scholarly journals Post-traumatic knee MRI findings and associations with patient, trauma, and clinical characteristics: a subgroup analysis in primary care in the Netherlands

2017 ◽  
Vol 67 (665) ◽  
pp. e851-e858 ◽  
Author(s):  
Kim van Oudenaarde ◽  
Nynke M Swart ◽  
Johan L Bloem ◽  
Sita MA Bierma-Zeinstra ◽  
Paul R Algra ◽  
...  
Keyword(s):  
Primary Care ◽  
The Netherlands ◽  
Subgroup Analysis ◽  
Clinical Characteristics ◽  
Diagnostic Yield ◽  
Mri Findings ◽  
Predictive Values ◽  
Post Traumatic ◽  
Mean Differences ◽  
Active Patients

BackgroundThe added value of magnetic resonance imaging (MRI) in primary care is still being debated. A high diagnostic yield can be expected in young and active patients with post-traumatic knee complaints.AimTo determine the frequency of MRI abnormalities in young and active patients (aged 18–45 years) and the associations with patient, trauma, and clinical characteristics.Design and settingA subgroup analysis of 174 patients, aged 18–45 years with knee trauma of <6 months, allocated to MRI in a randomised controlled trial on the yield of MRI in primary care. Patients were recruited by 150 GPs in the Netherlands from October 2012 to November 2015.MethodAssociations were expressed using mean differences, odds ratio (OR) and predictive values.ResultsSixty-seven out of 174 patients (39%) had a positive MRI finding, predominantly anterior cruciate ligament (ACL) ruptures (22%) and/or traumatic meniscal tears (15%). Patients with a pre-existing musculoskeletal comorbidity had a two-fold lower prevalence of positive MRI findings (21%), OR 3.0 (95% confidence interval [CI] = 1.3 to 7.0). A ‘sports related trauma’ showed the highest OR of 4.6 (95% CI = 2.2 to 9.3) for a positive MRI finding. Clinical scores were statistically, significantly worse in patients with positive MRI findings, with mean differences ranging from 10 to 20%. Furthermore, increasing duration of complaints was correlated with decreasing prevalence rates of positive MRI findings. Overall, a popping sound and direct swelling showed the highest positive predictive value of 65% for the presence of positive MRI findings.ConclusionThe results from this study enable a preselection of patients to increase the diagnostic yield of MRI in primary care.

scholarly journals Evaluation of a faecal calprotectin care pathway for use in primary care

2016 ◽  
Vol 17 (05) ◽  
pp. 428-436 ◽  
Author(s):  
James Turvill ◽  
Shaun O’Connell ◽  
Abigail Brooks ◽  
Karen Bradley-Wood ◽  
James Laing ◽  
...  
Keyword(s):  
Primary Care ◽  
Clinical Decision Making ◽  
Diagnostic Yield ◽  
Care Pathway ◽  
Gastrointestinal Symptoms ◽  
Clinical Decision ◽  
Traffic Light ◽  
Faecal Calprotectin ◽  
Predictive Values ◽  
Light System

BackgroundNational Institute for Health and Care Excellence have recommended faecal calprotectin (FC) testing as an option in adults with lower gastrointestinal symptoms for whom specialist investigations are being considered, if cancer is not suspected and it is used to support a diagnosis of inflammatory bowel disease (IBD) or irritable bowel syndrome. York Hospital and Vale of York Clinical Commissioning Group have developed an evidence-based care pathway to support this recommendation for use in primary care. It incorporates a higher FC cut-off value, a ‘traffic light’ system for risk and a clinical management pathway.ObjectivesTo evaluate this care pathway.MethodsThe care pathway was introduced into five primary care practices for a period of six months and the clinical outcomes of patients were evaluated. Negative and positive predictive values (NPV and PPV) were calculated. GP feedback of the care pathway was obtained by means of a web-based survey. Comparator gastroenterology activity in a neighbouring trust was obtained.ResultsThe care pathway for FC in primary care had a 97% NPV and a 40% PPV. This was better than GP clinical judgement alone and doubled the PPV compared with the standard FC cut-off (&lt;50 mcg/g), without affecting the NPV. In total, 89% of patients with IBD had an FC&gt;250 mcg/g and were diagnosed by ‘straight to test’ colonoscopy within three weeks. The care pathway was considered helpful by GPs and delivered a higher diagnostic yield after secondary care referral (21%) than the conventional comparator pathway (5%).ConclusionsA care pathway for the use of FC that incorporates a higher cut-off value, a ‘traffic light’ system for risk and supports clinical decision making can be achieved safely and effectively. It maintains the balance between a high NPV and an acceptable PPV. A modified care pathway for the use of FC in primary care is proposed.

