Publications by authors named "Chris van Weel"

300 Publications

A Review of 50-Years of International Literature on the Internal Environment of Building Practice-Based Research Networks (PBRNs).

J Am Board Fam Med 2021 Jul-Aug;34(4):762-797

From Department of Family Medicine/General Practice, CAPHRI Institute, Maastricht University, The Netherlands (AD, JWMM); University of Oklahoma Health Sciences Center, Department of Family and Preventive Medicine, Oklahoma City (ZN); Department of Nursing Science, University of Eastern Finland, Kuopio (AH); University of Exeter Medical School, Exeter, UK (PHE); Institute of Public Health and Clinical Nutrition, Unit of General Practice, University of Eastern Finland, Kuopio (PM); Kuopio University Hospital, Kuopio, Finland (PM); Department of Primary and Community Care, Radboud Institute of Health Sciences, Radboud University Nijmegen, The Netherlands (CvW); Department of Health Services Research and Policy, Australian National University, Canberra (CvW).

Purpose: Practice-based research networks (PBRNs) have developed dynamically across the world, paralleling the emergence of the primary care discipline. While this review focuses on the internal environment of PBRNs, the complete framework will be presented incrementally in future publications.

Methods: We conducted a scoping review of the published and gray literature. Electronic databases, including MEDLINE (PubMed), OVID, CINAHL (EBSCOhost), Scopus, and SAGE Premier, were searched for publications between January 1, 1965 and December 31, 2020 for English-language articles. Rigorous inclusion/exclusion criteria were implemented to identify relevant publications, and inductive thematic analysis was applied to elucidate key elements, subthemes, and themes. Social network theory was used to synthesize findings.

Results: A total of 229 publications described the establishment of 93 PBRNs in 15 countries that met the inclusion criteria. The overall framework yielded 3 main themes, 12 subthemes, and 57 key elements. Key PBRN activities included relationship building between academia and practitioners and development of a learning environment through multidirectional communication.

Conclusions: PBRNs across many countries contributed significantly to shaping the landscape of primary health care and became an integral part of it. Many common features within the sphere of PBRNs can be identified that seem to promote their establishment across the world.
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http://dx.doi.org/10.3122/jabfm.2021.04.200595DOI Listing
November 2020

Purposeful Incorporation of Patient Narratives in the Medical Record in the Netherlands.

J Am Board Fam Med 2021 Jul-Aug;34(4):709-723

From the Department of Primary and Community Care (117-ELG), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.

Introduction: Structuring patient and practice data into episodes formed the foundation of the earliest evidence base of family medicine. We aim to make patients' narratives part of the evidence base for family medicine by incorporating coded and structured information on the patient's reason to visit the family physician (FP) and adding the patient's personal and contextual characteristics to routine registration data. This documentation allows studies of relations between morbidity and elements of the patient story, providing more insight into the range of problems presented to primary care and in the patient-centeredness applied by FPs.

Methods: The Dutch Practice-Based Research Network (PBRN), named FaMe-Net, is the world's oldest PBRN. Seven Dutch family practices provide regular primary care and participate in the PBRN. It contains all morbidity data of the approximately 40,000 listed patients (308,000 patient-years and 2.2 million encounters from 2005 until 2019). All information belonging to 1 health problem is ordered in 1 episode. Morbidity (diagnoses), reasons for encounter (RFE), and interventions are coded according to the International Classification of Primary Care (ICPC-2). Registration occurs within the electronic health record (EHR), specially designed to facilitate the extensive registration for the PBRN. Since 2016, the network expanded routine registration with the duration of symptoms and coded personal and contextual characteristics (eg, country of birth, level of education, family history, traumatic events) obtained through the self-reported 'context survey' of listed patients. These data are added to the EHR. Registered data are extracted from the EHR and processed for scientific research.We present data on the differences in RFEs of the most prominent symptoms of COVID-19 between 2019 and 2020; the relation between the diagnosis of pneumonia and presentation of the symptom 'cough,' and how personal determinants influence the chances of final diagnoses. Lastly, we show the relation of self-reported abuse with patient's contact frequency and psychosocial problems.

Results: Prompt introduction of registration rules brought insight into COVID-19-related symptoms early in the pandemic. In March 2020, symptoms related to COVID-19 were presented more often than in March 2019. Chronic conditions and prevention showed a collapsing contact frequency. Telephone, email, and video consultations increased from 31% to 53%.Episodes of pneumonia most frequently started with the RFE 'cough.' A combination of 'cough' and 'fever' as RFE increases the likelihood of pneumonia, as does cough in the presence of comorbid COPD among older men. The prevalence of pneumonia is higher among patients with low socioeconomic status.

Discussion: The Dutch PBRN FaMe-Net has started to add elements of patients' narratives and context to decades of morbidity registration, creating options for a scientific approach to primary care's core values. Assumptions of 'pre/post chances' of the final diagnosis, already existing implicitly in FPs minds, can be elaborated and quantified by investigating the associations between multiple registered variables, including parts of patients' 'stories.' This way, we aim to make visible what is intuitively already known by FPs.
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http://dx.doi.org/10.3122/jabfm.2021.04.200609DOI Listing
August 2021

Clinician Use of Primary Care Research Reports.

