General Practitioner Database Research Articles

GP consultations for menstrual disorders after COVID-19 vaccination – A self-controlled cohort study based on routine healthcare data from the Netherlands

IntroductionSeveral studies described that COVID-19 vaccinations can cause menstrual disorders. Our study aimed to describe whether this also resulted in more general practitioner (GP) consultations for menstrual disorders after COVID-19 vaccination, based on a large cohort study. MethodsA retrospective self-controlled cohort study was performed including vaccinated women in 2021 aged 12–49 years from two large, representative GP databases in the Netherlands. Incidence rates and incidence rate ratio’s (IRR) were calculated using Poisson regression, adjusting for SARS-CoV-2 infection as time-varying confounder. The exposed period was set at maximum six months after each COVID-19 vaccination and the non-exposed period was defined as all-time outside the exposed period. ResultsThe cohort included 631,802 women, of which 18,986 (3 %) consulted the GP for a menstrual disorder during 2021. Increased GP consultations were observed among 12–14 year olds for amenorrhea/hypomenorrhea/oligomenorrhea (IRR: 1.85, 95 % CI: 1.30–2.65) and irregular/frequent menstruation (IRR: 1.33, 95 % CI: 1.06–1.69) after COVID-19 vaccination in general, and after Pfizer/BioNTech vaccination (IRR: 1.87, 95 % CI: 1.31–2.67 for amenorrhea/hypomenorrhea/oligomenorrhea and IRR: 1.35, 95 % CI: 1.06–1.70 for irregular/frequent menstruation). Persons from this age group were in general also vaccinated with Pfizer/BioNTech. No increase in the frequency of GP consultations were observed for older age groups, other vaccine brands, and potential risk groups. ConclusionFor the majority of women, no increased GP consultations for menstrual disorders was found. Solely for the youngest age group (12–14 year olds) increased GP consultations for specific types of menstrual disorders was found after Pfizer/BioNTech vaccination.

A novel case-finding strategy based on artificial intelligence for the systematic identification and management of individuals with osteoporosis or at varying risk of fragility fracture.

Osteoporotic fractures represent a major cause of morbidity and, in older adults, a precursor of disability, loss of independence, poor quality of life and premature death. Despite the detrimental health impact, osteoporosis remains largely underdiagnosed and undertreated worldwide. Subjects at risk for osteoporosis-related fractures are identified either via organised screening or case finding. In the absence of a population-based screening policy, subjects at high risk of fragility fractures are opportunistically identified when a fracture occurs or because of other clinical risk factors (CRFs) for osteoporotic fracture and areal bone mineral density (aBMD) measured by dual-energy X-ray absorptiometry (DXA). This paper describes the development of a novel case-finding strategy, named Osteoporosis Diagnostic and Therapeutic Pathway (ODTP), which enables to identify subjects with osteoporosis or at varying risk of fragility fracture. This strategy is based on a specifically designed software tool, named "Bone Fragility Query" (BFQ), which analyses the electronic health record (EHR) databases of General Practitioners (GPs) to systematically identify individuals who should be prescribed DXA-BMD measurement, vertebral fracture assessment (VFA) and anti-osteoporosis medications (AOM). The ODTP through BFQ tool is a feasible, convenient and time-saving osteoporosis model of care for GPs during routine clinical practice. It enables GPs to shift their focus from what to do (clinical guidelines) to how to do it in the primary health care setting. It also allows a systematic approach to primary and secondary prevention of fragility fractures, thereby overcoming clinical inertia and contributing to closing the gap between evidence and practice for the management of osteoporosis in primary care.