scholarly journals Cost Effectiveness of using Faecal Immunochemical Testing (FIT) as an Initial Diagnostic Investigation for Patients with Lower Gastrointestinal Symptoms Suggestive of Malignancy.

2021 ◽  
Author(s):  
Christopher Kearsey ◽  
Catherine Graham ◽  
Harry Lobb ◽  
Jerry Chako ◽  
Rachael Weatherburn ◽  
...  
Keyword(s):  
Primary Care ◽  
High Risk ◽  
Diagnostic Yield ◽  
Gastrointestinal Symptoms ◽  
Theoretical Data ◽  
Current Sensitivity ◽  
Predictive Values ◽  
Colorectal Malignancy ◽  
Total Cost ◽  
The Cost

Abstract BackgroundThere has been an increase in the numbers of patients presenting to primary care with suspected colorectal malignancy and subsequently an increase in demand for endoscopy. This study aims to forecast the cost of faecal immunochemical testing (FIT) compared to conventional diagnostic tests as a primary investigation for patients with symptoms suggestive of colorectal malignancy.MethodsRetrospectively, 1950 patients with symptoms suggestive of colorectal malignancy who were referred through primary care and underwent investigations through standard endoscopic evaluation were included. These patients were used to forecast the cost of faecal immunochemical testing creating theoretical data for sensitivity and specificity. Outcome measures included: the number of investigations under current protocol; cost of current investigations; number of predicted false negatives and false positives and positive/negative predictive values using current sensitivity data for FIT; the cost forecast of using FIT as the primary investigation for colorectal malignancy.Results: Median age was 65 (IQR 47-82) with 43.7% male and 56.3% female. A total of 1950 investigations were carried out with a diagnostic yield of 26 cancers (18 colon, 8 rectal), 138 polyps and 29 high risk adenomas (HGD +/- >10mm). In total, £713,948 was spent on the investigations. The commonest investigation was colonoscopy totalling £533,169. The total cost per cancer diagnosis was £27,459. Sensitivity (92.1% CI 86.9-95.3) and specificity (85.8% CI 78.3-90.1) for FIT in colorectal cancer was taken from NICE and was costed via the manufacturer(s). The projected total cost of FIT for the same population using a ≥4μg haemoglobin cut off was £415,680 (£15,554 per cancer). The total cost of high-risk polyps using ≥4μg cut off was £404,427 (sensitivity 71.2% CI 60.5-87.2, specificity 79.8%CI 76.1-83.7) or £13,945 per polyp.Conclusions: FIT is a cheaper and effective alternative test with the potential to replace current expensive methods. The forecast is based on the limited data available for sensitivity/specificity in the current literature. FIT has now been commenced for symptomatic patients in the UK and therefore sensitivity may change in the future.

scholarly journals Cost effectiveness of using Faecal Immunochemical Testing (FIT) as an initial diagnostic investigation for patients with lower gastrointestinal symptoms suggestive of malignancy

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
CC Kearsey ◽  
C Graham ◽  
HS Lobb ◽  
J Chacko ◽  
R Weatherburn ◽  
...  
Keyword(s):  
Primary Care ◽  
High Risk ◽  
Diagnostic Yield ◽  
Gastrointestinal Symptoms ◽  
Theoretical Data ◽  
Current Sensitivity ◽  
Predictive Values ◽  
Colorectal Malignancy ◽  
Total Cost ◽  
The Cost