J Am Board Fam Med 2021 May-Jun;34(3):648-660

From the University of Washington, Seattle (WRP, AY); Monash University, Melbourne, Victoria, Australia, (ES, GMR); Bond University, Robina, Queensland, Australia (PG); Radboud Institute of Health Sciences, Radboud University, Nijmegen, The Netherlands (TOH, CvW); University of Toronto, Toronto, Ontario, Canada (AO); Australia National University, Canberra, ACT, Australia (CvW).

Purpose: To assess how primary care practitioners use reports of general health care (GHC) and primary care (PC) research and how well reports deliver what they need to inform clinical practice.

Methods: International, interprofessional online survey, 2019, of primary care clinicians who see patients at least half time. Respondents used frequency scales to report how often they access both GHC and PC research and how frequently reports meet needs. Free-text short comments recorded comments and suggestions.

Results: Survey yielded 252 respondents across 29 nations, 55% (121) women, including 88% (195) physicians, nurses 5% (11), and physician assistants 3% (7). Practitioners read research reports frequently but find they usually fail to meet their needs. For PC research, 33% (77) accessed original reports in academic journals weekly or daily, and 36% found reports meet needs "frequently" or "always." They access reports of GHC research slightly more often but find them somewhat less useful.

Conclusions: PC practitioners access original research in academic journals frequently but find reports meet information needs less than half the time. PC research reflects the unique PC setting and so reporting has distinct focus, needs, and challenges. Practitioners desire improved reporting of study context, interventions, relationships, generalizability, and implementation.
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http://dx.doi.org/10.3122/jabfm.2021.03.200436DOI Listing
September 2021

Developing measures to capture the true value of primary care.

BJGP Open 2021 Apr 26;5(2). Epub 2021 Apr 26.

Department of General Practice & Primary Health Care, University of Auckland, Auckland, New Zealand.

Primary care (PC) is an essential building block for any high quality healthcare system, and has a particularly positive impact on vulnerable patients. It contributes to the overall performance of health systems, and countries that reorient their health system towards PC are better prepared to achieve universal health coverage. Monitoring the actual performance of PC in health systems is essential health policy to support PC. However, current indicators are often too narrowly defined to account for quality of care in the complex populations with which PC deals. This article reviews a number of conceptual frameworks developed to capture PC values in robust measures and indicators that can inform policy and practice performance. Each have benefits and limitations. Further work is needed to develop meaningful primary health care (PHC) and PC measures to inform strategic action by policymakers and governments for improved overall performance of health systems.
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http://dx.doi.org/10.3399/BJGPO.2020.0152DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8170610PMC
April 2021

Improving the Reporting of Primary Care Research: An International Survey of Researchers.

J Am Board Fam Med 2021 Jan-Feb;34(1):12-21

From the University of Washington, Seattle, WA (WRP); Monash University, Melbourne, Australia (ES, GMR); Radboudumc, Nijmegen, The Netherlands (LH); Bond University, Robina, Australia (PG); Radboud Institute of Health Sciences, Nijmegen, The Netherlands (TOH, CVW); University of Toronto, Toronto, Canada (AO); Hull York Medical School, Hull, UK (JR); Australia National University, Canberra, Australia (CVW).

Purpose: To assess opportunities to improve reporting of primary care (PC) research to better meet the needs of its varied users.

Methods: International, interprofessional online survey of PC researchers and users, 2018 to 2019. Respondents used Likert scales to rate frequency of difficulties in interpreting, synthesizing, and applying PC research reports. Free-text short answers were categorized by template analysis to record experiences, concerns, and suggestions. Areas of need were checked across existing reporting guidelines.

Results: Survey yielded 255 respondents across 24 nations, including 138 women (54.1%), 169 physicians (60%), 32 scientists (11%), 20 educators (7%), and 18 public health professionals (6%). Overall, 37.4% indicated difficulties using PC research reports "50% or more of the time." The most common problems were synthesizing findings (58%) and assessing generalizability (42%). Difficulty was reported by 49% for qualitative, 46% for mixed methods, and 38% for observational research. Most users wanted richer reporting of theoretical foundation (53.7%); teams, roles, and organization of care (53.4%); and patient involvement in the research process (52.7%). Few reported difficulties with ethics or disclosure of funding or conflicts. Free-text answers described special challenges in reporting PC research: context of clinical care and setting; practical details of interventions; patient-clinician and team relationships; and generalizability, applicability and impact in the great variety of PC settings. Cross-check showed that few current reporting guidelines focus on these needs.

Conclusions: Opportunities exist to improve the reporting of PC research to make it more useful for its many users, suggesting a role for a PC research reporting guideline.
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http://dx.doi.org/10.3122/jabfm.2021.01.200266DOI Listing
August 2021

The COVID-19 Pandemic in Nijmegen, the Netherlands: Changes in Presented Health Problems and Demand for Primary Care.

Ann Fam Med 2021 Jan-Feb;19(1):44-47

Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands.

