Objectives This study explored healthcare professionals’ experiences with (asynchronous) teleconsultations and (synchronous) joint consultations in primary and secondary care as well as perceived implementation barriers and facilitators to their use in clinical practice. Design An implementation-focused qualitative study employing semi-structured interviews guided by the Consolidated Framework for Implementation Research (CFIR). A systematic examination of implementation barriers and facilitators using deductive and inductive approaches, followed by thematic analysis that identified patterns, developed conceptual categories and synthesised these into overarching themes and thematic areas. Setting Teleconsultation and joint consultation used to support collaboration and continuity of care between general practitioners and medical specialists in a Dutch urbanised area. Participants 37 participants were interviewed between August 2021 and October 2022, including 14 general practitioners and 23 medical specialists. Results Four thematic areas were identified: (1) intervention, (2) interprofessional collaboration, (3) perceived patient perspective and (4) prerequisites for implementation and sustainability. Teleconsultations were highly valued by healthcare professionals, as they enhanced the quality, efficiency and flexibility of their work and improved access to care and the overall care experience for patients. Joint consultations were particularly appreciated for their interactive nature, which strengthened interprofessional relationships and supported their educational value while facilitating delivery of the right care in the right place. However, next to these facilitators several challenges were identified. Specifically, teleconsultations were hindered by variation in use, unclear expectations, a lack of dialogue and limited IT interoperability. Furthermore, scaling up joint consultations was deemed challenging due to volume requirements, time inefficiencies and organisational constraints. Conclusions Teleconsultation and joint consultation were valued by healthcare professionals as tools that support continuity and quality of care. While serving distinct purposes, their combined use strengthened collaboration between general practitioners and medical specialists. However, sustainable implementation was hindered by organisational, technical, financial and governance-related barriers, as well as limited interoperability and lack of shared clinical ownership. Addressing these barriers is essential to enable scalable and routine use of digital interprofessional consultation models.

AIMS:Guideline-recommended long-term cardiovascular disease (CVD) risk prediction models use varying time horizons. This study compared which risk horizon (risk until ages 80 or 95 years, or 30-year risk) most effectively guides preventive treatment in apparently healthy individuals. METHODS:CVD risks for all horizon were estimated using the LIFE-CVD2 model in individuals aged 35-69 years without CVD or diabetes from the Dutch ELAN registry (2007-2024; n=364,003) and the EPIC-InterAct subcohort (1992-1998; n=8,813). Individuals in the top risk decile were compared across time horizons. Simulating blood pressure- and lipid-lowering therapy, the impact of using either time horizon was assessed by the expected gain in CVD-free life years and lifetime CVD events prevented. RESULTS:Individuals identified by 30-year risk were predominantly older and largely overlapped with 10-year risk (46%). In contrast, risk until ages 80 and 95 years showed less overlap with 10-year risk (18% and 20%, respectively) and identified more young men in the highest risk decile. Treatment guided by risk until ages 80 and 95 years yielded a median gain of 2.6 [IQR 2.2-2.9] CVD-free life years per person treated, with prevention of 4,434 and 4,658 CVD events, respectively, compared with 1.8 [IQR 1.4-1.9] years and 4,215 events for 30-year risk. A hybrid strategy combining 10-year risk with risk until age 80 years yielded a median gain of 2.5 [IQR 2.1-3.0] CVD-free life years. CONCLUSION:Long-term CVD risk estimation until age 80 years offers a pragmatic approach to identify younger high-risk individuals not captured by 10-year risk who may benefit from preventive treatment.

