OBJECTIVES:Recently, eosinophilic Chronic Obstructive Pulmonary Disease (COPD) has been identified as a clinically relevant phenotype, as patients with elevated blood eosinophil counts (BEC) demonstrate a better response to maintenance inhaled corticosteroids (ICS). This real-world study in Belgian primary care describes the distribution of BECs and the ICS use in stable COPD patients. METHODS:This study retrospectively analysed data from two primary care practices using the most recent values retrievable from the electronic health record. Patients were dichotomized based on BEC GOLD thresholds of 100 and 300 cells/µL. RESULTS:Eighty stable COPD patients (60% male, mean (SD) age of 70.7 (9.7)years, mean FEV1 (SD) of 65.4 (17.5) % Predicted) were included. Amongst them, 46% used ICS maintenance therapy. BEC values ranged from 0 to 667 cells/µL with a median (IQR) of 182 (80-291) cells/µL. 71% and 23% of patients presented BEC > 100 and ≥ 300 cells/µL, respectively. The mean age in the BEC≥300 group was significantly higher than in the BEC<300 group (MD = 7.2 y; p = 0.005). No other significant differences in demographic characteristics, dyspnea, FEV1 % Predicted, ≥1 moderate/severe exacerbations in the previous year, current maintenance ICS use, number of comorbidities or Charlson Comorbidity Index were detected between groups. CONCLUSION:In this primary care population in Belgium, elevated BECs and maintenance ICS use are prevalent. Besides age, clinical characteristics were comparable between eosinophil-based groups whether the 100 or 300 cells/µL threshold was used. TRIAL REGISTRATION:Not applicable given the retrospective nature of the study.

Background Medication adherence plays a crucial role in effectively managing hypertension, a significant public health concern, especially in regions like Central Vietnam. This study aimed to assess medication adherence levels among hypertensive patients in primary care settings and explore the factors influencing adherence within this specific population. Methods We conducted a cross-sectional study to evaluate medication adherence and its determinants among individuals with hypertension in Central Vietnam. Medication adherence was assessed using the 5-item version of the Medication Adherence Report Scale self-report. We collected data on the demographics, medical history, lifestyle, hypertension knowledge, along with the patient beliefs and perceptions about hypertension. Logistic regression analysis was employed to identify the key factors associated with their medication adherence. Results Our study revealed that only half of the hypertensive patients adhered to their prescribed medication regimens. Several factors significantly influenced their medication adherence, including age, ethnicity, educational level, home blood pressure monitoring, healthy diet, time since hypertension diagnosis, hypertension knowledge, and patient beliefs. According to the logistic regression analysis, a healthy diet and patient beliefs emerged as primary predictors of medication adherence. Patients who strongly believed in the necessity of medication demonstrated better adherence, while concerns about overuse and harm were linked to lower adherence levels. Conclusions This study highlighted the suboptimal levels of medication adherence among hypertensive patients in primary care settings in Central Vietnam. It underscored the urgent need for tailored interventions to address this issue. For the sake of better medication adherence, healthcare providers were suggested to prioritize patient education, address patient beliefs and concerns about medication, and promote the practice of home blood pressure monitoring.

The high prevalence of burnout in medical education indicates an urgent need to develop and implement effective interventions at both the individual and organisational levels. Currently, there is a shortage of studies that include perspectives from multiple stakeholders, such as medical students, trainees and university staff. Our objective is to identify and discuss interventions from various stakeholders using a bottom-up approach to guide future implementation. A co-creation methodology was adopted, including workshops and a Delphi session, engaging 96 participants. The study included 12 workshops with medical students and trainees in Flanders (Belgium): first-year bachelor students (n = 12), first-year master students (n = 13), first-year General Practice (GP) trainees (n = 14) and first-year specialist trainees (n = 39). Additionally, one Delphi session was held with 18 other relevant stakeholders, including university staff. All workshops were transcribed verbatim and thematically analysed using NVivo. Our results identified interventions to prevent and mitigate burnout among medical students and trainees. On the individual level, participants discussed personalized coaching, annual health assessments and training sessions. On the organisational level, a distinction was made between interventions intended for universities, and those for hospitals and GPs involved in medical training. Six interventions focused on preventing burnout in all contexts (i.e., onboarding programs); three were meant for universities only (i.e., pass-fail system), and six were tailored for hospitals and GPs (i.e., flexibility in scheduling). Through an iterative multistakeholder co-creation process, this study identified interventions to prevent and mitigate burnout within medical education. These interventions span individual and organisational levels, targeting universities, hospitals and GPs. While organisational interventions are increasingly recognized as crucial to address burnout, individual-focused interventions remain predominant in current research. There is a pressing need to further investigate organisational interventions and their combination with individual-focused strategies.