We studied the changes in presented health problems and demand for primary care since the outbreak of coronavirus disease 2019 (COVID-19) in the Netherlands. We analyzed prominent symptom features of COVID-19, and COVID-19 itself as the reason for encounter. Also, we analyzed the number and type of encounters for common important health problems. Respiratory tract symptoms related to COVID-19 were presented more often in 2020 than in 2019. We observed a dramatic increase of telephone/e-mail/Internet consultations in the months after the outbreak. Contacts for other health problems such as prevention and acute and chronic conditions plummeted substantially ( <0.001); mental health problems stabilized.
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http://dx.doi.org/10.1370/afm.2625DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7800742PMC
January 2021

Lessons on the COVID-19 pandemic, for and by primary care professionals worldwide.

Eur J Gen Pract 2020 Dec;26(1):129-133

Department of Primary and Community Health, Radboud University Medical Center, Nijmegen, The Netherlands.

The COVID-19 pandemic has modified organisation and processes of primary care. In this paper, we aim to summarise experiences of international primary care systems. We explored personal accounts and findings in reporting on the early experiences from primary care during the pandemic, through the online During the early stage of the pandemic, primary care continued as the first point of contact to the health system but was poorly informed by policy makers on how to fulfil its role and ill equipped to provide care while protecting staff and patients against further spread of the infection. In many countries, the creativity and initiatives of local health professionals led to the introduction or extension of the use of telephone, e-mail and virtual consulting, and introduced triaging to separate 'suspected' COVID-19 from non-COVID-19 care. There were substantial concerns of collateral damage to the health of the population due to abandoned or postponed routine care. The pandemic presents important lessons to strengthen health systems through better connection between public health, primary care, and secondary care to cope better with future waves of this and other pandemics.
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http://dx.doi.org/10.1080/13814788.2020.1820479DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7534357PMC
December 2020

Priorities for primary health care policy implementation: recommendations from the combined experience of six countries in the Asia-Pacific.

Aust J Prim Health 2020 Oct;26(5):351-357

Department of General Practice and Primary Health Care, University of Auckland, PB 92 019, Auckland 1142, New Zealand.

Primary health care is essential for equitable, cost-effective and sustainable health care. It is the cornerstone to achieving universal health coverage against a backdrop of rising health expenditure and aging populations. Implementing strong primary health care requires grassroots understanding of health system performance. Comparing successes and barriers between countries may help identify mutual challenges and possible solutions. This paper compares and analyses primary health care policy in Australia, Malaysia, Mongolia, Myanmar, Thailand and Vietnam. Data were collected at the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA) Asia-Pacific regional conference in November 2017 using a predetermined framework. The six countries varied in maturity of their primary health care systems, including the extent to which family doctors contribute to care delivery. Challenges included an insufficient trained and competent workforce, particularly in rural and remote communities, and deficits in coordination within primary health care, as well as between primary and secondary care. Asia-Pacific regional policy needs to: (1) focus on better collaboration between public and private sectors; (2) take a structured approach to information sharing by bridging gaps in technology, health literacy and interprofessional working; (3) build systems that can evaluate and improve quality of care; and (4) promote community-based, high-quality training programs.
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http://dx.doi.org/10.1071/PY19194DOI Listing
October 2020

Disparities in cancer-related healthcare among people with intellectual disabilities: A population-based cohort study with health insurance claims data.

Cancer Med 2020 09 25;9(18):6888-6895. Epub 2020 Jul 25.

Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.

Background: Concerns have been raised about the accessibility and quality of cancer-related care for people with intellectual disabilities (ID). However, there is limited insight into cancer incidence and the utilization of cancer care at the ID population level to inform targeted cancer control strategies. Therefore, we aimed to examine differences in the utilization of cancer-related care between people with and without ID, identified through diagnostic codes on health insurance claims.

Methods: In a population-based cohort study, Dutch individuals of all ages who received residential care through the Chronic Care Act due to an ID (n = 65 183) and an age and sex-matched sample of persons without ID (1:2 ratio), who were cancer-free at enrollment in 2013 were followed through 2015. Incidence rates (IRs) of newly started cancer care and IR ratios (IRRs) with 95% CIs were used to compare groups. Separate analyses were performed per cancer type.

Results: Individuals with ID received less cancer-related care than individuals without (IRR = 0.64, 95% CI 0.62-0.66). Differences increased with age and were larger for females than for males. Utilization of care for cancers within the national screening program (female breast, cervical, and colon cancer) was lower for people with ID compared to people without ID.

Conclusion: Cancer may be underdiagnosed and/or undertreated in people with ID, or cancer is truly less prevalent in this population. In particular, the differences detected between males and females with ID, and the potential underutilization of national screening programs, require urgent follow-up investigations.
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http://dx.doi.org/10.1002/cam4.3333DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7520346PMC
September 2020

Fostering global primary care research: a capacity-building approach.

BMJ Glob Health 2020 07;5(7)

General Practice, University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand.