Attention-based neural networks for clinical prediction modelling on electronic health records

BackgroundDeep learning models have had a lot of success in various fields. However, on structured data they have struggled. Here we apply four state-of-the-art supervised deep learning models using the attention mechanism and compare against logistic regression and XGBoost using discrimination, calibration and clinical utility.MethodsWe develop the models using a general practitioners database. We implement a recurrent neural network, a transformer with and without reverse distillation and a graph neural network. We measure discrimination using the area under the receiver operating characteristic curve (AUC) and the area under the precision recall curve (AUPRC). We assess smooth calibration using restricted cubic splines and clinical utility with decision curve analysis.ResultsOur results show that deep learning approaches can improve discrimination up to 2.5% points AUC and 7.4% points AUPRC. However, on average the baselines are competitive. Most models are similarly calibrated as the baselines except for the graph neural network. The transformer using reverse distillation shows the best performance in clinical utility on two out of three prediction problems over most of the prediction thresholds.ConclusionIn this study, we evaluated various approaches in supervised learning using neural networks and attention. Here we do a rigorous comparison, not only looking at discrimination but also calibration and clinical utility. There is value in using deep learning models on electronic health record data since it can improve discrimination and clinical utility while providing good calibration. However, good baseline methods are still competitive.

High vaccine confidence and strong approval of the mandatory immunization schedule among Bulgarian general practitioners in 2022

ABSTRACT In a context of recently decreasing childhood immunization coverage and low uptake of COVID-19 vaccines in Bulgaria, this study measures vaccine hesitancy among general practitioners (GPs) in the country, as they are central to forming patients’ attitudes. In 2022, a face-to-face survey was conducted through a simple random sample from an exhaustive national database of Bulgarian GPs. This study measured attitudes on vaccine importance, safety, and effectiveness, and attitudes toward the Bulgarian immunization schedule. Information was collected on demographic and GP practice characteristics and possible predictors of vaccine confidence in order to test for associations with attitudes toward immunization. GP attitudes toward vaccines and the immunization schedule in Bulgaria were generally positive. Among 358 respondents, 351 (98%,95%CI96–99%) strongly agreed/agreed that vaccines are important, 352 (98%,95%CI96–99%) that vaccines are effective, and 341 (95%,95%CI93–97%) that vaccines are safe. 347 respondents (97%,95%CI95–98%) affirmed that “it’s good that vaccines from the children’s immunization schedule are mandatory”, and 331 (92%,95%CI89–95%) agreed with the statement “Bulgaria’s childhood immunization has my approval”. Trust in information from official institutions was among the strongest predictors of vaccine confidence. Respondents’ vaccine confidence levels are within the ranges reported by GPs in other European countries and above those reported within the general Bulgarian population. GPs’ vaccine confidence is highly associated with trust in official institutions. It is important to maintain trust in official institutions and to support GPs in communicating vaccine knowledge with patients so that vaccine hesitancy in the general population is countered.

Incomplete capture of apremilast in Clinical Practice Research Datalink Aurum: An example of exposure misclassification of specialty treatments in United Kingdom general practice databases.

Nearly all apremilast users captured in Clinical Practice Research Datalink (CPRD) Aurum have only one prescription, which is inconsistent with its prescribing pattern. The goal of this study was to assess capture of apremilast prescriptions in CPRD Aurum by comparison to CPRD GOLD and general practitioner (GP) questionnaires. We compared the number of apremilast prescriptions for patients in Aurum to (1) those in GOLD and (2) those reported by the GPs via questionnaire responses. There were 441 Aurum patients with an apremilast prescription (424 [96%] in England) and 341 GOLD patients (11 [3%]) in England). In Aurum 91% of all patients (and 96% of English patients) had only one apremilast prescription while in GOLD 29% of all patients (and 82% of English patients) had only one prescription. We received questionnaire responses from GPs for 50 of 390 (13%) patients participating in Aurum who had 57 total apremilast exposed months captured in Aurum. GPs reported 8 (16%) patients with only one prescription and a median of 4 (range 1-35) apremilast prescriptions per patient, yielding 463 total months of apremilast exposure. CPRD Aurum captures only one apremilast prescription for most recorded users, though questionnaire responses indicated most patients received multiple prescriptions. Researchers using any UK GP database should be aware of potential for significant exposure misclassification of apremilast and other treatments classified as specialist or shared care by local Area Prescribing Committees.

