[Burnout in family practice: comment on the NHG guideline 'Stress and burnout']

Burnout is a serious health problem and the cause of career disruption in 15% of women and 9% of men who quit their job. Of all work-related complaints, 37% is attributable to workload and stress. Many workers visit their general practitioner with work-related complaints. Recently, the Dutch College of General Practitioners (NederlandsHuisartsenGenootschap) published a guideline on burnout. While the guideline provides a good framework for managing patients with a burnout, additional attention could be paid to prevention and how to distinguish burnout from depression.

Experiences of pregnant women with a third trimester routine ultrasound - a qualitative study

Background

Studies showed that pregnant women generally value routine ultrasounds in the first two trimesters because these provide reassurance and a chance to see their unborn baby. This, in turn, might help to decrease maternal anxiety levels and increase the bond with the baby. However, it is unclear whether pregnant women hold the same positive views about a third trimester routine ultrasound, which is increasingly being used in the Netherlands as a screening tool to monitor fetal growth. The aim of this study was to explore pregnant women’s experiences with a third trimester routine ultrasound.

Methods

We held semi-structured interviews with fifteen low-risk pregnant women who received a third trimester routine ultrasound in the context of the Dutch IUGR RIsk Selection (IRIS) study. The IRIS study is a nationwide cluster randomized controlled trial carried out among more than 13,000 women to examine the effectiveness of a third trimester routine ultrasound to monitor fetal growth. For the interviews, participants were purposively selected based on parity, age, ethnicity, and educational level. We performed thematic content analysis using MAXQDA.

Results

Most pregnant women appreciated a third trimester routine ultrasound because it provided them confirmation that their baby was fine and an extra opportunity to see their baby. At the same time they expressed that they already felt confident about the health of their baby, and did not feel that their bond with their baby had increased after the third trimester ultrasound. Women also reported that they were getting used to routine ultrasounds throughout their pregnancy, and that this increased their need for another one.

Conclusions

Pregnant women seem to appreciate a third trimester routine ultrasound, but it does not seem to reduce anxiety or to improve bonding with their baby. Women’s appreciation of a third trimester routine ultrasound might arise from getting used to routine ultrasounds throughout pregnancy. We recommend to examine the psychological impact of third trimester routine ultrasounds in future studies. Results should be taken into consideration when balancing the gains, which are as yet not clear, of introducing a third trimester routine ultrasound against unwanted side effects and costs.

A supported self-help for recurrent depression in primary care; An economic evaluation alongside a multi-center randomised controlled trial

BACKGROUND

Major depression is a prevalent mental disorder with a high risk of relapse or recurrence. Only few studies have focused on the cost-effectiveness of interventions aimed at the prevention of relapse or recurrence of depression in primary care.

AIM

To evaluate the cost-effectiveness of a supported Self-help Preventive Cognitive Therapy (S-PCT) added to treatment-as-usual (TAU) compared with TAU alone for patients with a history of depression, currently in remission.

METHODS

An economic evaluation alongside a multi-center randomised controlled trial was performed (n = 248) over a 12-month follow-up. Outcomes included relapse or recurrence of depression and quality-adjusted-life-years (QALYs) based on the EuroQol-5D. Analyses were performed from both a societal and healthcare perspective. Missing data were imputed using multiple imputations. Uncertainty was estimated using bootstrapping and presented using the cost-effectiveness plane and the Cost-Effectiveness Acceptability Curve (CEAC). Cost estimates were adjusted for baseline costs.

RESULTS

S-PCT statistically significantly decreased relapse or recurrence by 15% (95%CI 3;28) compared to TAU. Mean total societal costs were €2,114 higher (95%CI -112;4261). From a societal perspective, the ICER for relapse or recurrence was 13,515. At a Willingness To Pay (WTP) of 22,000 €/recurrence prevented, the probability that S-PCT is cost-effective, in comparison with TAU, is 80%. The ICER for QALYs was 63,051. The CEA curve indicated that at a WTP of 30,000 €/QALY gained, the probability that S-PCT is cost-effective compared to TAU is 21%.

CONCLUSIONS

Though ultimately depending on the WTP of decision makers, we expect that for both relapse or recurrence and QALYs, S-PCT cannot be considered cost-effective compared to TAU.

Factors related to intentional non-initiation of bisphosphonate treatment in patients with a high fracture risk in primary care: a qualitative study

BACKGROUND

Adherence to osteoporosis treatment is crucial for good treatment effects. However, adherence has been shown to be poor and a substantial part of the patients don't even initiate treatment. This study aimed to gain insight into the considerations of both osteoporosis patients and general practitioners (GP) concerning intentional non-initiation of bisphosphonate treatment.

METHODS

Osteoporosis patients and GPs were recruited from the SALT Osteoporosis Study and a transmural fracture liaison service, both carried out in the Netherlands. Using questionnaires, we identified non-starters and starters of bisphosphonate treatment. Semi-structured interviews were conducted to gain a detailed overview of all considerations until saturation of the data was reached. Starters were asked to reflect on the considerations that were brought forward by the non-starters. Interviews were open coded and the codes were classified into main themes and subthemes using an inductive approach.

RESULTS

16 non-starters, 10 starters, and 13 GPs were interviewed. We identified three main themes: insufficient medical advice, attitudes towards medication use including concerns about side effects, and disease awareness. From patients' as well as GPs' perspective, insufficient or ambiguous information from the GP influenced the decision of the non-starters to not start bisphosphonates. In contrast, starters were either properly informed, or they collected information themselves. Patients' aversion towards medication, fear of side effects, and a low risk perception also contributed to not starting the medication, whereas starters were aware of their fracture risk and were confident of the outcome of the treatment. Concerns about osteoporosis treatment and its side effects were also expressed by several GPs. Some GPs appeared to have a limited understanding of the current osteoporosis guidelines and the indications for treatment.