INTRODUCTION:Medical education is associated with considerable demands, often resulting in increased burnout risk and higher dropout intentions. However, longitudinal evidence on how these factors evolve and interact across different stages of training remains limited. This study examines the evolution of dropout intentions throughout medical education, identifies the learning stages most at risk, and investigates the roles of demands, resources, and burnout (i.e. emotional exhaustion and cynicism) in influencing these dropout intentions. METHODS:In a longitudinal cohort study, medical students and residents (n = 1.257) from five Flemish universities completed annual online surveys over three consecutive years (T0-T2). Dropout intentions were assessed as the outcome variable, with emotional exhaustion and cynicism integrated as mediators. Key demands and resources included workload, work-home conflict, meaningfulness, learning opportunities, and the learning environment. Linear Mixed-Effects Models examined changes in dropout intentions across stages, and Structural Equation Modelling tested direct and indirect pathways via emotional exhaustion and cynicism. RESULTS:The results showed a progressive increase in dropout intentions, with the highest levels during residency. Workload and work-home conflict were consistently associated with emotional exhaustion and cynicism, while meaningfulness showed protective effects. Cynicism was the strongest determinant of dropout intentions among students, whereas both cynicism and emotional exhaustion were related to intentions among residents. Indirect effects indicated that workload, work-home conflict, and meaningfulness influenced dropout intentions primarily through cynicism in students, and through both burnout complaints in residents. CONCLUSION:Dropout intentions in medical education are influenced by distinct stage-specific pathways of demands, resources, and burnout complaints. Interventions should target reducing workload and work-home conflict and enhancing meaningful tasks with academic and clinical tasks.

Objective: Medication adherence and controlled hypertension have low prevalence rates in Vietnam. Global research has highlighted associations between patients’ beliefs, hypertension knowledge, and medication adherence. Despite this, limited information exists on these aspects among Vietnamese hypertensive patients. This study aims to investigate patient beliefs and medication adherence among hypertensive individuals in community health centers in Vietnam. Design and method: In this cross-sectional study, patient beliefs and medication adherence among hypertensive patients were examined using the Belief about Medicine Questionnaire (BMQ) and Medication Adherence Report Scale (MARS-5). Additionally, demographic information, patients’ knowledge about hypertension, and data on controlled hypertension were collected. Descriptive, analytical, and multivariate logistic regression analyses were conducted using SPSS 29 software. Results: The study involved 761 hypertensive patients, with 55.7% being men. Findings revealed a mean medication adherence score of 21.8 (SD: 4.6). The MARS-5 score was higher in the ethnic majority (22 ± 4.3) and older patients (22.1 ± 4.1). The mean score for BMQ-Specific Necessity was 18.3 (SD 3.8), while BMQ-Specific Concern was relatively low at 14.4 (SD: 3.8). BMQ-General Overuse and BMQ-General Harm mean scores were 10.8 (SD: 2.6) and 9.9 (SD: 2.8), respectively. The BMQ-Specific Necessity score in older patients and those in urban areas had significantly higher scores than their counterparts in rural areas (p < 0.05). However, no difference was observed in patient beliefs and medication adherence based on gender. Patients with higher education or a high mean score for BMQ-Specific Necessity exhibited greater hypertension knowledge and better medication adherence (p < 0.001). Furthermore, patients with a higher mean score of medication adherence exhibited more controlled hypertension. Conclusions: Hypertensive patients in Vietnam exhibit high scores of necessity and low scores of concern regarding medication, with associations noted between patients’ knowledge and medication adherence. This study also revealed a low mean score of medication adherence among hypertensive patients. These findings highlighted the requirement for a holistic approach to deal with this concern. Healthcare planners and general practitioners should actively explore patients’ beliefs, enhance hypertension knowledge, and promote medication adherence for effective hypertension management.