BACKGROUND:In a previous study, an opioid reduction tool was designed to reduce inappropriate opioid treatment in patients with chronic noncancer pain. OBJECTIVES:This study aimed to assess whether the tool facilitated opioid tapering in patients with chronic noncancer pain and long-term opioid treatment in primary care. In addition, it evaluated the impact on pain-related outcome measures. METHODS:In a cohort study, 55 general practices and 30 collaborating pharmacies were recruited to implement the tool containing six reduction measures. Patients on long-term opioid treatment (>3 months) for chronic noncancer pain received a tailored taper programme from their healthcare provider and were monitored via questionnaires. The primary outcome was reduction in oral morphine equivalent daily dose over 3 months retrieved through pharmacy dispensing data. Secondary outcomes included trends in opioid use over 9 months, pain severity, pain interference, well-being, withdrawal symptoms, discontinuation rate, and nonopioid analgesic use. RESULTS:Of the 366 patients approached, 116 agreed to taper, of whom 27 were included in our cohort. The median oral morphine equivalent daily dose decreased significantly from 40.0 mg (interquartile range (IQR), 16.5-120.0) at baseline to 15.2 mg (IQR, 0.0-60.0) at 3 months. Opioid dose continued to decrease over 9 months, with 12 participants discontinuing completely. Pain-related outcome measures remained stable throughout the study period. CONCLUSION:With a significant decrease in opioid dose without negative impact on pain, this study showed promising results for an opioid reduction tool tapering long-term opioid treatment in primary care. A larger controlled trial is needed to assess the effectiveness of the tool.

Background & Aims A fasting-mimicking programme in primary care demonstrated metabolic benefits for persons with type 2 diabetes (T2D). This study evaluated the feasibility of this approach. Methods Persons with T2D who used metformin or no medication for glycemic control, were randomly assigned to monthly 5-day fasting-mimicking diet (FMD) cycles plus usual care (n=51) or usual care alone (n=49) for one year. In this mixed method study, feasibility of following an FMD was evaluated by combining quantitative data, including reasons for discontinuation, serum ketone levels, and treatment satisfaction, and qualitative data from focus group discussions. Results In the FMD group, 61% of the participants completed the FMD programme, 31% discontinued the programme due to diet-related issues, and 8% discontinued the programme for other reasons. Ketone levels were consistently higher in the FMD group than in the control group (p<0.01). Treatment satisfaction did not differ between the groups. Focus groups (n=20) revealed facilitators of adherence, including convenience, short FMD cycles, not feeling hungry, internal motivation, believing in beneficial effects, experiencing health effects and social support. Barriers included taste, quantity, and frequency of the FMD, environmental temptations, and lack of social support. Conclusions The implementation of periodic FMD cycles appears feasible for T2D patients in primary care, supported by adherence rates, ketone levels, and treatment satisfaction. Adherence might be enhanced by addressing identified facilitators and barriers. Trial registration ClinicalTrials.gov; NCT03811587. Registered 22 January 2019.

ABSTRACT Background Two-thirds of Dutch cardiovascular risk management (CVRM) for patients at risk of cardiovascular disease is delivered in primary care practices. While individual risk scores are increasingly used during consultation, a population-level structure for risk-based patient outreach is not currently available. We therefore developed the PROSPERA programme, a multilevel intervention comprising population-level risk stratification and individual-level support tools. Aim To assess anticipated and experienced barriers and facilitators among healthcare professionals (HCPs) to inform implementation in primary care. Methods We conducted four focus groups and six interviews with nine primary care HCPs to explore anticipated and experienced barriers and facilitators. Inductive codes were thematically analysed and assigned to corresponding domains of the Theoretical Domains Framework (TDF) and the related Capability, Opportunity, Motivation model of Behaviour. Results Barriers and facilitators were identified in 11 TDF domains. Population-level barriers included altered professional roles and limitations in technological infrastructure. Individual-level barriers were limited skills in interpreting risk calculations and difficulty integrating tools into clinical routine. Facilitators were related to beliefs on the importance of providing proactive care (population level), the use of U-Prevent for risk communication (individual level) and positive patient responses to the Lifestylecheck questionnaire (individual level). Conclusion Addressing barriers and facilitators identified at both the population and individual levels can support implementation of the PROSPERA programme. Opportunities exist in education and training of HCPs in risk communication, as well as support in restructuring the physical and digital environment.