Heavy menstrual bleeding in adolescents: incidence, diagnostics, and management practices in primary care

BackgroundHeavy menstrual bleeding (HMB), self-reported by 37% of adolescents, can be the first sign of a bleeding disorder (BD) during adolescence. The Dutch general practitioner (GP) guideline demands laboratory diagnostics and referral for patients at risk for a BD. How often adolescents consult the GP for HMB and which diagnostic and management strategies are used are unknown. ObjectivesThis study aims to estimate the incidence of HMB in adolescents in primary care and to identify diagnostic and management practices for HMB, considering the HMB GP guideline. MethodsRetrospective analyses of a GP network database containing over 200 Dutch GPs were performed. Adolescents aged 10 to 21 years, with a new diagnosis of HMB between 2010 and 2020, and a 6-month follow-up were eligible. The incidence rate and diagnostic and therapeutic strategy data were extracted. ResultsWe identified 1879 new diagnoses of HMB in adolescents. The average incidence rate was 7.91 per 1000 person-years. No diagnostic studies were performed in 67%. Laboratory studies were mainly restricted to hemoglobin levels (31%). Full coagulation screening occurred in 1.3%, and ferritin levels in 10%. Medication was prescribed in 65%; mostly hormonal treatment (56%) and/or nonsteroidal antiinflammatory drugs (NSAIDs) (18%). The referral rate was higher after >2 follow-up visits (6.7%) vs after 1 GP visit for HMB (1.6%; Odds ratio: 8.8; 95% CI: 5.1-15), mostly to gynecologists (>85%). ConclusionAccording to this GP database study, few adolescents visit their GP with HMB despite its high self-reported incidence. Most adolescents were prescribed hormonal contraception without further diagnostics. Referral was rare and mostly occurred after multiple follow-up visits.

19 General practitioners’ perspectives on advance care planning: a qualitative study

Abstract Background An Advance Care Plan (ACP) outlines patient preferences for future treatment for a time when capacity is lacking. With our ageing population and rising dementia prevalence, ACPs are of increasing relevance and importance; however, very few are created each year. This study aims to explore General Practitioner (GP) perspectives on ideal timing, facilitators, and barriers to ACPs. Methods To date, ten GPs with a range of clinical experience have been purposely sampled from the Irish College of General Practitioners database. Semi-structured interviews were conducted by phone, video call, or in person, concurrently recorded, and subsequently transcribed. The Braun and Clarke method of thematic analysis was utilised, and coding was performed using NVivo software. Results All GPs spoke to the importance of ACPs for care of those with dementia and believed GPs are ideally placed to have these discussions. Two themes arose regarding timing of discussion: (1) routine proactive discussion prior to potential cognitive issues arising and (2) discussion within a few appointments of diagnosis. Identified barriers to ACP include: (1) lack of patient awareness of ACPs, (2) lack of GP education on ACPs, (3) difficulty predicting disease progression, (4) poor family dynamics, (5) short appointment times, and (6) lack of remuneration. Identified facilitators include: (1) patient’s acceptance of death and understanding of diagnosis, (2) use of an established template to guide discussion, (3) presence of a trusted family member, (4) long appointment times and (5) remuneration. Conclusion There was universal agreement on the importance of ACPs. Inclusion of ACP teaching in the curriculum for undergraduate medical education and postgraduate GP training should be strongly considered. There is need for heightened public awareness of the Assisted Decision-Making Act and ACPs. Further qualitative and quantitative research is needed to explore this issue nationally and identify how it has been resolved internationally.

Incidence of Lyme Borreliosis in the Dutch General Practice Population: A Large-Scale Population-Based Cohort Study Across the Netherlands Between 2015 and 2019