CONCLUSIONS

Many reasons we found for not starting bisphosphonate treatment were related to the patients or the GPs themselves being insufficiently informed. Attitudes of the GPs were shown to play a role in the decision of patients not to start treatment. Interventions need to be developed that are aimed at GPs, and at education of patients.

Effectiveness of Supported Self-Help in Recurrent Depression: A Randomized Controlled Trial in Primary Care

BACKGROUND

The burden and economic consequences of depression are high, mostly due to its recurrent nature. Due to current budget and time restraints, a preventive, low- cost, accessible minimal intervention is much needed. In this study, we evaluated the effectiveness of a supported self-help preventive cognitive therapy (S-PCT) added to treatment as usual (TAU) in primary care, compared to TAU alone.

METHODS

We conducted a randomized controlled trial among 248 patients with a history of depression, currently in full or partial remission or recovery. Participants were randomized to TAU augmented with S-PCT (n = 124) or TAU alone (n = 124). S-PCT consisted of an 8-week self-help intervention, supported by weekly telephone guidance by a counselor. The intervention included a self-help book that could be read at home. The primary outcome was the incidence of relapse or recurrence and was assessed over the telephone by the Structured Clinical Interview for DSM-IV axis 1 disorders. Participants were observed for 12 months. Secondary outcomes were depressive symptoms, quality of life (EQ-5D and SF-12), comorbid psychopathology, and self-efficacy. These secondary outcomes were assessed by digital questionnaires.

RESULTS

In the S-PCT group, 44 participants (35.5%) experienced a relapse or recurrence, compared to 62 participants (50.0%) in the TAU group (incidence rate ratio = 0.71, 95% CI 0.52-0.97; risk difference = 14, 95% CI 2-24, number needed to treat = 7). Compared to the TAU group, the S-PCT group showed a significant reduction in depressive symptoms over 12 months (mean difference -2.18; 95% CI -3.09 to -1.27) and a significant increase in quality of life (EQ-5D) (mean difference 0.04; 95% CI 0.004-0.08). S-PCT had no effect on comorbid psychopathology, self-efficacy, and quality of life based on the SF-12.

CONCLUSIONS

A supported self-help preventive cognitive therapy, guided by a counselor in primary care, proved to be effective in reducing the burden of recurrent depression.

Longitudinal associations of multiple physical symptoms with recurrence of depressive and anxiety disorders

OBJECTIVE

To examine longitudinal associations of multiple physical symptoms with recurrence of depressive and anxiety disorders.

METHODS

Follow-up data of 584 participants with remitted depressive or anxiety disorders were used from the Netherlands Study of Depressive and Anxiety disorders. Multiple physical symptoms were measured at baseline (T1) and two-year follow-up (T2) by the Four-Dimensional Symptom Questionnaire (4DSQ) somatization subscale. Recurrence of depressive and anxiety disorders was assessed at two-year (T2) and four-year (T4) follow-up with the Composite International Diagnostic Interview. Logistic Generalized Estimating Equations were used to examine associations of multiple physical symptoms with recurrence of depressive and anxiety disorders. Depressive (IDS-SR) and anxiety symptoms (BAI), and other relevant covariates were taken into account.

RESULTS

Multiple physical symptoms were significantly associated with recurrence of depression (OR=1.04, 95%CI=1.00-1.08), anxiety (OR=1.07, 95%CI=1.03-1.12), and depressive or anxiety disorders (OR=1.06, 95%CI=1.02-1.10), on average over time. Odds ratios did not change substantially when the IDS-SR mood-cognition and BAI subjective scale were included as covariates.

CONCLUSION

The presence of multiple physical symptoms was positively related to recurrence of depressive and anxiety disorders, independent of depressive and anxiety symptoms. Knowledge of risk factors for recurrence of depressive and anxiety disorders, such as the presence of multiple physical symptoms, could provide possibilities for better targeting interventions to prevent recurrence.

Recognition of patients with medically unexplained physical symptoms by family physicians: results of a focus group study

BACKGROUND

Patients with medically unexplained physical symptoms (MUPS) form a heterogeneous group and frequently attend their family physician (FP). Little is known about how FPs recognize MUPS in their patients. We conducted a focus group study to explore how FPs recognize MUPS and whether they recognize specific subgroups of patients with MUPS. Targeting such subgroups might improve treatment outcomes.

METHODS

Six focus groups were conducted with in total 29 Dutch FPs. Two researchers independently analysed the data applying the principles of constant comparative analysis in order to detect characteristics to recognize MUPS and to synthesize subgroups.

RESULTS

FPs take into account various characteristics when recognizing MUPS in their patients. More objective characteristics were multiple MUPS, frequent and long consultations and many referrals. Subjective characteristics were negative feelings towards patients and the feeling that the FP cannot make sense of the patient's story. Experience of the FP, affinity with MUPS, consultation skills, knowledge of the patient's context and the doctor-patient relationship seemed to influence how and to what extent these characteristics play a role. Based on the perceptions of the FPs we were able to distinguish five subgroups of patients according to FPs: 1) the anxious MUPS patient, 2) the unhappy MUPS patient, 3) the passive MUPS patient, 4) the distressed MUPS patient, and 5) the puzzled MUPS patient. These subgroups were not mutually exclusive, but were based on how explicit and predominant certain characteristics were perceived by FPs.

