para desarrollar investigación aplicada al territorio, realizaron un estudio exploratorio, descriptivo, de corte transversal en los países miembros de la Confederación Iberoamericana de Medicina Familiar (CIMF). Para la recolección de información, se diseñó una encuesta con 51 items, cuyo contenido fue validado por el grupo de trabajo. El instrumento se almacenó en Google Drive y su divulgación se efectuó a través de medios virtuales. Se obtuvo respuesta de 277 personas, representantes de 16 países de Iberoamérica en los que se encontró que existe interés y potencial dentro del grupo de la Red IBIMEFA, para realizar estudios con el enfoque de investigación aplicada al territorio, aunque se deben superar dificultades de tiempo y financiación para lograrlo, así como encontrar estratégias que permitan hacer un trabajo cooperativo que consolide la Red.

Change in frequency of patient requests for diagnostic screening and interventions during primary care encounters from 1985 to 2014.

The reason why patients contact a care provider, the reason for encounter (RFE), reflects patients' personal needs and expectations regarding medical care. RFEs can be symptoms or complaints, but can also be requests for diagnostic or therapeutic interventions. Over the past 30 years, we aim to analyse the frequency with which patients consult a GP to request an intervention, and to analyse the impact of these requests on the subsequent diagnostic process. We included all patients with a request for diagnostics, medication prescription or referral from 1985 to 2014. We analysed the number of requests, granted requests and interventions originating from a request. We compared the final diagnosis (symptom or disease diagnosis) between patients with and without a request. This is a retrospective cohort study with data from Family Medicine Network, a Dutch primary healthcare registration network. Over time, patients more often present to their GP with a request for intervention. GPs are increasingly compliant with these requests. Patients presenting with a request for intervention are more likely to be diagnosed with a symptom rather than a disease. This study provides insight into the changes in patients' and GPs' behaviour and patients' influence on the medical process, and confirms the clinical relevance of the RFE. This study could support GPs in daily practice when deciding whether or not to grant a request.

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

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. Retrospective cohort study in a Dutch practice-based research network (Family Medicine Network). 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. 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%). 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.

The promise of an intra-African family medicine network: Connecting? Southern and East Africa

Extracted from text ... Editorial Editorial The past few decades have been characterized by a mixed picture of unprecedented human progress and unspeakable human misery.1 Much of the world's population has enjoyed improved health and living conditions in recent years, yet an immense burden of disease persists, especially in low-income countries. In an era of scarce resources and many competing health priorities, the efficient organization of available resources is critical to equitable, costeffective and relevant health care, particularly for the poor. Mounting evidence indicates that primary health care teams anchored by generalist physicians are well equipped to deal with frequently occurring illnesses in ..