Abstract Background Children with acute abdominal pain pose a diagnostic challenge for general practitioners (GPs), as it can be difficult to distinguish appendicitis from self-limiting conditions due to overlapping symptoms. To support GPs, a diagnostic strategy for appendicitis was developed that integrates an externally validated prediction rule with C-reactive protein point-of-care testing (CRP POCT) and risk-based management advice. This study will compare the impact of this diagnostic strategy to usual care in children with acute abdominal pain in primary care in terms of: (i) clinical effectiveness, (ii) cost-effectiveness, and (iii) implementation potential. Methods We will conduct a pragmatic, hybrid type 1 effectiveness-implementation, cluster randomised controlled trial in Dutch general practice. Children aged 4–18 years with acute (≤ 7 days) abdominal pain will be included. GP practices will be randomly allocated to either: (i) use of the diagnostic strategy for appendicitis, or (ii) usual care. In the intervention group, children are stratified into low, medium, or high risk for appendicitis based on a seven-item prediction rule including symptoms and signs. Management advice is tailored to appendicitis risk: safety netting for low-risk, immediate referral for high-risk, or CRP POCT for medium-risk (CRP < 10 mg/L: safety netting; CRP 10–50 mg/L: reassessment or immediate referral (based on GPs’ clinical judgement and parent/child preference); CRP ≥ 50 mg/L: immediate referral). The primary outcome is referral efficiency (proportion of non-referrals amongst patients with no appendicitis during 30 days follow-up). Secondary outcomes include safety, proportion of children with CRP POCT, proportion of children with planned reassessment, child anxiety, patient satisfaction, quality of life, and costs. A parallel process evaluation will assess implementation outcomes, including the reach, adoption, implementation, and maintenance of the diagnostic strategy. We aim to include 566 children without appendicitis to determine an improvement of efficiency from 88% to 95%. Discussion We hypothesise that use of the diagnostic strategy will reduce referrals without increasing delayed diagnoses of appendicitis, compared to usual care in children presenting with acute abdominal pain in primary care. This may ultimately result in better patient outcomes, lower costs, and reduced health care resource use. Trial registration ClinicalTrials.gov: NCT06762275 (registration date: 2024/12/03).

BACKGROUND:Older patients with chronic kidney disease (CKD) often experience relatively slow kidney function decline, suggesting that, despite meeting referral criteria, primary care management may be appropriate. We assessed guideline recommended CKD management in patients with CKD stage 4-5 across primary and nephrology care. METHODS:Population-based study using routine healthcare data from primary care and hospitals, including patients ≥ 65 years with incident or prevalent eGFR <30 ml/min/1.73m2 between 2015 and 2024. Guideline adherence was evaluated using thirteen quality indicators, calculated as the proportion of patients fulfilling these indicators or the proportion of follow-up time covered by adherent care. RESULTS:Of 1969 patients (mean age 81.8 years, median eGFR 25 ml/min/1.73m2), 61.2% were managed in primary care. These patients were older and were more often considered frail. In primary care, monitoring covered 82.5% of follow-up time for kidney function, 47.8% for albuminuria, 76.6% for blood pressure, 85.6% for haemoglobin, 50.9% for LDL-cholesterol and 68.3% for HbA1c among patients with diabetes. Corresponding estimates in nephrology care were 86.8%, 65.2%, 84.4%, 97.5%, 68.3% and 84.9%, respectively. Monitoring of metabolic complications, which falls beyond primary care guidelines, was 28.4%-79.2% in primary care and 73.6%-97.8% in nephrology care. RAAS inhibitors were prescribed in 56.9% (primary care) and 84.4% (nephrology care); SGLT2 inhibitors in 4.3% and 10.1%, and NSAIDs in both settings < 7%. Guideline adherence did not vary by socio-economic status or country of origin. In primary care, adherence was higher in patients with diabetes. CONCLUSION:The majority of older patients with CKD stage 4-5 are managed in primary care. Guideline adherence varied across care settings, which served substantially different patient populations. Higher adherence in patients with diabetes, typically enrolled in structured disease management programs, suggests that embedding similar structured approaches may enhance adherence to CKD guideline in primary care.