The Alma Ata and Astana Declarations reaffirm the importance of high-quality primary healthcare (PHC), yet the capacity to undertake PHC research-a core element of high-quality PHC-in low-income and middle-income countries (LMIC) is limited. Our aim is to explore the current risks or barriers to primary care research capacity building, identify the ongoing tensions that need to be resolved and offer some solutions, focusing on emerging contexts. This paper arose from a workshop held at the 2019 North American Primary Care Research Group Annual Meeting addressing research capacity building in LMICs. Five case studies (three from Africa, one from South-East Asia and one from South America) illustrate tensions and solutions to strengthening PHC research around the world. Research must be conducted in local contexts and be responsive to the needs of patients, populations and practitioners in the community. The case studies exemplify that research capacity can be strengthened at the (practice), (institutional) and (national policy and international collaboration) levels. Clinicians may lack coverage to enable research time; however, practice-based research is precisely the most relevant for PHC. Increasing research capacity requires local skills, training, investment in infrastructure, and support of local academics and PHC service providers to select, host and manage locally needed research, as well as to disseminate findings to impact local practice and policy. Reliance on funding from high-income countries may limit projects of higher priority in LMIC, and 'brain drain' may reduce available research support; however, we provide recommendations on how to deal with these tensions.
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http://dx.doi.org/10.1136/bmjgh-2020-002470DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7337619PMC
July 2020

The extraordinary diagnostic sensitivity of family physicians.

Authors:
Chris van Weel

Fam Pract 2020 09;37(4):431-433

Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands.

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http://dx.doi.org/10.1093/fampra/cmaa045DOI Listing
September 2020

Managing costs and access to healthcare in the Netherlands: impact on primary care.

BMJ 2020 Apr 8;369:m1181. Epub 2020 Apr 8.

Department of Family Medicine, Maastricht University, Maastricht, Netherlands

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http://dx.doi.org/10.1136/bmj.m1181DOI Listing
April 2020

Patients' attitudes to discontinuing not-indicated long-term antidepressant use: barriers and facilitators.

Ther Adv Psychopharmacol 2019 3;9:2045125319872344. Epub 2019 Sep 3.

Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, Netherlands.

Background: Long-term antidepressant use has increased exponentially, though this is not always according to guidelines. Our previous randomized controlled trial (RCT) showed that participants using antidepressants long term without a proper indication were apprehensive to stop: only half were willing to attempt to discontinue their antidepressant use. The objective of this study was to explore participants' barriers and facilitators for stopping long-term antidepressant use without a current proper indication.

Methods: Semistructured interviews with participants from the intervention group of our RCT, a cluster-RCT in general practice in the Netherlands. The latter study was a stop trial with patients on long-term antidepressant use without a current indication (no psychiatric diagnosis). Participants of the intervention group of the RCT had been provided with advice to stop antidepressants. Participants of the current interview study were purposively sampled (from the intervention group of the RCT) to ensure diversity in age, sex, and intention to discontinue the antidepressant. Analysis was performed as an iterative process, based on the constant comparative method. Data collection proceeded until saturation was reached.

Results: A total of 16 participants were interviewed. Fear (of recurrence, relapse, or to disturb the equilibrium) was the most important barrier; prior attempts fueled these anticipations. Also prominent as a barrier was the notion that antidepressants are necessary to counter a deficiency of serotonin. Facilitators were information on duration of usage given at the time of first prescription and confidence in a successful attempt. We found many participants struggling between barriers and facilitators to discontinue and participants not discontinuing while experiencing no barriers (ambivalence).

Conclusion: Fear is an important motive for patients considering discontinuation of antidepressants. Serotonin deficiency as explanation for antidepressant effectiveness promotes life-long use and hinders discontinuation of antidepressant treatment. The prospect of discontinuation at first prescription can facilitate a future discontinuation attempt. General practitioners should be aware of their patients' fears, expectations, and attributions toward antidepressant use/discontinuation, and of new developments in taper methods.
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http://dx.doi.org/10.1177/2045125319872344DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6724488PMC
September 2019

Research gaps in the organisation of primary healthcare in low-income and middle-income countries and ways to address them: a mixed-methods approach.

BMJ Glob Health 2019 16;4(Suppl 8):e001482. Epub 2019 Aug 16.

Radboud Institute of Health Research, Department Primary and Community Care, Radboud Universiteit Nijmegen, Nijmegen, The Netherlands.

Introduction: Since the Alma-Ata Declaration 40 years ago, primary healthcare (PHC) has made great advances, but there is insufficient research on models of care and outcomes-particularly for low-income and middle-income countries (LMICs). Systematic efforts to identify these gaps and develop evidence-based strategies for improvement in LMICs has been lacking. We report on a global effort to identify and prioritise the knowledge needs of PHC practitioners and researchers in LMICs about PHC organisation.

Methods: Three-round modified Delphi using web-based surveys. PHC practitioners and academics and policy-makers from LMICs sampled from global networks. First round (pre-Delphi survey) collated possible research questions to address knowledge gaps about organisation. Responses were independently coded, collapsed and synthesised. Round 2 (Delphi round 1) invited panellists to rate importance of each question. In round 3 (Delphi round 2), panellists ranked questions into final order of importance. Literature review conducted on 36 questions and gap map generated.

Results: Diverse range of practitioners and academics in LMICs from all global regions generated 744 questions for PHC organisation. In round 2, 36 synthesised questions on organisation were rated. In round 3, the top 16 questions were ranked to yield four prioritised questions in each area. Literature reviews confirmed gap in evidence on prioritised questions in LMICs.