Abstract Background There has been an increase in the numbers of patients presenting to primary care with suspected colorectal malignancy and subsequently an increase in demand for endoscopy. This study aims to forecast the cost of faecal immunochemical testing (FIT) compared to conventional diagnostic tests as a primary investigation for patients with symptoms suggestive of colorectal malignancy. Methods Retrospectively, 1950 patients with symptoms suggestive of colorectal malignancy who were referred through primary care and underwent investigations through standard endoscopic evaluation were included. These patients were used to forecast the cost of faecal immunochemical testing creating theoretical data for sensitivity and specificity. Outcome measures included: the number of investigations under current protocol; cost of current investigations; number of predicted false negatives and false positives and positive/negative predictive values using current sensitivity data for FIT; the cost forecast of using FIT as the primary investigation for colorectal malignancy. Results Median age was 65 (IQR 47–82) with 43.7% male and 56.3% female. A total of 1950 investigations were carried out with a diagnostic yield of 26 cancers (18 colon, 8 rectal), 138 polyps and 29 high risk adenomas (HGD ±  > 10 mm). In total, £713,948 was spent on the investigations. The commonest investigation was colonoscopy totalling £533,169. The total cost per cancer diagnosis was £27,459. Sensitivity (92.1% CI 86.9–95.3) and specificity (85.8% CI 78.3–90.1) for FIT in colorectal cancer was taken from NICE and was costed via the manufacturer(s). The projected total cost of FIT for the same population using a ≥ 4 μg haemoglobin cut off was £415,680 (£15,554 per cancer). The total cost of high-risk polyps using ≥ 4 μg cut off was £404,427 (sensitivity 71.2% CI 60.5–87.2, specificity 79.8%CI 76.1–83.7) or £13,945 per polyp. Conclusions FIT is a cheaper and effective alternative test with the potential to replace current expensive methods. The forecast is based on the limited data available for sensitivity/specificity in the current literature. FIT has now been commenced for symptomatic patients in the UK and therefore sensitivity may change in the future.

scholarly journals When “unclear headache” has an obvious reason—Applying ID-Migraine™ to referral letters

2019 ◽  
Vol 2 ◽  
pp. 251581631986620
Author(s):  
Stephanie Kluser ◽  
Andrew Chan ◽  
Niklaus Meier
Keyword(s):  
Primary Care ◽  
Clinical Characteristics ◽  
Care Setting ◽  
Primary Care Setting ◽  
Diagnostic Yield ◽  
Tertiary Care ◽  
Obvious Reason ◽  
Id Migraine ◽  
Headache Center ◽  
Referral Letters

Background: Migraine is underdiagnosed especially by general practitioners and non-neurologists. In our experience, validated screening and diagnosing tools for migraine are generally not used outside neurology. The three-item identification of migraine (ID-Migraine™) is a short and validated screening/diagnosing tool; positive predictive value for migraine is 93% if at least two out of nausea, photophobia, or disability are present. Aim: To investigate the diagnostic yield of ID-Migraine™ when applied to the information provided in the referral letters. Methods: Retrospective analysis of 95 referral letters of patients referred for undetermined headache who were finally diagnosed with migraine at our Tertiary Care Headache Center. Results: Median age was 34 years, and 75% were women. Migraine was suspected by the referring physician in 33% of patients, whereas the remainder were classified as unclear. ID-Migraine™ criteria were fulfilled in 59% of patients with referral diagnosis of suspected migraine and 23% of patients with unclear headache, respectively. Clinical characteristics associated with migraine suspicion were photophobia and other visual symptoms. Conclusion: Applying ID-Migraine™ in primary care, emergency departments, or in specialists’ consultations outside neurology might lead to an increased frequency of migraine recognition. Knowledge about and access to those criteria should be increased, especially in the primary care setting.

scholarly journals Changes to the frequency and appropriateness of vitamin D testing after the introduction of new Medicare criteria for rebates in Australian general practice: evidence from 1.5 million patients in the NPS MedicineInsight database

BMJ Open ◽  
2019 ◽  
Vol 9 (3) ◽  
pp. e024797 ◽  
Author(s):  
David Gonzalez-Chica ◽  
Nigel Stocks
Keyword(s):  
Primary Care ◽  
Vitamin D ◽  
Vitamin D Deficiency ◽  
Clinical Characteristics ◽  
Low Socioeconomic ◽  
Severe Vitamin ◽  
Australian General Practice ◽  
Active Patients ◽  
New Criteria ◽  
Small Improvement