BACKGROUND:Somatic symptoms of common persistent somatic symptom (PSS) syndromes like irritable bowel syndrome (IBS), chronic fatigue syndrome (CFS), and fibromyalgia (FM) are not fully attributed to well-established biomedical pathological processes. These syndromes are often under-recognized and diagnosis is often delayed. This study assessed the extent to which mental health problems precede the onset of IBS, CFS, and FM diagnoses using large-scale registry-based data from primary care settings. METHOD:Data from 11,409 patients were anonymously extracted from primary care data-bases in the Netherlands. Cases (IBS, CFS, or FM) and non-cases were matched for age and sex using a 1:2 ratio. Associations with preceding mental health were available mental health-related registrations in the dataset (i.e., mental health-related ICPC-codes, referrals, and psychopharmaceuticals) registered prior to diagnosis. For predictive modeling, logistic LASSO regressions were applied. RESULTS:A total of 27 variables were longitudinally associated with IBS, CFS or FM (IBS k = 25, CFS k = 10, and FM k = 20). Five variables were longitudinally associated with all three syndromes (i.e., anxiety, psychosis, addiction behavior, and concentration disorders had positive predictive value and mental health-related referrals had negative predictive value). The overall classification performance of the models was fair (AUCIBS = 0.77) to good (AUCCFS = 0.82, AUCFM = 0.88). CONCLUSIONS:Findings indicate that mental health-related registrations in primary care are associated with, vary between, and can accurately predict IBS, CFS, and/or FM. Prediction rules derived from mental health-related registrations might be able to support GPs in identifying patients with PSS. Future studies should investigate whether distinct decision rules are needed for the different syndromes.

Background It remains a challenge for GPs to identify all patients at increased risk of cardiovascular disease (CVD) in their practice, as performing cardiovascular risk assessment in every single patient is not feasible in routine practice. There is need for a simple tool to screen who is eligible for cardiovascular risk assessment and identify those at increased CVD risk. Aim To investigate the value of measuring waist circumference in primary care by investigating: current recording practices of GPs; barriers and facilitators; and its contribution as a screening tool in the identification of patients at increased risk of CVD. Design and setting A mixed-methods study was conducted in Dutch primary care. Method We investigated the following three datasets: routine data from general practices ( n = 676 708 health records of adults); qualitative data from six focus groups ( n = 21 GPs); data from the Netherlands Epidemiology of Obesity (NEO) study ( n = 6671 middle-aged individuals). Results Between 2012 and 2023, incidence rates of recorded waist circumference by GPs decreased from 47 to 3 per 1000 person-years. Barriers to GPs measuring waist circumference included discomfort, inability to measure it accurately, lack of measuring tape, and perceived uselessness. Facilitators included knowledge that increased waist circumference is a cardiovascular risk factor. In the NEO study population, after excluding patients already treated for the prevention of CVD ( n = 2407), 1731 patients were at increased risk of CVD ( n = 1113 intermediate risk, n = 618 high risk). Measuring waist circumference would identify 89% (993/1113) of those at intermediate and 93% (575/618) of those at high predicted cardiovascular risk. Conclusion Waist circumference measurement may serve as a valuable screening tool to select patients eligible for cardiovascular risk assessment to identify those at increased risk of CVD in primary care. Since GPs currently rarely measure waist circumference, inclusion in guidelines and addressing identified barriers and facilitators is warranted.

Abstract Background High blood pressure (BP) is an often treatable cause of cardiovascular disease. We developed an intervention, featuring a cardiovascular expert team and a toolbox, to support healthcare professionals (HCPs) in hypertension management and enhance patient self-management. Aim This study evaluates the adoption and feasibility of this intervention. Design and Setting A mixed-methods study in general practices in the Netherlands. Methods HCPs could consult a cardiovascular expert team and use a self-management toolbox for their patients as preferred. We interviewed HCPs guided by the Consolidated Framework of Implementation Research (CFIR), and HCPs completed the Determinants of Implementation Behaviour Questionnaire (DIBQ). Using CFIR-ERIC matching tool, we matched implementation strategies to identified barriers. Adults with elevated BP, who were prescribed at least two blood pressure lowering medications were eligible to participate. Patient and disease characteristics were extracted from the electronical medical record. Results Of 591 eligible patients at thirteen general practices, 176 participated. The cardiovascular expert team was well-received, with 33 unique consultations, although nurse practitioners (NPs) might need the expertise of the expert team more frequently than general practitioners (GP) (adoption). The toolbox was perceived as challenging to use (feasibility). We subsequently identified three key strategies to improve implementation. Mean systolic and diastolic BP were 158/87 mmHg at baseline and 148/85 mmHg after 12 months, although this change cannot be conclusively linked to the intervention. Conclusions Structured implementation strategies may be helpful in hypertension management. The cardiovascular expert team was considered valuable, but might be better targeted to NPs rather than GPs.