Conclusion: In line with the 2018 Astana Declaration, this mixed-methods study has produced a unique list of essential gaps in our knowledge of how best to organise PHC, priority-ordered by LMIC expert informants capable of shaping their mitigation. Research teams in LMIC have developed implementation plans to answer the top four ranked research questions.
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http://dx.doi.org/10.1136/bmjgh-2019-001482DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6703507PMC
August 2019

Primary care financing: a systematic assessment of research priorities in low- and middle-income countries.

BMJ Glob Health 2019 16;4(Suppl 8):e001483. Epub 2019 Aug 16.

Radboud Institute of Health Research, Department Primary and Community Care, Radboud Universiteit Nijmegen, Nijmegen, The Netherlands.

Introduction: Financing of primary healthcare (PHC) is the key to the provision of equitable universal care. We aimed to identify and prioritise the perceived needs of PHC practitioners and researchers for new research in low- and middle-income countries (LMIC) about financing of PHC.

Methods: Three-round expert panel consultation using web-based surveys of LMIC PHC practitioners, academics and policy-makers sampled from global networks. Iterative literature review conducted in parallel. First round (Pre-Delphi survey) elicited possible research questions to address knowledge gaps about financing. Responses were independently coded, collapsed and synthesised to two lists of questions. Round 2 (Delphi Round 1) invited panellists to rate importance of each question. In Round 3 (Delphi Round 2), panellists ranked questions in order of importance.

Results: A diverse range of PHC practitioners, academics and policy-makers in LMIC representing all global regions identified 479 knowledge gaps as potentially critical to improving PHC financing. Round 2 provided 31 synthesised questions on financing for rating. The top 16 were ranked in Round 3e to produce four prioritised research questions.

Conclusions: This novel exercise created an expansive and prioritised list of critical knowledge gaps in PHC financing research questions. This offers valuable guidance to global supporters of primary care evaluation and implementation, including research funders and academics seeking research priorities. The source and context specificity of this research, informed by LMIC practitioners and academics on a global and local basis, should increase the likelihood of local relevance and eventual success in implementing the findings.
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http://dx.doi.org/10.1136/bmjgh-2019-001483DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6703294PMC
August 2019

Primary care healthcare policy implementation in the Eastern Mediterranean region; experiences of six countries: Part II.

Eur J Gen Pract 2020 Dec 1;26(1):1-6. Epub 2019 Aug 1.

UK: Imperial College London & WHO Collaborating Centre, London, UK.

Primary healthcare (PHC) is essential for equitable access and cost-effective healthcare. This makes PHC a key factor in the global strategy for universal health coverage (UHC). Implementing PHC requires an understanding of the health system under prevailing circumstances, but for most countries, no data are available. This paper describes and analyses the health systems of Algeria, Kuwait, Morocco, Saudi Arabia, Jordan and Iraq to PHC. Data were collected during a workshop at the Wonca East Mediterranean Regional Conference in 2018. Academic family physicians (FP) presented their country; using the Wonca framework of 11 PowerPoint slides, with queries of the country demographics, main health challenges, and the position of PHC in the health system. The six countries had achieved a significant improvement in populations' health but currently face challenges of health financing, a small number of certified FPs, difficulties in accessing services and bureaucratic procedures. Primary concerns were the absence of a family practice model, brain drain and immigration of FPs. Countries differed in building a coherent policy. Priorities should be focused on: developing PHC model in Eastern Mediterranean region with advocacy for community-based PHC to policymakers; capacity building for strengthening PHC-oriented health systems with FP specialty training and restrict practising to fully trained FPs; engage communities to improve understanding of PHC; adopt quality and accreditation policies for better services; validation of the referral and follow-up process; and, develop public-private partnership mechanisms to enhance PHC for UHC.
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http://dx.doi.org/10.1080/13814788.2019.1640210DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7006796PMC
December 2020

The Essential Role of Primary Care Professionals in Achieving Health for All.

Ann Fam Med 2019 07;17(4):293-295

Radboud University Medical Centre, Radboud Institute of Health Sciences, Department of Primary and Community Care, Nijmegen, The Netherlands

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http://dx.doi.org/10.1370/afm.2436DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6827640PMC
July 2019

Primary Care Research Priorities in Low-and Middle-Income Countries.

Ann Fam Med 2019 01;17(1):31-35

Department of Primary and Community Care, Radboud Institute of Health Sciences, Nijmegen, The Netherlands.

Purpose: To identify and prioritize the needs for new research evidence for primary health care (PHC) in low-and middle-income countries (LMICs) about organization, models of care, and financing of PHC.

Methods: Three-round expert panel consultation of LMIC PHC practitioners and academics sampled from global networks, via web-based surveys. Iterative literature review conducted in parallel. Round 1 (pre-Delphi survey) elicited possible research questions to address knowledge gaps about organization and models of care and about financing. Round 2 invited panelists to rate the importance of each question, and in round 3 panelists provided priority ranking.