CONCLUSIONS

FPs believe that they can properly identify MUPS in their patients during consultations and five distinct subgroups of patients could be distinguished. If these subgroups can be confirmed in further research, personalized treatment strategies can be developed and tested for their effectiveness.

Non-fatal disease burden for subtypes of depressive disorder: population-based epidemiological study

BACKGROUND

Major depression is the leading cause of non-fatal disease burden. Because major depression is not a homogeneous condition, this study estimated the non-fatal disease burden for mild, moderate and severe depression in both single episode and recurrent depression. All estimates were assessed from an individual and a population perspective and presented as unadjusted, raw estimates and as estimates adjusted for comorbidity.

METHODS

We used data from the first wave of the second Netherlands-Mental-Health-Survey-and-Incidence-Study (NEMESIS-2, n = 6646; single episode Diagnostic and Statistical Manual (DSM)-IV depression, n = 115; recurrent depression, n = 246). Disease burden from an individual perspective was assessed as 'disability weight * time spent in depression' for each person in the dataset. From a population perspective it was assessed as 'disability weight * time spent in depression *number of people affected'. The presence of mental disorders was assessed with the Composite International Diagnostic Interview (CIDI) 3.0.

RESULTS

Single depressive episodes emerged as a key driver of disease burden from an individual perspective. From a population perspective, recurrent depressions emerged as a key driver. These findings remained unaltered after adjusting for comorbidity.

CONCLUSIONS

The burden of disease differs between the subtype of depression and depends much on the choice of perspective. The distinction between an individual and a population perspective may help to avoid misunderstandings between policy makers and clinicians.

Medically unexplained physical symptoms and work functioning over 2 years: their association and the influence of depressive and anxiety disorders and job characteristics

Background

Medically unexplained physical symptoms (MUPS) are highly prevalent and may affect work functioning. In this study we aimed to assess the longitudinal association between MUPS and work functioning over 2 years and the influence of job characteristics and depressive and anxiety disorders on this association.

Methods

We assessed the longitudinal association between MUPS and work functioning, operationalized in terms of absenteeism and disability at work, in 1887 working participants from the Netherlands Study of Depression and Anxiety (NESDA). The NESDA study population included participants with a current depressive and/or anxiety disorder, participants with a lifetime risk and/or subthreshold symptoms and healthy controls. Absenteeism was assessed with the Health and Labour Questionnaire Short Form and disability with the World Health Organization Disability Assessment Schedule II. MUPS were measured with the Four Dimensional Symptom Questionnaire. Measurements were taken at baseline and at 2 years follow-up. We used mixed model analyses to correct for the dependency of observations within participants.

Results

MUPS were positively associated with disability (regression coefficient 0.304; 95 % CI 0.281–0.327) and with short and long-term absenteeism over 2 years (OR 1.030, 95 % CI 1.016–1.045; OR 1.099, 95 % CI 1.085–1.114). After adjusting for depressive disorders, anxiety disorders and job characteristics, associations weakened but remained significant.

Conclusion

Our results show that MUPS were positively associated with disability and absenteeism over 2 years, even after adjusting for depressive and anxiety disorders and job characteristics. This suggests that early identification of MUPS and adequate management is important.

The association between medically unexplained physical symptoms and health care use over two years and the influence of depressive and anxiety disorders and personality traits: a longitudinal study

Background

Medically unexplained physical symptoms (MUPS) are highly prevalent and are associated with frequent health care use (HCU). MUPS frequently co-occur with psychiatric disorders. With this study we examined the longitudinal association between MUPS and HCU over 2 years and the influence of depressive and anxiety disorders and personality traits on this association.

Methods

We analysed follow-up data from 2045 to 2981 participants from the Netherlands Study of Depression and Anxiety (NESDA), a multisite cohort study. The study population included participants with a current depressive and/or anxiety disorder, participants with a lifetime risk and/or subthreshold symptoms for depressive and/or anxiety disorders and healthy controls. HCU, measured with the Trimbos and iMTA questionnaire on Costs associated with Psychiatric illness (TIC-P), was operationalized as the number of used medical services and the number of associated contacts. MUPS were measured with the Four Dimensional Symptoms Questionnaire, depressive and anxiety disorders with the Composite International Diagnostic Interview and personality traits with the NEO Five-Factory Inventory. Measurements were taken at baseline, 1 and 2 years follow-up. We used generalized estimating equations (GEE), using HCU at all three measurements as (multivariate) outcome. GEE also takes into account the dependency of observations within participants.

Results

MUPS were positively associated with HCU over 2 years (medical services: RR 1.020, 95 % CI 1.017–1.022; contacts: RR 1.037, 95 % CI 1.030–1.044). Neuroticism and depression had the strongest influence on the associations. After adjustment for these factors, the associations between MUPS and HCU weakened, but remained significant (services: RR 1.011, 95 % CI 1.008–1.014; contacts: RR 1.023, 95 % CI 1.015–1.032).

Conclusions

Our results show that MUPS were positively associated with HCU over 2 years, even after adjusting for depressive and anxiety disorders and personality traits.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1332-7) contains supplementary material, which is available to authorized users.