Background:The successful implementation of decision support systems promises to enhance high-quality care. However, the successful implementation of a clinical decision support system (CDSS) depends on user acceptance and adoption. A machine learning (ML)-based CDSS to assist primary care professionals treating urinary tract infections (UTIs) was implemented, and usability and usefulness were assessed through a questionnaire. Objective:This study aimed to assess the system's usability by examining users' experiences with the software. A secondary goal was to assess users' attitudes toward evidence-based practice and innovation in health care. Methods:In collaboration with the Netherlands Institute for Health Services Research (NIVEL) and Leiden University Medical Center (LUMC), Pacmed Ltd developed the CDSS. The cohort was mostly recruited at the care group level; practices within participating care groups were required to participate. Health insurers partly funded the research. Practitioners participated in the implementation study for 4 months. A survey based on the Unified Theory of Acceptance and Use of Technology (UTAUT) was sent to 263 general practitioners and assistants shortly after the implementation period. Furthermore, usage data were analyzed. Results:Of the 34 participating practices that used the software, 30 (88%) submitted at least one survey response, with a mean of 2.23 responses per practice (SD 1.43). The CDSS was used throughout the pilot period, and 31 practices continued using the tool, with 9% dropping out during the first 8 weeks. Sixty-seven percent of respondents trusted the tool's output, and 73% found it understandable how the algorithm came to predictions. Sixty-five percent of respondents indicated that the information provided was useful in addition to the available guidelines, and 52% agreed that it supported their decision-making. However, many respondents were uncertain whether the tool improved patient care (46%) or patient outcomes (66%). Forty-eight percent of respondents found the software easy to integrate into their clinical workflow. Conclusions:The CDSS was perceived as trustworthy and easy to use. However, users were unable to determine whether the CDSS improved patient outcomes. In addition, the CDSS development could have benefited from including assistants as well as general practitioners more in the design phase of the software. Because assistants play an important role in UTI care, designing the software to better fit existing workflows may reduce the perceived time investment associated with using the tool. Finally, respondents reported strong motivation to contribute to further research in this field and indicated willingness to embrace change in health care delivery, which may also reflect selection bias in our sample.

Background While insomnia, depression and anxiety disorders are most frequently diagnosed and treated in primary care, the longitudinal relationship between these phenomena remains elusive in this setting. The present study aimed to quantify the association of registered insomnia with subsequent depression or anxiety in primary care.Methods A matched population-based cohort study was conducted using International Classification of Primary Care (ICPC) and Anatomical Therapeutic Classification (ATC) codes extracted from medical records of 84 Dutch general practices. Patients without documented psychological or social problems, aged 18 to 65 years, with a registered insomnia diagnosis (ICPC: P06) or prescribed sleep medication (ATC: N05CD, N05CF, N05CH) were matched 1:1 to healthy controls on sex, year of birth, and general practice. Controls could be used more than once. The primary outcome measure was depression (ICPC: P03, P76, P76.02) or anxiety (ICPC: P01, P74, P74.01, P74.02) registration up to five years after the insomnia diagnosis.Results Patients with insomnia between 1 January 2010 and 1 January 2015 (n = 1535) and the control group (n = 1502) were followed for five years after the insomnia diagnosis. Patients with insomnia had a higher risk of depression or anxiety (odds ratio (OR) = 1.53, 95% confidence interval (CI) [1.18-1.98]).Conclusions Patients with an insomnia diagnosis in primary care were at higher risk to develop depression or anxiety compared to healthy controls. This finding identifies insomnia as a potential marker for early detection and prevention of depression and anxiety in primary care.