Background: There is a need for updated incidence rates (IRs) of Lyme borreliosis (LB) in Europe, including the Netherlands. We estimated LB IRs stratified by geographic area, year, age, sex, immunocompromised status, and socioeconomic status (SES). Methods: All subjects registered in the PHARMO General Practitioner (GP) Database without prior diagnosis of LB or disseminated LB and having ≥1 year of continuous database enrolment were included. IRs and corresponding confidence intervals (CIs) of GP-recorded LB, erythema migrans (EM), and disseminated LB were estimated during the period 2015‒2019. Results: We identified 14,794 events (suspected, probable, or confirmed) with a diagnostic code for LB that included 8219 with a recorded clinical manifestation: 7985 (97%) with EM and 234 (3%) with disseminated LB. National annual LB IRs were relatively consistent, ranging from 111 (95% CI 106‒115) in 2019 to 131 (95% CI 126‒136) in 2018 per 100,000 person-years. Incidence of LB showed a bimodal age distribution, with peak IRs observed among subjects aged 5‒14 and 60‒69 years in men and women. Higher LB incidence was found in subjects who were residents of the provinces of Drenthe and Overijssel, immunocompromised, or of lower SES. Similar patterns were observed for EM and disseminated LB. Conclusions: Our findings confirm that LB incidence remains substantial throughout the Netherlands with no indication of decline in the past 5 years. Foci in two provinces and among vulnerable populations suggest potential initial target groups for preventive strategies such as vaccination.

Trends in antipsychotic prescribing in children and adolescents: more is not necessarily better

Monitoring trends in prescriptions remains a vital tool in improving rational and safe use of medications in the community. In The Lancet Psychiatry, Maja R Radojčić and colleagues1 examined such trends for antipsychotics, in a large general practitioner (GP) database in England, and identified a doubling in the prevalence of antipsychotic prescriptions for children and adolescents aged 3–18 years (3 480 730 [48·2%] girls and 3 736 061 [51·8%] boys; mean age at the start of follow-up 7·3 years [SD 4·9]), from 0·057% (95% CI 0·052–0·063%) in 2000 to 0·105% (0·100–0·111%) in 2019.

General practice database on mortality in adults on methylphenidate: cohort study

ObjectivesMethylphenidate is a ‘prescription only’ drug against attention disorders which is increasingly used by adults. We investigated whether methylphenidate in adults was associated with an increased risk of psychiatric events...

Incidence of malignancies in patients with multiple sclerosis versus a healthy matched cohort: A population-based cohort study in the Netherlands using the PHARMO Database Network

This study estimated the incidence of malignancy in patients with multiple sclerosis (MS) versus a matched general population cohort in the Netherlands. Adults with a diagnosis of MS between 2006 and 2014 in the General Practitioner (GP) Database of the PHARMO Database Network with ≥ 1 year of patient history were matched to four non-MS individuals based on year of birth, sex, and GP practice. Patients were followed-up until the earliest malignancy diagnosis, death, or end of data collection. Age-adjusted incidence rates (IR) were measured overall and by cancer type. Standardized incidence ratios (SIR) were calculated as the ratio of stratification-specific IRs in the MS and non-MS cohorts. A total of 1,692 MS patients were matched to 6,768 non-MS patients. Age-adjusted IR of any malignancy, excluding non-melanoma skin cancer (n = 27), in the MS cohort was 48.3 (95%CI:30.1–66.5) per 10,000 PY. An increased incidence of any malignancy was observed in the MS cohort versus the non-MS cohort (SIR 1.8 [95%CI:1.1–2.5]). The most commonly observed malignancies in the MS cohort were breast cancer (n = 8; IR 20.4 [95%CI:6.3–34.5] per 10,000 PY) and melanoma (n = 6; IR 14.8 [95%CI:3.0–26.7] per 10,000 PY). The corresponding SIR observed between cohorts was 1.4 (95%CI:0.4–2.4) and 3.4 (95%CI:0.7–6.2), respectively. While the small increased incidence of malignancy in the MS cohort could be an artefact created by a different distribution of risk factors, an increased incidence of malignancy in MS patients in the Netherlands cannot be excluded.

Mortality Rate Associated with Diabetes: Outcomes From a General Practice Level Analysis in England Using the Royal College of General Practitioners (RCGP) Database Indicate Stability Over a 15 Year Period.