Results: One hundred forty-one practitioners and academics from 50 LMICs from all global regions participated and identified 744 knowledge gaps critical to improving PHC organization and 479 for financing. Four priority areas emerged: effective transition of primary and secondary services, horizontal integration within a multidisciplinary team and intersectoral referral, integration of private and public sectors, and ways to support successfully functioning PHC professionals. Financial evidence priorities were mechanisms to drive investment into PHC, redress inequities, increase service quality, and determine the minimum necessary budget for good PHC.

Conclusions: This novel approach toward PHC needs in LMICs, informed by local academics and professionals, created an expansive and prioritized list of critical knowledge gaps in PHC organization and financing. It resulted in research questions, offering valuable guidance to global supporters of primary care evaluation and implementation. Its source and context specificity, informed by LMIC practitioners and academics, should increase the likelihood of local relevance and eventual success in implementing research findings.
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http://dx.doi.org/10.1370/afm.2329DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6342597PMC
January 2019

Withdrawal of unnecessary antidepressant medication: a randomised controlled trial in primary care.

BJGP Open 2018 Jan 15;1(4):bjgpopen17X101265. Epub 2017 Nov 15.

Professor of Psychiatry, Department of Psychiatry, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands.

Background: Antidepressant use has increased exponentially in recent decades, mostly due to long continuation.

Aim: To assess the effectiveness of a tailored recommendation to withdraw antidepressant treatment.

Design & Setting: Randomised controlled trial in primary care (PANDA study) in the Netherlands.

Method: Long-term antidepressant users (≥9 months) were selected from GPs prescription databases. Patients were diagnosed with the Composite International Diagnostic Interview (CIDI). Long-term users without indication for maintenance treatment (overtreatment) were selected. The intervention consisted of disclosure of the current psychiatric diagnosis combined with a tailored treatment recommendation. Patients were followed for 12 months.

Results: The study included 146 participants from 45 family practices. Of the 70 patients in the intervention group, 34 (49%) did not comply with the advice to stop their antidepressant medication. Of the 36 (51%) patients who agreed to try, only 4 (6%) succeeded. These figures were consistent with the control group, where 6 (8%) of the 76 patients discontinued antidepressant use successfully. Patients who were recommended to discontinue their antidepressant medication reported a higher relapse rate than the control group (26% versus 13%, = 0.05).

Conclusion: Changing inappropriate long-term antidepressant use is difficult.
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http://dx.doi.org/10.3399/bjgpopen17X101265DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6181099PMC
January 2018

Unfulfilled potential of primary care in Europe.

BMJ 2018 Oct 24;363:k4469. Epub 2018 Oct 24.

Nuffield Department of Primary Care Health Sciences, University of Oxford, UK.

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http://dx.doi.org/10.1136/bmj.k4469DOI Listing
October 2018

Training Undergraduates Skills in Breaking Bad News: How Students Value Educators' Feedback.

J Cancer Educ 2019 Dec;34(6):1103-1106

Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.

Feedback is a key factor in acquiring breaking bad news (BBN) communication skills and its' acceptance depends on the perceived credibility of the provider. Our aim was to investigate students' opinions on the provided feedback by different educators (surgeons, psychologists, and simulated patient (SP)) during BBN skills training. We developed a questionnaire investigating provided feedback by the surgeon, psychologist, and SP (yes or no statements), regarding (1) perceived safety of the atmosphere, (2) perceived positive feedback, (3) perceived specific feedback, and (4) perceived usefulness for improvement during BBN skills training. Five hundred twenty students returned the questionnaire after BBN skills training. Most students rated the feedback as positive, specific, and useful. Also, the atmosphere was considered safe. Feedback ratings of the SP were the same as for the surgeon and valued higher than for the psychologist. An unsafe atmosphere, or not receiving positive, specific, or useful feedback was mostly related to the psychologist's feedback. Feedback on BBN skills training by surgeons and SPs is rated equally helpful by students and is regarded specific, useful, and positive. When designing a BBN training, it is worth to consider involving SP's as well as clinicians.
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http://dx.doi.org/10.1007/s13187-018-1415-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6882760PMC
December 2019

Why strengthening primary health care is essential to achieving universal health coverage.

CMAJ 2018 04;190(15):E463-E466

Department of Primary and Community Care (van Weel), Radboud University Medical Center, Nijmegen, The Netherlands; Department of Health Services Research and Policy (van Weel), Australian National University, Acton, Australia; Department of Family and Community Medicine (Kidd), University of Toronto, Toronto, Ont.; Murdoch Childrens Research Institute (Kidd), Melbourne, Australia; Southgate Institute for Health, Equity and Society (Kidd), Flinders University, Adelaide, Australia.

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http://dx.doi.org/10.1503/cmaj.170784DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5903888PMC
April 2018

Being in control of Parkinson's disease: A qualitative study of community-dwelling patients' coping with changes in care.

Eur J Gen Pract 2018 Dec;24(1):138-145

a Department of Primary and Community Care , Radboud University Medical Center , Nijmegen , The Netherlands.

Background: Chronically ill patients have to cope with transfers in the level or setting of care. Patients with prevalent disorders such as diabetes mellitus can be supported by their general practitioner (GP) when experiencing such care changes, as the GP already offers them disease-specific care. For community-dwelling patients with low-prevalent diseases such as Parkinson's disease (PD) - for which disease-specific care is provided by medical specialists - tailoring support to handle care changes requires more insight into patients' coping.