Clinical value of DSM IV and DSM 5 criteria for diagnosing the most prevalent somatoform disorders in patients with medically unexplained physical symptoms (MUPS)

OBJECTIVE

This study aimed (1) to describe frequencies of DSM IV somatisation disorder, undifferentiated somatoform disorder and pain disorder versus DSM 5 somatic symptom disorder (SSD) in a multi-setting population of patients with medically unexplained physical symptoms (MUPS), (2) to investigate differences in sociodemographic and (psycho)pathological characteristics between these diagnostic groups and (3) to explore the clinical relevance of the distinction between mild and moderate DSM 5 SSD.

METHODS

We used baseline data of a cohort of 325 MUPS patients. Measurements included questionnaires about symptom severity, physical functioning, anxiety, depression, health anxiety and illness perceptions. These questionnaires were used as proxy measures for operationalization of DSM IV and DSM 5 diagnostic criteria.

RESULTS

92.9% of participants fulfilled criteria of a DSM IV somatoform disorder, while 45.5% fulfilled criteria of DSM 5 SSD. Participants fulfilling criteria of DSM 5 SSD suffered from more severe symptoms than those only fulfilling criteria of a DSM IV somatoform disorder(mean PHQ-15 score of 13.98 (SD 5.17) versus 11.23 (SD 4.71), P-value<0.001). Furthermore their level of physical functioning was significantly lower. Compared to patients with mild SSD, patients with moderate SSD suffered from significantly lower physical functioning and higher levels of depression.

CONCLUSION

Within a population of MUPS patients DSM 5 SSD criteria are more restrictive than DSM IV criteria for somatoform disorders. They are associated with higher symptom severity and lower physical functioning. However, further specification of the positive psychological criteria of DSM 5 SSD may improve utility in research and practice.

Cost-Effectiveness of a Chronic Care Model for Frail Older Adults in Primary Care: Economic Evaluation Alongside a Stepped-Wedge Cluster-Randomized Trial

OBJECTIVES

To evaluate the cost-effectiveness of the Geriatric Care Model (GCM), an integrated care model for frail older adults based on the Chronic Care Model, with that of usual care.

DESIGN

Economic evaluation alongside a 24-month stepped-wedge cluster-randomized controlled trial.

SETTING

Primary care (35 practices) in two regions in the Netherlands.

PARTICIPANTS

Community-dwelling older adults who were frail according to their primary care physicians and the Program on Research for Integrating Services for the Maintenance of Autonomy case-finding tool questionnaire (N = 1,147).

INTERVENTION

The GCM consisted of the following components: a regularly scheduled in-home comprehensive geriatric assessment by a practice nurse followed by a customized care plan, management and training of practice nurses by a geriatric expert team, and coordination of care through community network meetings and multidisciplinary team consultations of individuals with complex care needs.

MEASUREMENTS

Outcomes were measured every 6 months and included costs from a societal perspective, health-related quality of life (Medical Outcomes Study 12-item Short-Form Survey (SF-12) physical (PCS) and mental component summary (MCS) scales), functional limitations (Katz activities of daily living and instrumental activities of daily living), and quality-adjusted life years based on the EQ-5D.

RESULTS

Multilevel regression models adjusted for time and baseline confounders showed no significant differences in costs ($356, 95% confidence interval = -$488-1,134) and outcomes between intervention and usual care phases. Cost-effectiveness acceptability curves showed that, for the SF-12 PCS and MCS, the probability of the intervention being cost-effective was 0.76 if decision-makers are willing to pay $30,000 per point improvement on the SF-12 scales (range 0-100). For all other outcomes the probability of the intervention being cost-effective was low.

CONCLUSION

Because the GCM was not cost-effective compared to usual care after 24 months of follow-up, widespread implementation in its current form is not recommended.

Explaining fatigue: an examination of patient causal attributions and their (in)congruence with family doctors' initial causal attributions

BACKGROUND

General practitioners (GPs) and patients can have different ideas about the causes of fatigue, which may hinder management of fatigue.

OBJECTIVE

To investigate the causal attributions of patients and their GPs for fatigue, their level of agreement, and the association between patients' attributions, and fatigue characteristics and other illness perceptions.

METHODS

Baseline data, collected between 2004 and 2006, of a prospective cohort study among 642 adult patients presenting to Dutch primary care practices (n = 147) with a main symptom of fatigue, were used. Patient causal attributions and illness perceptions were measured using the revised illness perception questionnaire (fatigue version). GP causal attributions were measured with an open question included in the form that was completed at the end of the patient's visit. Fatigue severity was measured using the checklist individual strength.

RESULTS

Psychosocial causes were among the most often reported causal attributions by both patients and GPs. In 33% of 519 cases, the GP had no idea about the cause whereas the patient did. Overall, the agreement between the first reported causal attribution of patients and GPs was low. Qualitative differences in the labelling of causes were also found. Type of attribution (physical vs psychosocial/psychological) was associated with duration of fatigue (40 vs 25 months), and personal control (score 17.4 vs. 18.9).

CONCLUSION

Most patients and GPs had ideas about the causes of fatigue, but differences were found in the first reported causes and the labelling of causes. The findings may provide leads for optimizing communication about fatigue.

Exploration of the content validity and feasibility of the EQ-5D-3L, ICECAP-O and ASCOT in older adults

Background

In economic evaluations of care services for older adults health-related quality of life (QoL) measures such as the EQ-5D are increasingly replaced by the ICECAP-O and ASCOT, which cover a broader scope of QoL than health alone. Little is known about the content validity and feasibility of these measures. The purpose of this study was to explore the content validity and feasibility of the EQ-5D-3L, ICECAP-O and ASCOT in older adults.

