Otto R. Maarsingh

Continuity of care has been associated with lower health care use and costs. When general practitioners (GPs) serve as gatekeepers to hospital care, having an ongoing relationship with a GP may promote more efficient care and reduce urgent referrals, thereby lowering costs. We examined the association of 2 conceptually distinct measures of continuity in general practice with both urgent hospital admissions and hospital costs. We conducted a retrospective cohort study using routinely collected health care data from 100,450 adults in 48 Dutch general practices (2013-2018) who were linked to national hospital admission and cost records (2019). Continuity was separately measured by duration of GP-patient relationship (time registered with the practice) and by density of GP contacts (Herfindahl-Hirschman index). We assessed associations with urgent admissions and log-transformed hospital costs using multilevel logistic and linear models, adjusting for sex, age, comorbidity, migration background, and income. Compared with individuals registered with their practice for 0 to 5 years, those registered longer had 9% to 21% lower odds of urgent hospital admission, with the lowest odds seen in the group registered 15 to 20 years (adjusted odds ratio = 0.79; 95% CI, 0.70-0.88). No significant association was found between higher density of GP contacts and urgent admissions. All groups registered longer than 5 years had significantly lower hospital costs, with the largest model-based reduction (-39.7%) in the group registered 10 to 15 years. Higher density of GP contacts was also associated with lower costs, with an adjusted relative reduction of 6% to 7% in total hospital costs. Long-standing continuity of care in general practice among adult patients is associated with reduced urgent hospital admissions and health care costs in the Netherlands. These findings highlight the potential value of sustained GP-patient relationships in improving hospital outcomes.

The ageing population presents challenges to healthcare systems worldwide, with unplanned hospitalisations among older adults being a growing concern. Consequences include potential adverse effects...

Objectives Hypertension is a major modifiable risk factor for cardiovascular disease, and timely detection enables interventions that can substantially reduce this risk. General practice, with continuity of care (COC) as one of its core values, plays a pivotal role in hypertension detection. This study aimed to investigate the association between COC and the detection of hypertension in general practice. Design Longitudinal dynamic cohort study. Setting This study used routine care data from 48 Dutch general practices between 2013 and 2022. Participants 106 755 adults without known cardiovascular diseases or risk factors at baseline. Outcome measures The Herfindahl-Hirschman Index, an established measure for COC, was used to calculate both general practitioner (GP)- and team-COC. A multivariable Cox proportional hazard regression model was used to assess the association between COC level (low, intermediate, high) and the incidence of hypertension detection. Results We included 106 755 patients (59.5% female, median age 35 years) in our analysis. The overall incidence rate was 9.42 hypertension diagnoses per 1000 person-years (95% CI 9.20 to 9.64). Compared with low COC, patients receiving intermediate or high GP-COC had a 1.9 (95% CI 1.7 to 2.1) to 4.9 (95% CI 4.4 to 5.4) higher HR of hypertension detection; patients receiving intermediate or high team-COC had a 2.3 (95% CI 2.2 to 2.5) to 7.3 (95% CI 6.8 to 7.8) higher HR of hypertension detection. High personal continuity was associated with up to 8.3 months (95% CI 8.6 to 7.9) earlier detection of hypertension. The association between COC and hypertension detection was dose-dependent. Conclusions This study shows that both GP-COC and team-COC are dose-dependently associated with increased HRs and earlier detection of hypertension in adults without preregistered cardiovascular conditions. Promoting COC contributes to cardiovascular preventive care.

Background: Personal continuity — having a GP who knows and follows the patient — is a core value of general practice, yet changes in society and health care have challenged its provision. Therefore, we developed TOOL-kit: an intervention to opTimise persOnal cOntinuity for oLder patients in general practice, a multi-component intervention aimed to optimise personal continuity for patients aged ≥65 years. Aim: To evaluate TOOL-kit’s implementation and identify barriers and facilitators influencing its delivery. Design and setting: This mixed-methods study was embedded in the main effect trial (August 2020 to April 2022). Method: Implementation was assessed via 3-monthly surveys and 93 interviews with GPs and practice staff ( n = 221) from 31 general practices. Based on Saunders’ paradigm, it was evaluated on the process indicators of recruitment and reach, fidelity (adherence to protocol), dose delivered (extent of improvement plans), and dose received (goal achievement, sustained organisational change). Barriers and facilitators were evaluated on the intervention, staff, organisational, and sociopolitical levels. Results: Of 31 practices, 23 adhered to protocol. TOOL-kit was delivered at a (very) low dose in 17 of 31 practices. At study end, 55% of practice goals were met. After 24 months, 19 of 31 practices had observed sustained positive effects regarding personal continuity. A good-quality improvement infrastructure facilitated TOOL-kit implementation, while work pressure and staff shortages, exacerbated by COVID-19, were seen as the main barriers for implementation. Conclusion: Despite implementation challenges, TOOL-kit was able to enhance work procedures and improve the focus on personal continuity within practice. Fostering practices’ quality improvement infrastructure and decision-making processes could improve implementation.