OBJECTIVES:To explore whether routine electronic healthcare records can be used to identify triggers for initiating advance care planning (ACP) and the optimal time window to initiate ACP. We aimed to assess the prevalence of triggers for initiating ACP as defined for use in routine data, whether their presence is associated with death, and what their position is relative to a previously identified 'optimal time window for ACP'. DESIGN:Nested case-control study within a large dynamic population cohort dataset. SETTING:Primary care population-based, anonymised data extracted from GP centres in the South Holland province, The Netherlands. PARTICIPANTS:We selected records of individuals aged ≥65 registered with their general practice from 1 Jan 2014 to 1 Jan 2017. Cases were individuals who died between 1 Jan 2017 and 1 Jan 2020. Controls were individuals who remained alive. Cases were matched by age to controls in a 1:4 ratio. MAIN OUTCOME MEASURES:Outcomes include prevalence of triggers for ACP in the records of deceased and living individuals; association of the triggers' presence with death; timing of the identified triggers in deceased individuals relative to the 'optimal time window for ACP'. RESULTS:We included 17098 records, 4139 from deceased individuals (mean age 81) and 12959 from living individuals (mean age 79). Triggers most strongly associated with death were consultations concerning malignancy (OR 8.35, 95% CI 7.42 to 9.41), hospital admissions (OR 7.32, 95% CI 6.75 to 7.94), emergency department referrals (OR 7.11, 95% CI 6.52 to 7.75), registered home visits (OR 5.97, 95% CI 5.51 to 6.47), consultations concerning heart failure (OR 5.25, 95% CI 4.59 to 5.99), dementia (OR 4.75, 95% CI 3.99 to 6.56), opioid prescriptions (OR 4.58 (4.25-4.93), consultations concerning general decline/feeling old (OR 4.15, 95% CI 3.72 to 4.64) and skin ulcers/pressure sores (OR 4.04, 95% CI 3.55 to 4.61). Those closest to the median of the optimal time window for ACP were consultations regarding dyspnoea, general decline/feeling old, heart failure, skin ulcers/pressure sores and fever, opioid prescriptions, emergency department referrals, registered home visits and hospital admissions. CONCLUSIONS:Clinical triggers for initiating ACP in general practice can be recognised within the routine electronic health records and they align well with the 'window of opportunity' to initiate ACP.

INTRODUCTION:'Hotspotters' are patients with complex care needs, defined by problems in multiple life domains and high acute care use. These patients often receive mismatched care, resulting in overuse of care and increased healthcare costs. As reliable data on effective interventions for this population are scarce, the goal of this study is to assess the cost-effectiveness of proactive, personalised, integrated care for this group. METHODS AND ANALYSIS:The Hotspotters Project is planned as a stepped wedge cluster randomised controlled trial in 20 primary care practices in the Netherlands. All practices and participants will begin with standard care during the control period (2-8 months), followed by an intervention (12 months) consisting of a positive health intake with goal setting, multidisciplinary meetings, a personalised care plan and proactive care management. The study will conclude with a follow-up (2-8 months), resulting in a total study duration of 22 months. We plan to include 200 patients with (a) problems on two or more life domains and (b) at least two acute care encounters in the previous year. Possible Hotspotters are identified using an Adjusted Clinical Groups-based algorithm or via a local primary healthcare team. OUTCOMES:Questionnaires and routine care data will be used to gather data on cost-effectiveness, which will then be assessed using multilevel analysis, with levels for the individual, cluster and duration of control period. Secondary outcomes will include psychological outcomes on self-regulation (proactive coping, patient activation, self-efficacy and intention), experience of care (satisfaction, perceived autonomy support and qualitative data from focus groups) and quality of life, qualitative analysis of the Positive Health approach, implementation outcomes and process evaluation including integration of care. ETHICS AND DISSEMINATION:The Ethics Committee of Leiden University Medical Centre granted approval (METC-LDD, P21.123). Results will be shared through peer-reviewed publication and (inter)national conference presentations. TRIAL REGISTRATION NUMBER:NCT05878054.

BACKGROUND:General practitioners (GPs) play a crucial role in organ donation after euthanasia (ODE). This study explores their knowledge and perspectives regarding medical, ethical, and logistical aspects of ODE to improve patient-centred care and existing guidelines. METHODS:An exploratory study was conducted among Dutch GPs using an expert-validated online questionnaire covering awareness, experiences, barriers, and ethical considerations. Quantitative data were analysed descriptively; qualitative data underwent thematic analysis, following Standards for Reporting Qualitative Research. RESULTS:Fifty-two GPs participated. Of these, 78% (n = 38) were aware of ODE, 97% (n = 48) had a positive or neutral stance towards ODE, and 31% (n = 15) were familiar with national guidelines. Five themes emerged: (i) patient autonomy and decision-making; (ii) communication and information; (iii) logistical organization; (iv) impact and barriers; and (v) ethical debates. Patient autonomy was reported as central throughout the ODE process, particularly during decision-making and the final phase. Ninety per cent (n = 48) of the GPs preferred assessing whether discussing ODE within that patient's context was appropriate. GPs varied in opinion regarding the preferred timing for discussing ODE: 42% (n = 25) would introduce it during general end-of-life discussions, 27% (n = 16) would wait for the formal euthanasia request, and 17% (n = 10) would choose a patient-tailored moment. GPs expressed concerns regarding extra workload and emotional impact, with 52% (n = 24) hesitant to initiate ODE for these reasons. CONCLUSION:GPs play a central role in ODE, applying flexible, patient-tailored approaches supporting patient autonomy. Redistribution of tasks by early organ donation coordinator involvement, improved guidelines, and clear patient information could improve ODE care in Dutch general practice.