Methods

Ten older adults were purposively sampled using a maximum variation principle. Think-aloud and verbal probing techniques were used to identify response issues encountered during the interpretation of items and the selection of response options. We used constant comparative methods to analyse the data.

Results

Two types of response issues were identified for various items in all three measures: interpretation issues and positive responses. Issues with the mapping of a response on one of the response options were least often encountered for the EQ-5D-3L items. Older adults considered the items of the ICECAP-O and ASCOT valuable though more abstract than the EQ-5D-3L.

Conclusions

Researchers who intend to use the EQ-5D, ICECAP-O or ASCOT in economic evaluations of care services for older adults, should be aware of the response issues that occur during the administration of these measures. Older adults perceived none of the measures as providing a comprehensive picture of their QoL. A preference from older adults for one of the measures depends on the extent to which the items reflect current personal concerns in life.

Dutch translation and cross-cultural validation of the Adult Social Care Outcomes Toolkit (ASCOT)

BACKGROUND

The Adult Social Care Outcomes Toolkit was developed to measure outcomes of social care in England. In this study, we translated the four level self-completion version (SCT-4) of the ASCOT for use in the Netherlands and performed a cross-cultural validation.

METHODS

The ASCOT SCT-4 was translated into Dutch following international guidelines, including two forward and back translations. The resulting version was pilot tested among frail older adults using think-aloud interviews. Furthermore, using a subsample of the Dutch ACT-study, we investigated test-retest reliability and construct validity and compared response distributions with data from a comparable English study.

RESULTS

The pilot tests showed that translated items were in general understood as intended, that most items were reliable, and that the response distributions of the Dutch translation and associations with other measures were comparable to the original English version. Based on the results of the pilot tests, some small modifications and a revision of the Dignity items were proposed for the final translation, which were approved by the ASCOT development team. The complete original English version and the final Dutch translation can be obtained after registration on the ASCOT website ( http://www.pssru.ac.uk/ascot ).

CONCLUSIONS

This study provides preliminary evidence that the Dutch translation of the ASCOT is valid, reliable and comparable to the original English version. We recommend further research to confirm the validity of the modified Dutch ASCOT translation.

Comparing measurement properties of the EQ-5D-3L, ICECAP-O, and ASCOT in frail older adults

BACKGROUND

The ICEpop CAPability measure for Older people (ICECAP-O) and the Adult Social Care Outcomes Toolkit (ASCOT) are preference-based measures for assessing quality of life (QOL) from a broader perspective than do traditional health-related QOL measures such as the EuroQol five-dimensional questionnaire (EQ-5D). Measurement properties of these instruments have not yet been directly compared.

OBJECTIVE

The purpose of this study was to compare the test-retest reliability, construct validity, and responsiveness of the three-level EQ-5D (EQ-5D-3L), ICECAP-O, and ASCOT in frail older adults living at home.

METHODS

Cross-sectional data and longitudinal data were used. Parameters for reliability (the intraclass correlation coefficient) and agreement (standard error of measurement) were used to assess test-retest reliability after 1 week. We formulated hypotheses about correlations with other measures and tested these to assess construct validity and responsiveness (longitudinal validity).

RESULTS

The reliability parameters for all three scales were considered good (intraclass correlation coefficient values above 0.70). Standard error of measurement values were less than 10% of the scale. Hypotheses regarding construct validity were in general accepted; the EQ-5D-3L was more strongly associated with physical limitations than were ICECAP-O and ASCOT and less strongly with instruments measuring aspects beyond health. Longitudinally, as hypothesized, mental health was most strongly associated with ICECAP-O, and self-perceived QOL, mastery, and client-centeredness of home care most strongly with ASCOT.

CONCLUSIONS

Our findings support the adoption of ICECAP-O and ASCOT as outcome measures in economic evaluations of care interventions for older adults that have a broader aim than health-related QOL because they are at least as reliable as the EQ-5D-3L and are associated with aspects of QOL broader than health.

Evaluation of the measurement properties of the Manchester foot pain and disability index

Background

The Manchester Foot Pain and Disability Index (MFPDI, 19 items) was developed to measure functional limitations, pain and appearance for patients with foot pain and is frequently used in both observational studies and randomised controlled trials. A Dutch version of the MFPDI was developed. The aims of this study were to evaluate all the measurement properties for the Dutch version of the MFPDI and to evaluate comparability to the original version.

Method

The MFPDI was translated into Dutch using a forward/backward translation process. The dimensionality was evaluated using exploratory and confirmatory factor analysis. Measurement properties were evaluated per subscale according to the COSMIN taxonomy consisting of: reliability (internal consistency, test-retest reliability and measurement error), validity (structural validity, content validity and cross-cultural validity comparing the Dutch version to the English version) responsiveness and interpretation.

Results

The questionnaire consists of three scales, measuring foot function, foot pain and perception. The reliability of the foot function scale is acceptable (Cronbach’s α > 0.7, ICC = 0.7, SEM = 2.2 on 0-18 scale). The construct validity of the function and pain scale was confirmed and only the pain scale contains one item with differential item functioning (DIF). The responsiveness of the function and pain scale is moderate when compared to anchor questions.

Conclusion

Results using the Dutch MFPDI version can be compared to results using the original version. The foot function sub-scale (items 1-9) is a reliable and valid sub-scale. This study indicates that the use of the MFPDI as a longitudinal instrument might be problematic for measuring change in musculoskeletal foot pain due to moderate responsiveness.