ObjectivesTo assess changes in the frequency of vitamin D testing and detection of moderate/severe vitamin D deficiency (<30 nmol/L) among adults after the introduction of new Medicare Benefits Schedule (MBS) rebate criteria (November 2014), and their relationship to sociodemographic and clinical characteristics.DesignDynamic (open) cohort studySettingPrimary careParticipantsAbout 1.5 million ‘active’ patients aged 18+ years visiting a general practitioner and included in the National Prescribing Service MedicineInsight database.Outcome measuresThe frequency of vitamin D testing (per 1000 consultations) and moderate/severe vitamin D deficiency (%) recorded between October 2013 and March 2016, stratified by the release of the new MBS criteria for rebate.ResultsMore patients were female (57.7%) and 30.2% were aged 60+ years. Vitamin D testing decreased 47% (from 40.3 to 21.4 tests per 1000 consultations) after the new MBS criteria, while the proportion of tests with no indication for being performed increased from 71.3% to 76.5%. The proportion of patients identified as moderate/severe vitamin D deficient among those tested increased from 5.4% to 6.5%. Practices located in high socioeconomic areas continued to have the highest rates of testing, but moderate/severe vitamin D deficiency detection remained 90% more frequent in practices from low socioeconomic areas after the rebate change. Furthermore, the frequency of individuals being tested was reduced independent of the patients’ sociodemographic or clinical condition, and the gap in the prevalence of vitamin D deficiency detection between those meeting or not meeting the criteria for being tested remained the same. Moderate/severe vitamin D deficiency detection decreased slightly among patients with hyperparathyroidism or chronic renal failure.ConclusionsAlthough the new criteria for rebate almost halved the frequency of vitamin D testing, it also lessened the frequency of testing among those at higher risk of deficiency, with only a small improvement in vitamin D deficiency detection.

scholarly journals Optimisation of telephone triage of callers with symptoms suggestive of acute cardiovascular disease in out-of-hours primary care: observational design of the Safety First study

BMJ Open ◽  
2019 ◽  
Vol 9 (7) ◽  
pp. e027477 ◽  
Author(s):  
Daphne CA Erkelens ◽  
Loes TCM Wouters ◽  
Dorien LM Zwart ◽  
Roger AMJ Damoiseaux ◽  
Esther De Groot ◽  
...  
Keyword(s):  
Cardiovascular Disease ◽  
Primary Care ◽  
The Netherlands ◽  
Diagnostic Accuracy ◽  
Diagnostic Process ◽  
Telephone Triage ◽  
Predictive Values ◽  
Out Of Hours ◽  
Coronary Syndrome ◽  
Safety First

IntroductionIn the Netherlands, the ‘Netherlands Triage Standard’ (NTS) is frequently used as digital decision support system for telephone triage at out-of-hours services in primary care (OHS-PC). The aim of the NTS is to guarantee accessible, efficient and safe care. However, there are indications that current triage is inefficient, with overestimation of urgency, notably in suspected acute cardiovascular disease. In addition, in primary care settings the NTS has only been validated against surrogate markers, and diagnostic accuracy with clinical outcomes as the reference is unknown. In the Safety First study, we address this gap in knowledge by describing, understanding and improving the diagnostic process and urgency allocation in callers with symptoms suggestive of acute cardiovascular disease, in order to improve both efficiency and safety of telephone triage in this domain.Methods and analysisAn observational study in which 3000 telephone triage recordings (period 2014–2016) will be analysed. Information is collected from the recordings including caller and symptom characteristics and urgency allocation. The callers’ own general practitioners are contacted for the final diagnosis of each contact. We included recordings of callers with symptoms suggestive of acute coronary syndrome (ACS) or transient ischaemic attack (TIA)/stroke. With univariable and multivariable logistic regression analyses the diagnostic accuracy of caller and symptom characteristics will be analysed in terms of predictive values with urgency level, and ACS and TIA/stroke as outcomes, respectively. To further improve our understanding of the triage process at OHS-PC, we will carry out additional studies applying both quantitative and qualitative methods: (i) case-control study on serious adverse events (SAE), (ii) conversation analysis study and (iii) interview study with triage nurses.Ethics and disseminationThe Medical Ethics Committee Utrecht, the Netherlands endorsed this study (National Trial Register identification: NTR7331). Results will be disseminated at scientific conferences, regional educational sessions and publication in peer-reviewed journals.