Objectives: To explore PD patients' coping with care changes.

Methods: A qualitative interview study was performed in 2013-2015 with a purposive sample of 16 community-dwelling PD patients in the Netherlands. A research assistant visited patients every month to explore if they had experienced a care change. If so, patients were interviewed face-to-face. An inductive approach to comparative content analysis was used.

Results: Patients encountered a variety of care changes such as changes in the level of unpaid care, the purchase of tools, modification of pharmacotherapy or admission to hospital. Being able to anticipate, initiate and independently handle care changes contributes to patients' sense of control and acceptance of the post-change situation. Patients, who commenced care changes themselves, had more realistic expectations of it.

Conclusion: Community-dwelling PD patients seem to be able to cope with the care changes they face. Offering education to facilitate their anticipation and initiation of changes in care and their ability to act independently, can contribute to patients' wellbeing. GPs can play a role in this.
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http://dx.doi.org/10.1080/13814788.2018.1447561DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5917327PMC
December 2018

Role of the family doctor in the management of adults with obesity: a scoping review.

BMJ Open 2018 02 16;8(2):e019367. Epub 2018 Feb 16.

Academic Unit of General Practice, Australian Nation University Medical School, Canberra, Australia.

Objectives: Obesity management is an important issue for the international primary care community. This scoping review examines the literature describing the role of the family doctor in managing adults with obesity. The methods were prospectively published and followed Joanna Briggs Institute methodology.

Setting: Primary care. Adult patients.

Included Papers: Peer-reviewed and grey literature with the keywords obesity, primary care and family doctors. All literature published up to September 2015. 3294 non-duplicate papers were identified and 225 articles included after full-text review.

Primary And Secondary Outcome Measures: Data were extracted on the family doctors' involvement in different aspects of management, and whether whole person and person-centred care were explicitly mentioned.

Results: 110 papers described interventions in primary care and family doctors were always involved in diagnosing obesity and often in recruitment of participants. A clear description of the provider involved in an intervention was often lacking. It was difficult to determine if interventions took account of whole person and person-centredness. Most opinion papers and clinical overviews described an extensive role for the family doctor in management; in contrast, research on current practices depicted obesity as undermanaged by family doctors. International guidelines varied in their description of the role of the family doctor with a more extensive role suggested by guidelines from family medicine organisations.

Conclusions: There is a disconnect between how family doctors are involved in primary care interventions, the message in clinical overviews and opinion papers, and observed current practice of family doctors. The role of family doctors in international guidelines for obesity may reflect the strength of primary care in the originating health system. Reporting of primary care interventions could be improved by enhanced descriptions of the providers involved and explanation of how the pillars of primary care are used in intervention development.
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http://dx.doi.org/10.1136/bmjopen-2017-019367DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5829928PMC
February 2018

Strategies for Increasing the Role of Family Medicine in Mexican Health Care Reform.

J Am Board Fam Med 2017 Nov-Dec;30(6):843-847

From the Department of Family Medicine, Hospital Universitario Dr. Jose Eleuterio Gonzalez y Facultad de Medicina, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico (JMRA); Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands and Department of Health Services and Policy, Australian National University, Canberra, Australia (CvW); Department of General Practice & Primary Health Care, University of Auckland, Auckland, New Zealand (FGS).

There is little or no role for primary care and family medicine in current health reforms in Mexico. However, robust evidence shows that primary care helps prevent morbidity and mortality and increases health equity. Mexico has participated in several international meetings sponsored by the World Organization of National Colleges, Academies and Academic Associations and the North American Primary Care Research Group that are aimed at increased understanding of national health systems and the need to strengthen primary care for improved health outcomes. From 1 of these meetings the Cancún Manifesto emerged, with a strategic plan to increase the stature and impact of the Mexican College of Family Physicians (COLMEXAC) in strengthening primary care in Mexico. We aim to describe this strategic plan and discuss its early implementation, and for this account to serve as a possible formula for other countries. The 5 specific strategies discussed are 1) the need for consensus on the leading role of the Mexican family physician in the national health system; 2) health ecology research; 3) to improve the perception of patients about the benefits of primary care and family medicine; 4) to organize meetings of health providers, users, and other stakeholders; and 5) to promote the professionalization of COLMEXAC as a legal entity.
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http://dx.doi.org/10.3122/jabfm.2017.06.170024DOI Listing
July 2018

Primary healthcare policy implementation in the Eastern Mediterranean region: Experiences of six countries.

Eur J Gen Pract 2018 Dec 23;24(1):39-44. Epub 2017 Nov 23.

m Department of Community and Family Medicine , Fukushima Medical University , Fukushima , Japan.

Background: Primary healthcare (PHC) is essential for equitable access and cost-effective healthcare. This makes PHC a key factor in the global strategy for universal health coverage (UHC). Implementing PHC requires an understanding of the health system under prevailing circumstances, but for most countries, no data are available.

Objectives: This paper describes and analyses the health systems of Bahrain, Egypt, Lebanon, Qatar, Sudan and the United Arab Emirates, in relation to PHC.