Context: Hypertension is highly prevalent in Vietnam, yet the rate of controlled hypertension remains low. Knowledge about hypertension is linked to patient beliefs and medication adherence. However, there's limited data on hypertension knowledge among primary care patients in Vietnam. Aims: To evaluate the knowledge of hypertension among hypertensive patients in primary care settings in Central Vietnam and identify factors affecting their knowledge. Methods: A cross-sectional study was conducted, and a thorough examination was performed to assess hypertension knowledge and its related factors. Utilizing the Hypertension Knowledge Level Scale and Medication Adherence Report Scale, hypertension knowledge and medication adherence were evaluated. Additionally, demographic, clinical, lifestyle, and patient belief data were gathered. Statistical analyses and logistic regression models were applied to pinpoint key factors associated with hypertension knowledge. Results: In the study involving 761 participants (55.7% male), the average hypertension knowledge score was 15.0 (SD = 4.6), with only 45.3% demonstrating a high level of knowledge. Significant correlations were observed between hypertension knowledge and variables such as education level, ethnicity, home blood pressure monitoring, patient beliefs, and medication adherence. Logistic regression analysis indicated that higher education levels and belonging to the majority ethnicity were linked to enhanced hypertension knowledge. Notably, individuals with better hypertension knowledge tended to recognize the necessity of their prescribed medications. Conclusions: Hypertension knowledge among primary care patients in Central Vietnam is suboptimal, with approximately half having a high knowledge level. These findings emphasize the importance of hypertension knowledge in shaping patient beliefs, perceptions, and medication adherence. Tailored educational interventions are crucial, especially for those with lower education and minority backgrounds, to enhance hypertension management.

BACKGROUND:The DAWN antivirals trial was a multicentric, randomised placebo-controlled trial evaluating antiviral medication for COVID-19 in general practice. The trial was prematurely terminated because of insufficient recruitment. AIM:To explore which factors contributed to the premature termination. DESIGN & SETTING:General practice in Belgium. METHOD:Patients were randomised to camostat or placebo (patients and physicians blinded) between June 2021 and July 2022; a third arm evaluating molnupiravir (open label) was opened in March 2022. The outcome assessor was blinded for all comparisons except for the patient reported outcomes in case of molnupiravir. The authors analysed available trial data and evaluated trial context, implementation, and mechanisms of impact based on semi-structured interviews with trial stakeholders. RESULTS:The trial recruited 44 participants; 19 were allocated to camostat (median age 55 years), 8 to molnupiravir (median age 60 years), and 17 to placebo (median age 56 years). There were no serious adverse events in either group. Most difficulties were related to the pandemic context: disruption to routine clinical services; multiple changes to the service model for COVID-19 patients; overwhelmed clinical staff; delays of trial medication; and staff shortages in the sponsor and clinical team. In addition, regulatory approval processes were lengthy and led to additional study procedures. It was felt that the trial started too late, when vaccinations had already begun. CONCLUSION:The DAWN antivirals trial was stopped prematurely. Although many barriers were related to the pandemic itself, hurdles such as a small and inexperienced sponsor and clinical teams, delays in regulatory processes, and research capacity in routine settings could be overcome by established research infrastructure and standardisation of processes.

Background: Assessing the 10-year cardiovascular disease (CVD) risk is crucial for effective prevention and management. Despite its significance, information is limited on CVD risk among hypertensive patients in primary care in Central Vietnam. We conducted this study to estimate 10-year CVD risk in primary care settings and explore its associated risk factors, using the 2019 WHO CVD risk chart. Methods and Results: This cross-sectional study collected socio-demographic and clinical data through a standardized questionnaire. Cardiovascular risk was estimated using the WHO CVD risk charts for Southeast Asia. The prevalence of low, moderate, and high CVD risk was 52.1%, 38.9%, and 9.0%, respectively. Notably, men had significantly higher rates of moderate (48.6%) and high (17.6%) CVD risk than women (31.4 and 2.4%, respectively) (P=0.000). Age was a significant factor, with an increasing prevalence of moderate and high CVR as age advanced. Specifically, the 50-59 age group had a moderate risk of 18.6%, rising to 69.9% in the 70-74 age group. High CVD risk increased from 0.6% to 27.6% in the same age groups. Lower educational levels were associated with a higher proportion of moderate CVD risk. Smoking and excessive alcohol consumption were linked to elevated CVD risks (25.0% and 30.0%, respectively), surpassing those without these behaviors. Similar trends were observed for individuals with diabetes, high total cholesterol, and high blood pressure. Conclusion: Approximately one-tenth of hypertensive patients face a high risk of developing CVDs within the next 10 years. A comprehensive approach, encompassing behavioral changes and the management of metabolic risk factors, is essential to reduce CVD risk effectively.