IntroductionTotal population mortality rates have been falling and life expectancy increasing for more than 30 years. Diabetes remains a significant risk factor for premature death. Here we used the Oxford Royal College of General Practitioners Research and Surveillance Centre (RCGP RSC) practices to determine diabetes-related vs non-diabetes-related mortality rates.MethodsRCGP RSC data were provided on annual patient numbers and deaths, at practice level, for those with and without diabetes across four age groups (< 50, 50–64, 65–79, ≥ 80 years) over 15 years. Investment in diabetes control, as measured by the cost of primary care medication, was also taken from GP prescribing data.ResultsWe included 527 general practices. Over the period 2004–2019, there was no significant change in life years lost, which varied between 4.6 and 5.1 years over this period. The proportion of all diabetes deaths by age band was significantly higher in the 65–79 years age group for men and women with diabetes than for their non-diabetic counterparts. For the year 2019, 26.6% of deaths were of people with diabetes. Of this 26.6%, 18.5% would be expected from age group and non-diabetes status, while the other 8.1% would not have been expected—pro rata to nation, this approximates to approximately 40,000 excess deaths in people with diabetes vs the general population.ConclusionThere remains a wide variation in mortality rate of people with diabetes between general practices in UK. The mortality rate and life years lost for people with diabetes vs non-diabetes individuals have remained stable in recent years, while mortality rates for the general population have fallen. Investment in diabetes management at a local and national level is enabling us to hold the ground regarding the life-shortening consequences of having diabetes as increasing numbers of people develop T2DM at a younger age.

Assessing the use of antibiotics and the burden of varicella in Belgium using a retrospective GP database analysis

BackgroundVaricella is a highly contagious infection that typically occurs in childhood. While most cases have a generally benign outcome, infection results in a considerable healthcare burden and serious complications may occur.ObjectivesThe objective of this study was to characterize the burden of varicella in a real-world primary care setting in Belgium, including the rate of varicella-related complications, medication management and general practitioner (GP) visits.MethodsThe study was a retrospective observational study using data from a longitudinal patient database in a primary care setting in Belgium. Patients with a GP visit and a varicella diagnosis between January 2016 and June 2019 were eligible and data one month prior and three months after the diagnosis were included. Outcomes included varicella-related complications, antibiotic use, antiviral use, and GP follow-up visits. Antibiotic use could be specified by class of antibiotic and linked to a diagnosis. Complications were identified based on concomitant diagnosis with varicella during the study period.Results3,847 patients with diagnosis of varicella were included, with a mean age of 8.4 years and a comparable distribution of gender. 12.6% of patients with varicella had a concomitant diagnosis of a varicella-related complication. During the follow-up period, 27.3% of patients with varicella were prescribed antibiotics, either systemic (19.8%) and/or topical (10.3%). The highest rate of antibiotic prescriptions was observed in patients with complications (63.5%) and in patients younger than 1 year (41.8%). Nevertheless, 5.3% of the patients were prescribed antibiotics without a concomitant diagnosis of another infection. The most commonly prescribed systemic antibiotics were amoxicillin alone or combined with beta-lactamase inhibitor, and thiamphenicol. Fusidic acid and tobramycin were the most prescribed topical antibiotics. Antivirals were prescribed for 2.7% of the study population. 4.7% of the patients needed a follow-up visit with their GP.ConclusionsThis study reports a substantial burden of varicella in a primary care setting in Belgium, with high rates of complications and antibiotic use.

A population-based linked cohort of cancer and primary care data: A new source to study the management of cancer in primary care.

ObjectiveInsight into the management of cancer in the primary care setting is pivotal to improve early recognition and survival of cancer patients. Therefore, the Netherlands Cancer Registry (NCR) was linked to the General Practitioner (GP) Database of the PHARMO Database Network to make this research possible.MethodsThe NCR collects tumour data on all newly diagnosed cancer patients, whereas the GP Database comprises data from electronic patient records registered by GPs. Databases were linked using a probabilistic record linkage technology.ResultsThrough record linkage of the NCR and the GP Database, we have established a large population‐based cohort (NCR‐PHARMO GP cohort) of 135,868 cancer patients. Data are available on demographics, tumour characteristics, primary health care use before and after cancer diagnosis including medication use, medical conditions, laboratory tests, and referrals. Data can be used for a number of different studies, for example, to study the diagnostic pathway in the primary care setting in order to identify possibilities for early recognition.ConclusionThe NCR‐PHARMO GP cohort provides rich data on the primary care management of cancer facilitating large‐scale observational cancer research in the primary care setting. The patient‐level linkage allows for long‐term follow‐up of cancer patients, with ongoing annual updates.