Methods: Data were collected during a workshop at the WONCA East Mediterranean Regional Conference in 2017. Academic family physicians (FP) presented their country, using the WONCA framework of 11 PowerPoint slides with queries of the country demographics, main health challenges, and the position of PHC in the health system.

Results: All six countries have improved the health of their populations, but currently face challenges of non-communicable diseases, aging populations and increasing costs. Main concerns were a lack of trained FPs in community settings, underuse of prevention and of equitable access to care. Countries differed in the extent to which this had resulted in coherent policy.

Conclusion: Priorities were (i) advocacy for community-based PHC to policymakers, including the importance of coordination of healthcare at the community level, and UHC to respond to the needs of populations; (ii) collaboration with universities to include PHC as a core component of every medical curriculum; (iii) collaboration with communities to improve public understanding of PHC; (iv) engagement with the private sector to focus on PHC and UHC.
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http://dx.doi.org/10.1080/13814788.2017.1397624DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5795637PMC
December 2018

Challenging assumptions in obesity research.

BMJ 2017 11 22;359:j5303. Epub 2017 Nov 22.

Radboud University, Nijmegen, Netherlands.

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http://dx.doi.org/10.1136/bmj.j5303DOI Listing
November 2017

A cross-sectional examination of psychological distress, positive mental health and their predictors in medical students in their clinical clerkships.

BMC Med Educ 2017 Nov 17;17(1):219. Epub 2017 Nov 17.

Department of Psychiatry, Radboud University Medical Center, Nijmegen, the Netherlands.

Background: Medical students can experience the transition from theory to clinical clerkships as stressful. Scientific literature on the mental health of clinical clerkship students is scarce and mental health is usually defined as absence of psychological distress without assessing psychological, emotional and social wellbeing, together called 'positive mental health'. This cross-sectional study examines the prevalence of psychological distress and positive mental health and explores possible predictors in a Dutch sample of clinical clerkship students.

Methods: Fourth-year medical students in their first year of clinical clerkships were invited to complete an online questionnaire assessing demographics, psychological distress (Brief Symptom Inventory), positive mental health (Mental Health Continuum- SF), dysfunctional cognitions (Irrational Beliefs Inventory) and dispositional mindfulness skills (Five Facet Mindfulness Questionnaire). Multiple linear regression analysis was used to explore relationships between psychological distress, positive mental health (dependent variables) and demographics, dysfunctional cognitions and dispositional mindfulness skills (predictors).

Results: Of 454 eligible students, 406 (89%) completed the assessment of whom 21% scored in the clinical range of psychological distress and 41% reported a flourishing mental health. These proportions partially overlap each other. Female students reported a significantly higher mean level of psychological distress than males. In the regression analysis the strongest predictors of psychological distress were 'acting with awareness' (negative) and 'worrying' (positive). Strongest predictors of positive mental health were 'problem avoidance' (negative) and 'emotional irresponsibility' (negative).

Conclusions: The prevalence of psychopathology in our sample of Dutch clinical clerkship students is slightly higher than in the general population. Our results support conclusions of previous research that psychological distress and positive mental health are not two ends of one continuum but partially overlap. Although no conclusion on causality can be drawn, this study supports the idea that self-awareness and active, nonavoidant coping strategies are related to lower distress and higher positive mental health.
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http://dx.doi.org/10.1186/s12909-017-1035-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5693565PMC
November 2017

Patient characteristics do not predict the individual response to antihypertensive medication: a cross-over trial.

Fam Pract 2018 01;35(1):67-73

Division of General Internal Medicine, Department of Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.

Background: International guidelines on hypertension management do not agree on whether patient characteristics can be used for the first choice of treatment of uncomplicated essential hypertension.

Objective: We wanted to identify predictive patient characteristics to the response of two different classes of antihypertensive drugs in patients with newly diagnosed hypertension in primary care.

Methods: We conducted a prospective, open label, blinded endpoint cross-over trial in 120 patients with a new diagnosis of hypertension from 10 family practices. Patients received 4 weeks of 12.5 mgr hydrochlorothiazide once daily and 4 weeks of 80 mgr valsartan once daily, each followed by a 4-week washout. The sequence of drugs was randomized. Age, sex and menopausal state were recorded at run in and 24 h ambulatory blood pressure, office blood pressure, plasma renin concentration, NT-proBNP, potassium, estimated glomerular filtration rate, urinary albumin, body mass index and waist circumference at each regimen change. The difference in systolic blood pressure response between both study drugs, calculated from mean daytime ambulatory blood pressures, was the main outcome measure.

Results: Ninety-eight patients (52% female; median age 53 years) were eligible for per-protocol-analysis. None of the studied variables were predictive for the difference in systolic blood pressure response. Individual systolic blood pressure responses ranged from an increase by 18 mmHg to a decrease of 39 mmHg.

Conclusion: In a relevant group of primary care patients with newly diagnosed hypertension, we were unable to detect predictors of treatment response. This study rather supports the United States and European guidelines than the United Kingdom and Dutch guidelines on hypertension.
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http://dx.doi.org/10.1093/fampra/cmx075DOI Listing
January 2018
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