Background: Significantly fewer individuals with migration backgrounds than native-born individuals undertake advance care planning. Older adults with Turkish and Moroccan backgrounds represent one of the largest ageing non-Western minority groups in Europe. Their relatives could play important roles in facilitating or hindering advance care planning, but their views remain underexplored. Aim: To explore advance care planning knowledge, experience, views, facilitators and barriers among older Turkish and Moroccan adults’ relatives in Belgium. Design: Qualitative thematic analysis of semi-structured interview data. Setting/participants: Twenty-two relatives of older Turkish and Moroccan adults in Brussels, Mechelen and Antwerp, recruited via general practitioners. Results: Participants had limited advance care planning knowledge and had not discussed it with healthcare professionals. Some found discussing end-of-life preferences with relatives beneficial; others opposed the discussion of specific topics or felt discussions were unnecessary, as they felt responsible for caregiving and trusted by their relatives to make future decisions. Barriers included personal and relational characteristics, emotional difficulty and perceived non-urgency. Facilitators included information in older adults’ native languages, general practitioners’ cautious initiation and the involvement of several family members. Conclusions: Relatives of older people with Turkish and Moroccan backgrounds are unfamiliar with advance care planning and have highly variable views on it. People should be given opportunities to discuss advance care planning in a culturally appropriate manner, and the diversity of perspectives regarding whether and how to engage in such planning should be recognised. ClinicalTrials.gov no. NCT05241301.

BACKGROUND:In Flanders (Belgium), women not screened for cervical cancer (CC) within the last three years receive an invitation letter from the regional screening organization, the Centre for Cancer Detection (CCD), encouraging them to have a cervical specimen taken by their general practitioner (GP) or gynecologist. However, the coverage for CC screening remains suboptimal (63%). The offer of a self-sampling kit (SSK, for HPV testing) by a GP may trigger participation among women who do not attend regular screening. METHODS:The ESSAG-trial is a cluster-randomized controlled trial with three arms, each including 1125 women aged 31-64 years, who were not screened for CC in the last 6 years. In arm A, GPs offer a SSK when eligible women consult for any reason. In arm B, women receive a personal GP signed invitation letter including an SSK at their home address. In the control arm, women receive the standard invitation letter from the CCD. The primary outcome is the response rate at three months after inclusion. Secondary outcomes are: screen test positivity; compliance with foreseen follow-up among screen-positives; costs per invited and per screened women; as well as contrasts between trial arms and between socio-demographic categories. CONCLUSION:The ESSAG-trial will assess the effect of GP-based interventions using SSKs on CC screening participation among hard-to-reach populations. Findings will inform policymakers about feasible strategies on increasing CC screening that may be rolled-out throughout the whole region. TRIAL REGISTRATION:ClinicalTrials.gov: NCT05656976.

There is an increasing motivation to implement pharmacist-led screening services in community pharmacies. This study aims to develop tools to support the pharmacist in the context of a diabetes and cardiovascular disease risk assessment service. Our development involved a multistep process using a user-centred approach, including a need assessment phase (14 patients, 17 pharmacists) and a creative design phase, followed by the evaluation of the materials (10 patients, 16 pharmacists). Three following themes covering educational needs emerged from stakeholders' discussions: "content", "layout", and "form", with three additional themes regarding the practical organisation: "software", "awareness", and "referral". Based on the need assessment, tools for patient education purposes and awareness campaigns were created. During the development, special attention was paid to the writing style and structure with less text and more graphical colourful elements to suit patients with different health literacy and educational levels. The evaluation phase allowed researchers to observe participants engaging with the materials. Overall, participants were satisfied with the tools. The contents were considered valuable and relevant. However, adaptations were necessary to ensure their understanding and long-term usability. Finally, future research is required to evaluate the materials' impact on patients' behaviour towards their identified risk factors and ensure their effectiveness.