Cost-effectiveness of a stepped care programme to prevent depression and anxiety in residents in homes for the older people: a randomised controlled trial

BACKGROUND

Depression and anxiety are common in residents of elderly homes. Both disorders have negative effects on functioning, well-being and health-care utilisation. Besides treatment, prevention can be an option to reduce the burden of mental disorders. The objective of this study was to evaluate the cost-effectiveness of a stepped care programme to prevent the onset of depression and anxiety disorders in residents of elderly homes compared with usual care from a societal perspective.

METHODS

Outcomes were incidence of depression and/or anxiety, severity of depressive and anxiety symptoms and quality-adjusted life years. Health-care utilisation was measured during interviews. Multiple imputation was used to impute missing cost and effect data. Uncertainty around cost differences and incremental cost-effectiveness ratios was estimated using bootstrapping. Cost-effectiveness planes and acceptability curves were created.

RESULTS

The incidence of depression and anxiety combined in the intervention group was not reduced in comparison with the usual care group. There was also no effect on the other outcomes. Mean total costs in the intervention group were €838 higher than in the usual care group, but this difference was not statistically significant (95% confidence interval, -593 to 2420). Cost-effectiveness planes showed that there was considerable uncertainty. Cost-effectiveness acceptability curves showed that the maximum probability of the intervention being cost-effective in comparison with usual care was 0.46 for reducing the incidence of depression and anxiety combined.

CONCLUSION

A stepped care programme to prevent depression and anxiety in older people living in elderly homes was not considered cost-effective in comparison with usual care.

Cost-effectiveness of nurse-led self-help for recurrent depression in the primary care setting: design of a pragmatic randomised controlled trial

BACKGROUND

Major Depressive Disorder is a leading cause of disability, tends to run a recurrent course and is associated with substantial economic costs due to increased healthcare utilization and productivity losses. Interventions aimed at the prevention of recurrences may reduce patients' suffering and costs. Besides antidepressants, several psychological treatments such as preventive cognitive therapy (PCT) are effective in the prevention of recurrences of depression. Yet, many patients find long-term use of antidepressants unattractive, do not want to engage in therapy sessions and in the primary care setting psychologists are often not available. Therefore, it is important to study whether PCT can be used in a nurse-led self-help format in primary care. This study sets out to test the hypothesis that usual care plus nurse-led self-help for recurrent depression in primary care is feasible, acceptable and cost-effective compared to usual care only.

DESIGN

Patients are randomly assigned to 'nurse-led self-help treatment plus usual care' (134 participants) or 'usual care' (134 participants). Randomisation is stratified according to the number of previous episodes (2 or 3 previous episodes versus 4 or more). The primary clinical outcome is the cumulative recurrence rate of depression meeting DSM-IV criteria as assessed by the Structured-Clinical-Interview-for-DSM-IV- disorders at one year after completion of the intervention. Secondary clinical outcomes are quality of life, severity of depressive symptoms, co-morbid psychopathology and self-efficacy. As putative effect-moderators, demographic characteristics, number of previous episodes, type of treatment during previous episodes, age of onset, self-efficacy and symptoms of pain and fatigue are assessed. Cumulative recurrence rate ratios are obtained under a Poisson regression model. Number-needed-to-be-treated is calculated as the inverse of the risk-difference. The economic evaluation is conducted from a societal perspective, both as a cost-effectiveness analysis (costs per depression free survival year) and as a cost-utility analysis (costs per quality adjusted life-year).

DISCUSSION

The purpose of this paper is to outline the rationale and design of a nurse-led, cognitive therapy based self-help aimed at preventing recurrence of depression in a primary care setting. Only few studies have focused on psychological self-help interventions aimed at the prevention of recurrences in primary care patients.

TRIAL REGISTRATION

NTR3001 (http://www.trialregister.nl).

Implementing the chronic care model for frail older adults in the Netherlands: study protocol of ACT (frail older adults: care in transition)

BACKGROUND

Care for older adults is facing a number of challenges: health problems are not consistently identified at a timely stage, older adults report a lack of autonomy in their care process, and care systems are often confronted with the need for better coordination between health care professionals. We aim to address these challenges by introducing the geriatric care model, based on the chronic care model, and to evaluate its effects on the quality of life of community-dwelling frail older adults.

METHODS/DESIGN

In a 2-year stepped-wedge cluster randomised clinical trial with 6-monthly measurements, the chronic care model will be compared with usual care. The trial will be carried out among 35 primary care practices in two regions in the Netherlands. Per region, practices will be randomly allocated to four allocation arms designating the starting point of the intervention.

PARTICIPANTS

1200 community-dwelling older adults aged 65 or over and their primary informal caregivers. Primary care physicians will identify frail individuals based on a composite definition of frailty and a polypharmacy criterion. Final inclusion criterion: scoring 3 or more on a disability case-finding tool.

INTERVENTION

Every 6 months patients will receive a geriatric in-home assessment by a practice nurse, followed by a tailored care plan. Expert teams will manage and train practice nurses. Patients with complex care needs will be reviewed in interdisciplinary consultations.

EVALUATION

We will perform an effect evaluation, an economic evaluation, and a process evaluation. Primary outcome is quality of life as measured with the Short Form-12 questionnaire. Effect analyses will be based on the "intention-to-treat" principle, using multilevel regression analysis. Cost measurements will be administered continually during the study period. A cost-effectiveness analysis and cost-utility analysis will be conducted comparing mean total costs to functional status, care needs and QALYs. We will investigate the level of implementation, barriers and facilitators to successful implementation and the extent to which the intervention manages to achieve the transition necessary to overcome challenges in elderly care.