General practitioners (GPs) frequently prescribe anti-vertigo drugs (AVDs), even though there is limited evidence for their effectiveness. Meanwhile, they rarely apply vestibular rehabilitation, a treatment for various vestibular disorders with a strong evidence base. This study aimed to identify barriers and facilitators to appropriate vestibular care in general practice. We conducted a qualitative study in Dutch general practice using semi-structured interviews with GPs and patients with vestibular symptoms. We used purposive sampling to select participants. Interviews were audio-recorded, transcribed verbatim, and thematically analysed following the Template Analysis approach using MAXQDA 2022 software. We interviewed 11 GPs and 15 patients. We assessed barriers and facilitators to appropriate vestibular care for GPs (i.e. not prescribing AVDs, advising vestibular exercises) and patients (i.e. not using AVDs, doing vestibular exercises). We identified four themes: competence, mindset, relational determinants, and accessibility to care. Facilitators included adequate knowledge about vestibular disorders, GPs valuing delivering high-value care, positive experiences with physiotherapy, patients' coping skills, personal continuity, close collaboration between GP and colleagues, social support, and sufficient time and availability of providers. Barriers included diagnosis and treatment insecurity among GPs, patients doubting the GPs' competence, patients' desperation for treatment and GPs accommodating these wishes, positive experiences with AVDs, prescriptions by other providers, and insurance not covering physiotherapy. Multiple barriers and facilitators shape appropriate vestibular care in general practice. Interventions should strengthen GPs' and patients' knowledge of vestibular management. Internet-based vestibular rehabilitation may address key barriers, particularly logistic and financial ones.

Background: Continuity of care (CoC) is linked to better outcomes. Particularly, older adults and those with chronic conditions, like type 2 diabetes (T2D) and dementia, may benefit from CoC. Individuals with a migration background (MB) face challenges in accessing adequate healthcare. Our aim was to study associations between MB and personal continuity of general practitioner (GP) care among older adults, and in subgroups with T2D and dementia. Methods: Observational cohort study (2013–8) based on electronic records from 48 Dutch general practices linked to data from Statistics Netherlands. We specifically compared adults who migrated to the Netherlands to those without MB. The Herfindahl–Hirschman Index (HHI; low/medium/high) was used to measure CoC. We used multilevel ordinal regression to estimate associations between MB and CoC, adjusted for follow-up time/age/gender/comorbidity/income/practice. Results: 46 663 individuals aged ≥50 years were included: 72.9% with no MB, 5.7% with Surinamese, 4.3% Moroccan, 2.7% Turkish, 5.1% European, and 9.3% other MB. Compared with those without MB, persons with a Moroccan MB had lower odds of having moderate or high CoC [odds ratio (OR) 0.81, 95% CI 0.74–0.89], and persons with a European MB had higher odds of having moderate or high CoC (OR 1.16, 95% CI 1.07–1.26). Persons with a Moroccan MB in the T2D subgroup had lower odds of having moderate or high CoC (OR 0.75, 95% CI 0.64–0.89). No differences were found in the dementia subgroup. Conclusions: This study reveals inequalities in personal continuity of GP care by MB in the Netherlands. Interventions to improve CoC should actively incorporate MB groups to promote equitable CoC.