Objective: To explore advance care planning (ACP)-related knowledge, experience, views, facilitators and barriers among older Moroccan adults in Belgium.Method: General practitioners (GPs) recruited participants for semi-structured interviews. Data were analysed using the constant comparative method.Results: The 25 interviewees (average age, 74 years) lacked ACP knowledge and had not discussed it with healthcare professionals. After a brief explanation, most interviewees did not find ACP useful. After more explanation with a specific example, they had fewer religious objections and were more willing to have dis-cussions with their GPs and/or relatives. ACP barriers were a lack of knowledge, current good health, potential harm of talking about death, trust in one's children to make care decisions and fear of worrying one's children. Facilitators were GPs' information provision, children's involvement in ACP discussions and the desire to not depend on children.Conclusion: Many older Moroccan adults lacked familiarity, but were willing to discuss ACP after receiving understandable concrete information. GPs should facilitate ACP discussions for these patients, ideally with adult children involved, with consideration of barriers, individual preferences and generally low educational levels. Practice implications: GPs should provide comprehensible ACP information with case examples and consider potential barriers and facilitators in this group.

STUDY OBJECTIVES:International guidelines recommend using benzodiazepine receptor agonists (BZRA) for maximally four weeks. Nevertheless, long-term use for chronic insomnia disorder remains a common practice. This study aimed to test the effectiveness of blended care for discontinuing long-term BZRA use in general practice. METHODS:A pragmatic cluster randomized controlled superiority trial compared blended care to usual care through urine toxicology screening. In the intervention, care by the general practitioner (GP) was complemented by an interactive e-learning program, based on cognitive behavioral therapy for insomnia. Adults using BZRA daily for minimally 6 months were eligible. Participants were clustered at the level of the GP surgery for allocation (1:1). Effectiveness was measured as the proportion of patients who had discontinued at one-year follow-up. Data analysis followed intention-to-treat principles. RESULTS:In total, 916 patients in 86 clusters, represented by 99 GPs, were randomized. Primary outcome data was obtained from 727 patients (79%). At one-year follow-up, 82 patients (18%) in blended care, compared to 91 patients (20%) in usual care, had discontinued. There was no statistically significant effect for the intervention (OR: 0.924; 95% CI: 0.60; 1.43). No adverse events were reported to the research team. CONCLUSIONS:The findings did not support the superiority of blended care over usual care. Both strategies showed clinical effectiveness, with an average of 19% of patients having discontinued at one-year follow-up. Further research is important to study the effect of structurally implementing digital interventions in general practice. CLINICAL TRIAL:Big Bird trial; KCE-17016. This trial is registered at clinicaltrials.gov (NCT03937180).

Background: Anticoagulation is recommended to maintain the patency of the circuit in continuous renal replacement therapy (CRRT). However, anticoagulation-associated complications can occur. We performed a systematic review and meta-analysis to compare the efficacy and safety of citrate anticoagulation to heparin anticoagulation in critically ill patients treated with CRRT. Methods: Randomised controlled trials (RCTs) evaluating the safety and efficacy of citrate anticoagulation and heparin in CRRT were included. Articles not describing the incidence of metabolic and/or electrolyte disturbances induced by the anticoagulation strategy were excluded. The PubMed, Embase, and MEDLINE electronic databases were searched. The last search was performed on 18 February 2022. Results: Twelve articles comprising 1592 patients met the inclusion criteria. There was no significant difference between the groups in the development of metabolic alkalosis (RR = 1.46; (95% CI (0.52–4.11); p = 0.470)) or metabolic acidosis (RR = 1.71, (95% CI (0.99–2.93); p = 0.054)). Patients in the citrate group developed hypocalcaemia more frequently (RR = 3.81; 95% CI (1.67–8.66); p = 0.001). Bleeding complications in patients randomised to the citrate group were significantly lower than those in the heparin group (RR 0.32 (95% CI (0.22–0.47); p < 0.0001)). Citrate showed a significantly longer filter lifespan of 14.52 h (95% CI (7.22–21.83); p < 0.0001), compared to heparin. There was no significant difference between the groups for 28-day mortality (RR = 1.08 (95% CI (0.89–1.31); p = 0.424) or 90-day mortality (RR 0.9 (95% CI (0.8–1.02); p = 0.110). Conclusion: regional citrate anticoagulation is a safe anticoagulant for critically ill patients who require CRRT, as no significant differences were found in metabolic complications between the groups. Additionally, citrate has a lower risk of bleeding and circuit loss than heparin.