Fast decliner phenotype of chronic obstructive pulmonary disease (COPD): applying machine learning for predicting lung function loss

BackgroundChronic obstructive pulmonary disease (COPD) is a heterogeneous group of lung conditions challenging to diagnose and treat. Identification of phenotypes of patients with lung function loss may allow early intervention...

The cardiovascular phenotype of Chronic Obstructive Pulmonary Disease (COPD): Applying machine learning to the prediction of cardiovascular comorbidities

BackgroundChronic Obstructive Pulmonary Disease (COPD) is a heterogeneous group of lung conditions that are challenging to diagnose and treat. As the presence of comorbidities often exacerbates this scenario, the characterization of patients with COPD and cardiovascular comorbidities may allow early intervention and improve disease management and care. MethodsWe analysed a 4-year observational cohort of 6883 UK patients who were ultimately diagnosed with COPD and at least one cardiovascular comorbidity. The cohort was extracted from the UK Royal College of General Practitioners and Surveillance Centre database. The COPD phenotypes were identified prior to diagnosis and their reproducibility was assessed following COPD diagnosis. We then developed four classifiers for predicting cardiovascular comorbidities. ResultsThree subtypes of the COPD cardiovascular phenotype were identified prior to diagnosis. Phenotype A was characterised by a higher prevalence of severe COPD, emphysema, hypertension. Phenotype B was characterised by a larger male majority, a lower prevalence of hypertension, the highest prevalence of the other cardiovascular comorbidities, and diabetes. Finally, phenotype C was characterised by universal hypertension, a higher prevalence of mild COPD and the low prevalence of COPD exacerbations. These phenotypes were reproduced after diagnosis with 92% accuracy. The random forest model was highly accurate for predicting hypertension while ruling out less prevalent comorbidities. ConclusionsThis study identified three subtypes of the COPD cardiovascular phenotype that may generalize to other populations. Among the four models tested, the random forest classifier was the most accurate at predicting cardiovascular comorbidities in COPD patients with the cardiovascular phenotype.

Quality improvement in general practice: what do GPs and practice managers think? Results from a nationally representative survey of UK GPs and practice managers

BackgroundThis paper presents the results of the first UK-wide survey of National Health Service (NHS) general practitioners (GPs) and practice managers (PMs) designed to explore the service improvement activities being...

Multimorbidity and polypharmacotherapy in Italian primary care patients with NAFLD: General Practitioner databaSe NAFLD (GPS-NAFLD) Study

Multimorbidity and polypharmacotherapy in Italian primary care patients with NAFLD: General Practitioner databaSe NAFLD (GPS-NAFLD) Study

General Practitioner databaSe NAFLD (GPS-NAFLD) study: Italian regional variability of the NAFLD prevalence rate

Introduction: Non-alcoholic fatty liver disease (NAFLD) affects 25% of the global adult population. It is closely associated with a number of metabolic diseases. In fact, the increasing prevalence of obesity, type 2 diabetes mellitus, hypertension, and hypercholesteremia not only increases the prevalence of NAFLD but also places patients at higher risk for progressive liver disease.

General Practitioner databaSe NAFLD (GPS-NAFLD) Study: prevalence of advanced liver fibrosis among Italian primary care patients with NAFLD

Introduction: Nonalcoholic fatty liver disease (NAFLD) is now the most prevalent liver disease in the world. Its prevalence varies from 20 to 28% in adults. NAFLD involves a spectrum of conditions from simple steatosis to steatohepatitis (NASH) and fibrosis. Liver fibrosis is considered as an integral part in the progression of chronic liver disease ultimately leading to cirrhosis and hepatocellular carcinoma.