BACKGROUND Longitudinal observational databases collect real–world data (RWD), registered by healthcare providers, and make these data available to researchers. Metadata, that is, data describing other data, are crucial to facilitate meaningful interpretation of such RWD. The FAIR Principles hold that data and metadata should be richly described with accurate, relevant attributes. Yet, data reuse is impeded by low–quality or absent metadata. Despite existence of metadata frameworks, supporting data annotation, there is little insight into the actual metadata needed to interpret third–party data. OBJECTIVE The aim of the study was to gain such insight by exploring the metadata needs in a real–world study, reusing RWD from two organizations that collected general practitioner patient data. We started our real–world study with a specific research goal (ie, chronic kidney disease cohort identification) and identified what metadata were needed to reach this goal. METHODS The metadata elicitation process involved inventorying all metadata documentation available to the researchers, covering metadata fragments (eg, data dictionaries) and records of interactions (eg, email exchange, meeting minutes). We compiled both the metadata required to understand the data or related inquiries. After deduplication and merging these items, stages of concept mapping were employed to identify categories of metadata by creating cluster maps and to inspect perceived importance. RESULTS A diverse group of 23 participants took part in the concept mapping. We identified 84 metadata items within 9 distinct clusters, including data collection, data processing, data quality, and data modelling. The variety of items and clusters illustrate the challenge of achieving a predefined metadata set. Most items (70/84) were rated on average as moderately important (3) to important (4) on a 5–point Likert scale. Categories concerning features that enable data interpretation were rated as more important (3.638 [SD 0.836] – 3.739 [SD 0.841]) than those focused on technical details (2.876 [SD 0.954] – 3.261 [SD 0.832]). Most items (79/84) and all categories are not domain–specific for the descriptive study. While existing frameworks offer relevant high–level metadata, they do not accommodate the detailed insights uncovered through our practice–based metadata elicitation. CONCLUSIONS Our study shows that for a practical use case an extensive set of metadata items is required which is unlikely to be available upfront. However, as most of the required items are generic, they can be specified and made available on demand resulting in an increasingly rich set of metadata. These results guide the further development of more in–depth metadata frameworks and of procedures for incremental specification of metadata.

Introduction: Vertigo is a common symptom that strongly impacts patients’ quality of life. More than 80% of patients experiencing vertigo are primarily treated by their general practitioner (GP). The GP’s'diagnostic toolkit' for vertigo has serious limitations, though, because diagnostic accuracy studies on conditions that may cause vertigo have never been performed in a general practice setting. Our aim was to determine which tests should be investigated in a diagnostic accuracy study for patients with vertigo in general practice. Method: We conducted an online Delphi procedure involving national and international experts. The experts were asked to judge a selection of 40 diagnostic tests based on the Dutch GP guideline on vestibular symptoms, supplemented by tests identified during a systematic review. Panellists were allowed to suggest additional tests after the first round. In case of consensus of at least 70%, a test was included or excluded. We also conducted a secondary sub-analysis of our Delphi procedure to demonstrate non-dominance of Dutch experts within our expert panel. Data were analysed using descriptive statistics and content analysis. Data were analysed using descriptive statistics and content analysis. Results: A panel of 20 experts from five countries, including 7 specialists in otolaryngology, 6 neurologists and 7 GPs, participated in the Delphi procedure. The panel judged 46 diagnostic tests in total, with 6 additional tests added to the original selection based on suggestions by experts. After the first two rounds (100% response rate), 16 tests were included, 22 tests were excluded and no consensus was reached on 8 tests. During the consensus round, one of the 8 tests was added to the included 16 tests. Of these 17 tests, 15 are recommended by the Dutch GP guideline, supplemented by the non-recommended Tandem walking test and the Romberg test. Conclusions: An international expert panel reached consensus on 17 tests for vertigo in general practice that should be investigated in a diagnostic accuracy study.

Background: There is limited evidence that anti-vertigo drugs (AVDs) are effective in patients with vestibular symptoms. Still, betahistine is one of the most frequently prescribed off-label drugs. GPs are likely to contribute substantially to these potentially inappropriate prescriptions. Aim: To evaluate the frequency of (long-term) AVD prescriptions in primary care and characteristics associated with long-term prescriptions. Design & setting: We conducted a retrospective observational cohort study using anonymised routine primary care data from ≥1.2 million patients registered at 269 general practices throughout the Netherlands, covering the period 2018–2021. Method: We included adult patients with vestibular symptoms and/or AVD prescriptions. Outcomes were the prevalence and incidence of (long-term) AVD prescriptions. We used a multivariable logistic regression analysis to identify characteristics associated with long-term prescriptions. Results: Among 66718 patients with vestibular symptoms, 6172 patients (9%) received AVD prescriptions of which 32% were long term. The majority of patients with prescriptions and long-term prescriptions (88% and 77%, respectively) had any other vestibular disorder than Ménière’s disease. Still, Ménière’s disease was associated with long-term prescriptions as well as increasing age. Patients with benign paroxysmal positional vertigo (BPPV) and a symptom diagnosis of lightheadedness were less likely to receive long-term prescriptions, in addition to patients registered at practices in extremely urbanised areas. Conclusion: AVD prescriptions, including long-term prescriptions, are common among patients with a wide array of vestibular symptoms and disorders, despite limited evidence. Management of vestibular symptoms by GPs can be improved by reducing these potentially inappropriate prescriptions.