Background Data on advance care planning (ACP) among migrants in Europe is lacking. Research has shown that few older migrants in the United States perform ACP due to healthcare system distrust, collectivistic values and spirituality/religion.Objectives To explore the ACP knowledge and perspectives of older Turkish-origin adults in Belgium requiring palliative care.Method General practitioners (GPs) in Brussels and Antwerp recruited Turkish-origin participants aged >= 65 years with palliative care eligibility for this qualitative study. A GP conducted semi-structured interviews in Turkish in respondents' homes between May 2019 and February 2022 using a topic guide. Two researchers performed combined inductive/deductive thematic data analysis.Results All 15 interviewees (average age, 79 years) lacked ACP awareness and information. Some had discussed specific end-of-life preferences (e.g. care location, burial place) with family. Still, many did not feel the need to discuss future healthcare preferences, due mainly to trust in God and family for caretaking and decision-making. Some respondents viewed ACP discussions as applicable, relieving the burden on family and enabling proactive addressing of 'what if' questions. Self-identified ACP barriers were fear of making wrong decisions, 'living in the moment' and difficulty discussing death. Facilitators were obtaining sufficient ACP information and recent family illness or death.Conclusion Our sample of Turkish-origin older adults in Belgium requiring palliative care lacked ACP knowledge. Our findings suggest that their lack of engagement in discussing end-of-life medical care planning was linked to their family dynamics and religion. The findings have implications for healthcare providers to ethnic-minority groups.

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)The IJIC 20th Anniversary Issue was published in 2021.

In 2014, a group of undocumented migrants started a hunger strike in Brussels. The medical monitoring was mainly done by young, committed health professionals with no prior experience of medical monitoring of people on hunger strike. Following the hunger strike, two focus groups were organized to assess the experiences of the health professionals during the medical monitoring of the hunger strike. Their main motivation for assisting was wanting to help the people on hunger strike but they were also curious about the living conditions among undocumented migrants and the reasons behind starting the strike. They were puzzled by the paradox of hunger strikers putting their life at risk in order to get a better life and obtain a residence permit. They felt conflicted about their own role as a caregiver: they did not know how to deal with patients who did not comply with medical advice, they struggled to build a relationship of mutual trust and feared that they would end up being instrumentalized by the hunger strikers or their environment. Afterwards, some of the health professionals were deeply touched by the experience and there were reports of symptoms of secondary traumatic stress such as re-experiencing and avoidance. During the focus group's discussions, the respondents made suggestions on how to improve the medical monitoring in the event of any future hunger strikes.

The implementation of a new service is often challenging when translating research findings into routine clinical practices. This paper presents the results of the implementation study of a pilot project for a diabetes and cardiovascular diseases risk-assessment service in Belgian community pharmacies. To evaluate the implementation of the service, a mixed method was used that follows the RE-AIM framework. During the testing stage, 37 pharmacies participated, including five that dropped out due to a lack of time or COVID-19-related temporary obligations. Overall, 502 patients participated, of which 376 (74.9%) were eligible for according-to-protocol analysis. Of these, 80 patients (21.3%) were identified as being at high risk for the targeted diseases, and 100 (26.6%) were referred to general practice for further investigation. We presented the limited effectiveness and the key elements influencing optimal implementation. Additional strategies, such as interprofessional workshops, a data-sharing platform, and communication campaigns, should be considered to spread awareness of the new role of pharmacists. Such strategies could also promote collaboration with general practitioners to ensure the follow-up of patients at high risk. Overall, this service was considered easy to perform and feasible in practice but would require financial and external support to ensure its effectiveness, sustainability, and larger-scale implementation.