DISCUSSION

This is one of the first studies assessing the effectiveness, cost-effectiveness and implementation process of the chronic care model for frail community-dwelling older adults.

TRIAL REGISTRATION

The Netherlands National Trial Register NTR2160.

Reliability of consultation skills assessments using standardised versus real patients

OBJECTIVES

Training in and assessment of consultation skills are high on the agenda of vocational training institutes for postgraduate training. There is a need to establish valid and reliable instruments to assess consultation skills in authentic settings. We investigated the number of assessors and observations needed to achieve reliable assessments of the consultation skills of general practice trainees (GPTs) using a communication instrument (MAAS-Global) and either standardised patient (SP) encounters or videotaped real patient (RP) encounters.

METHODS

Eight teachers at the Vrije Universiteit (VU) University Medical Centre in Amsterdam attended a training course on the use of the MAAS-Global instrument, which they subsequently used to assess the consultation skills of 53 GPTs in 176 videotaped consultations (102 with SPs, 74 with RPs). All consultations were randomly allocated and assessed by two teachers independently. The reliability of the ratings was estimated using generalisability theory.

RESULTS

It was easier to obtain acceptable reliability using RP consultations than SP consultations. Two assessors and five consultations were required to achieve minimal reliability (generalisability coefficient 0.7) with RPs, whereas three assessors and 30 consultations were needed to achieve minimal reliability with SPs.

CONCLUSIONS

Inter-observer and context variability in the assessment of the consultation skills of GPTs remains high. To achieve acceptable levels of reliability, large samples of observations are required in both formats, but, interestingly, RP encounters require a smaller sample than SP encounters.

The center for epidemiological studies depression scale (CES-D) is an adequate screening instrument for depressive and anxiety disorders in a very old population living in residential homes

OBJECTIVE

The CES-D is an instrument that is commonly used to screen for depression in community-based studies of the elderly, but the characteristics of the CES-D in a residential home population have not yet been studied. The aim of this study was to investigate the criterion validity and the predictive power of the CES-D for both depressive and anxiety disorders in a vulnerable, very old population living in residential homes.

METHODS

Two hundred seventy seven residents were screened with the CES-D, and subsequently interviewed with a diagnostic instrument, the Mini International Neuropsychiatric Instrument (MINI). The sensitivity, specificity, and positive and negative predictive value of the CES-D were calculated by cross-tabulation at different cut-off scores. Receiver Operating Characteristics (ROC) curves were used to assess the optimal cut-off point for each disorder and to asses the predictive power of the instrument.

RESULTS

In a residential home population the CES-D had satisfactory criterion validity for depressive disorders and for any combination of depressive and/or anxiety disorders. With a desired sensitivity of at least 80%, the optimal cut-off scores varied between 18 and 22. The predictive power of the CES-D in this population was best for major depression and dysthymia (Area Under the Curve, AUC 0.87), closely followed by the score for any combination of depressive and/or anxiety disorder (AUC 0.86).

CONCLUSION

The use of one single instrument to screen for both depression and anxiety disorders at the same time has obvious advantages in this very old population. The CES-D seems to be a suitable instrument for this purpose.

High incidence of clinically relevant depressive symptoms in vulnerable persons of 75 years or older living in the community

OBJECTIVES

Clinically relevant depressive symptoms are highly prevalent in people who are 75 years of age or older. However, very old people with a vulnerable health status are under-represented in studies focussing on incidence and risk factors, while the risk of developing depressive symptoms is expected to be very high in this group. The incidence rates of clinically relevant depressive symptoms and their predictors were investigated in a vulnerable elderly population.

METHODS

In a community-based cohort, 651 vulnerable elderly (75+) people were identified by means of the COOP-WONCA charts (Dartmouth Coop Functional Health Assessment Charts/World Organisation of Family Doctors). To study the incidence of clinically relevant symptoms of depression and their predictors, 266 people with no symptoms (Centre for Epidemiologic Studies Depression Scale, CES-D score <16 at baseline) were selected and measured again at six and 18 months. The incidence of clinically relevant symptoms of depression was defined as a CES-D score > or =16, in combination with at least a five-point change between measurements. Logistic regression analyses were applied to determine risk indicators.

RESULTS

After 18 months, the incidence rate of all clinically relevant symptoms of depression was 48% (95% confidence interval, CI 44.2-51.8). No specific risk factors were identified within this population.

CONCLUSION

Our estimates of the incidence of depressive symptoms were considerably higher than those previously found in elderly populations living in the community. A vulnerable health status is associated with a high risk of depressive symptoms.

Causes of persistent dizziness in elderly patients in primary care

PURPOSE

Although dizzy patients are predominantly seen in primary care, most diagnostic studies on dizziness have been performed among patients in secondary or tertiary care. Our objective was to describe subtypes of dizziness in elderly patients in primary care and to assess contributory causes of dizziness.

METHODS

We performed a cross-sectional diagnostic study among elderly patients in the Netherlands consulting their family physician for persistent dizziness. All patients underwent a comprehensive evaluation according to a set of diagnostic tests that were developed during an international Delphi procedure. Data for each patient were independently reviewed by a panel consisting of a family physician, a geriatrician, and a nursing home physician, which resulted in major and minor contributory causes of dizziness.