The Validity of Gout Diagnosis in Primary Care: Results from a Patient Survey

2019 ◽  
Vol 46 (11) ◽  
pp. 1531-1534 ◽  
Author(s):  
Mats Dehlin ◽  
Anton J. Landgren ◽  
Ulrika Bergsten ◽  
Lennart T.H. Jacobsson
Keyword(s):  
Primary Care ◽  
The Netherlands ◽  
International Classification Of Diseases ◽  
Patient Survey ◽  
Classification Criteria ◽  
International Classification ◽  
Predictive Values ◽  
Classification Of Diseases

Objective.Validate primary care diagnosis of gout by the Mexico and the Netherlands classification criteria.Methods.Questionnaires on gout characteristics were sent to all individuals aged ≥ 18 with ≥ 1 International Classification of Diseases, 10th ed. diagnosis of gout at 12 primary care centers.Results.Positive predictive values for gout diagnosis ranged from 71% for the Netherlands criteria to 80% for the Mexico criteria. Maximum inflammation within 24 h was the most common reported symptom (86%).Conclusion.The vast majority of gout cases in primary care fulfill classification criteria and are valid for research purposes.

scholarly journals CHARGE-AF in a national routine primary care electronic health records database in the Netherlands: validation for 5-year risk of atrial fibrillation and implications for patient selection in atrial fibrillation screening

Open Heart ◽  
2021 ◽  
Vol 8 (1) ◽  
pp. e001459
Author(s):  
Jelle C L Himmelreich ◽  
Wim A M Lucassen ◽  
Ralf E Harskamp ◽  
Claire Aussems ◽  
Henk C P M van Weert ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Primary Care ◽  
High Risk ◽  
The Netherlands ◽  
Patient Selection ◽  
Low Cost ◽  
Calibration Plot ◽  
Primary Care Data ◽  
C Statistic ◽  
Kaplan Meier

AimsTo validate a multivariable risk prediction model (Cohorts for Heart and Aging Research in Genomic Epidemiology model for atrial fibrillation (CHARGE-AF)) for 5-year risk of atrial fibrillation (AF) in routinely collected primary care data and to assess CHARGE-AF’s potential for automated, low-cost selection of patients at high risk for AF based on routine primary care data.MethodsWe included patients aged ≥40 years, free of AF and with complete CHARGE-AF variables at baseline, 1 January 2014, in a representative, nationwide routine primary care database in the Netherlands (Nivel-PCD). We validated CHARGE-AF for 5-year observed AF incidence using the C-statistic for discrimination, and calibration plot and stratified Kaplan-Meier plot for calibration. We compared CHARGE-AF with other predictors and assessed implications of using different CHARGE-AF cut-offs to select high-risk patients.ResultsAmong 111 475 patients free of AF and with complete CHARGE-AF variables at baseline (17.2% of all patients aged ≥40 years and free of AF), mean age was 65.5 years, and 53% were female. Complete CHARGE-AF cases were older and had higher AF incidence and cardiovascular comorbidity rate than incomplete cases. There were 5264 (4.7%) new AF cases during 5-year follow-up among complete cases. CHARGE-AF’s C-statistic for new AF was 0.74 (95% CI 0.73 to 0.74). The calibration plot showed slight risk underestimation in low-risk deciles and overestimation of absolute AF risk in those with highest predicted risk. The Kaplan-Meier plot with categories <2.5%, 2.5%–5% and >5% predicted 5-year risk was highly accurate. CHARGE-AF outperformed CHA2DS2-VASc (Cardiac failure or dysfunction, Hypertension, Age >=75 [Doubled], Diabetes, Stroke [Doubled]-Vascular disease, Age 65-74, and Sex category [Female]) and age alone as predictors for AF. Dichotomisation at cut-offs of 2.5%, 5% and 10% baseline CHARGE-AF risk all showed merits for patient selection in AF screening efforts.ConclusionIn patients with complete baseline CHARGE-AF data through routine Dutch primary care, CHARGE-AF accurately assessed AF risk among older primary care patients, outperformed both CHA2DS2-VASc and age alone as predictors for AF and showed potential for automated, low-cost patient selection in AF screening.

Sign in / Sign up

Export Citation Format

Share Document