RESULTS

From June 2006 to January 2008, we included 417 patients aged 65 to 95 years. Presyncope was the most common dizziness subtype (69%). Forty-four percent of the patients were assigned more than 1 dizziness subtype. Cardiovascular disease was considered to be the most common major contributory cause of dizziness (57%), followed by peripheral vestibular disease (14%), and psychiatric illness (10%). An adverse drug effect was considered to be the most common minor contributory cause of dizziness (23%). Sixty-two percent of the patients were assigned more than 1 contributory cause of dizziness.

CONCLUSIONS

Contrary to most previous studies, cardiovascular disease was found to be the most common major cause of dizziness in elderly patients in primary care. In one-quarter of all patients an adverse drug effect was considered to be a contributory cause of dizziness, which is much higher than reported in previous studies.

Dizziness reported by elderly patients in family practice: prevalence, incidence, and clinical characteristics

Background

Although dizziness in elderly patients is very common in family practice, most prevalence studies on dizziness are community-based and include a study population that is not representative of family practice. The aim of this study was to investigate the prevalence and incidence of dizziness reported by elderly patients in family practice, to describe their final diagnoses as recorded by the family physician, and to compare the clinical characteristics of dizzy patients with those of non-dizzy patients.

Methods

Data were obtained from the Second Dutch National Survey of General Practice, a prospective registration study which took place over a 12-month period in 2001. We developed a search strategy consisting of 15 truncated search terms (based on Dutch synonyms for dizziness), and identified all patients aged 65 or older who visited their family physician because of dizziness (N = 3,990). We used the mid-time population as denominator to calculate the prevalence and incidence, and for group comparisons we used the Student's t and Chi-square test, and logistic regression analysis.

Results

The one-year prevalence of dizziness in family practice in patients aged 65 or older was 8.3%, it was higher in women than in men, and it increased with age. In patients aged 85 or older the prevalence was similar for men and women. The incidence of dizziness was 47.1 per 1000 person-years. For 39% of the dizzy patients the family physicians did not specify a diagnosis, and recorded a symptom diagnosis as the final diagnosis. Living alone, lower level of education, pre-existing cerebrovascular disease, and pre-existing hypertension were independently associated with dizziness.

Conclusions

Dizziness in family practice patients increases with age. It is more common in women than in men, but this gender difference disappears in the very old. Because a large proportion of dizzy elderly patients in family practice remains undiagnosed, it would be worthwhile to carry out more diagnostic research on dizziness in a family practice setting.

Development of a diagnostic protocol for dizziness in elderly patients in general practice: a Delphi procedure

Background

Dizziness in general practice is very common, especially in elderly patients. The empirical evidence for diagnostic tests in the evaluation of dizziness is scarce. Aim of our study was to determine which set of diagnostic tests should be part of a diagnostic protocol for evaluating dizziness in elderly patients in general practice.

Methods

We conducted a Delphi procedure with a panel of 16 national and international experts of all relevant medical specialities in the field of dizziness. A selection of 36 diagnostic tests, based on a systematic review and practice guidelines, was presented to the panel. Each test was described extensively, and data on test characteristics and methodological quality (assessed with the Quality Assessment of Diagnostic Accuracy Studies, QUADAS) were presented. The threshold for in- or exclusion of a diagnostic test was set at an agreement of 70%.

Results

During three rounds 21 diagnostic tests were selected, concerning patient history (4 items), physical examination (11 items), and additional tests (6 items). Five tests were excluded, although they are recommended by existing practice guidelines on dizziness. Two tests were included, although several practice guidelines question their diagnostic value. Two more tests were included that have never been recommended by practice guidelines on dizziness.

Conclusion

In this study we successfully combined empirical evidence with expert opinion for the development of a set of diagnostic tests for evaluating dizziness in elderly patients. This comprehensive set of tests will be evaluated in a cross-sectional diagnostic study.

Offering preconceptional cystic fibrosis carrier couple screening in the absence of established preconceptional care services

OBJECTIVE

To investigate the feasibility and acceptability of different modes of offering preconceptional carrier screening for cystic fibrosis (CF) in the absence of established preconceptional care services.

METHODS

Individuals aged 20-35 years were invited by mail, either by the Municipal Health Services (MHS) or by their own general practitioner (GP) to participate in a screening program with their partner. Pretest education was provided either during a group educational session or during a GP consultation. The reasons given by participants and nonrespondents for (not) responding to the invitation for screening, sociodemographic characteristics, and their attitudes were assessed by means of questionnaires.

RESULTS

Of 38,114 individuals who received a first invitation, approximately 20% had a partner with whom they were planning to have children. The response rate, as measured by attendance at either a group educational session or a GP consultation, was not affected by whether the letter was sent by the MHS or the person's GP. However, the response rate was about 2.5 times higher when the letter invited people to make an appointment with their GP for a consultation regarding CF carrier screening than when it invited them to attend an educational group session. A total of 559 couples (96%) consented to have the test after education. Repetition of the invitation increased the response. The main reason given by couples for not responding was "lack of time to attend" or "forgot about it" (48%). Another reason given was that they did not want to know their test results (28%). Eighty-nine percent of participants and 69% of nonrespondents believed that screening should be offered routinely to couples planning to have children. The GPs consulted (n = 18) reported no negative experiences, but due to the extra workload, 11 of them would not consider it to be part of their task.

CONCLUSIONS

Among couples planning to have children, there is generally a positive attitude towards routinely offering population-based CF carrier screening. Preconceptional CF carrier screening appeared feasible, both in terms of practical achievements and target group accessibility. Participation varied according to the pretest education setting, with the primary care setting producing the highest rate of attendance.