BACKGROUND AND AIMS:Type 2 diabetes is associated with a heightened risk of cardiovascular complications, including myocardial steatosis. Fasting-mimicking diets (FMDs) may mimic the metabolic benefits of fasting, while being less intensive than fasting. This study aims to investigate the effect of following an FMD program on myocardial triglyceride content (MTGC), as assessed by Magnetic Resonance Spectroscopy (MRS), in patients with type 2 diabetes. METHODS AND RESULTS:100 patients with type 2 diabetes, who used metformin as the only glucose-lowering drug or no medication were randomly assigned to either an FMD group or a control group. The FMD group received the FMD program for 5 consecutive days a month alongside usual care, while the control group received usual care only. Both groups underwent baseline, 6-months and 12-months examinations, including single voxel cardiac 1H-MRS to assess MTGC. N = 13 participants of the FMD and n = 13 of the control group had complete data at baseline and twelve month follow-up. The FMD group exhibited a significant reduction in MTGC over the twelve month period (-0.235 % MTGC, p = 0.027), while the control group saw no significant change (0.143 % MTGC, p = 0.236). The decrease of MTGC in the FMD group was statistically different (p = 0.018) from control. CONCLUSION:Following an FMD program reduces MTGC, which indicates a favorable effect on cardiac metabolism and thereby may be an effective strategy to reduce the cardiovascular risk in patients with type 2 diabetes. CLINICAL TRIALS REGISTRATION NUMBER:NCT03811587. TRIAL REGISTRATION:ClinicalTrials.gov; NCT03811587, submitted January 13th, 2019.

The overuse of antimicrobials is the main driver of the increasing antimicrobial resistance (AMR). Between 80 and 90

BACKGROUND & AIMS:This study aimed to assess whether a fasting-mimicking diet (FMD) programme as an adjunct to usual care can reduce liver fat and liver inflammation/fibrosis as measured by Magnetic Resonance Imaging (MRI) in patients with type 2 diabetes. METHODS:This study analyses secondary outcomes of the Fasting In diabetes Treatment (FIT) trial, which was a randomised, controlled, assessor-blinded trial in which people with type 2 diabetes using metformin only and/or diet alone for glycaemic control were randomised to receive 5-consecutive day cycles of FMD monthly as adjunct to usual care or usual care only for twelve months. Laboratory measurements, anthropometric measurements and MRI were performed at baseline, 6 and 12 months. Two MRI-derived biomarkers were measured: proton density fat-fraction (PDFF), a biomarker for liver fat, and iron content corrected T1 (cT1), a biomarker for liver inflammation/fibrosis. RESULTS:Data were available of 89 participants who completed baseline visits including MRI (n = 48 in the FMD group and n = 41 in the control group). Intention-to-treat analyses, using linear mixed models, revealed significant adjusted estimated treatment effects of the FMD on PDFF (-2.8 %, 95 % CI -4.7 to -0.8, p < 0.01) and cT1 (-29.9 ms, 95 % CI -51.8 to -8.0, p < 0.01) at 12 months. In a post-hoc analysis, more participants in the FMD group compared to the control group transitioned from high to low risk for liver disease and cardiovascular disease based on PDFF ≥5.6 %. In the FMD and control group combined, every percent decrease in PDFF was associated with a decrease in HbA1c of 0.75 mmol/mol (95 % CI 0.51 to 0.99), fasting glucose of 0.14 mmol/L (95 % CI 0.08 to 0.20), triglycerides of 0.04 mmol/L (95 % CI 0.02 to 0.07), total cholesterol of 0.03 mmol/L (95 % CI 0.01 to 0.05) and weight of 0.52 kg (CI 0.33 to 0.70). Every millisecond decrease in cT1 was associated with a decrease in HbA1c of 0.05 mmol/mol (95 % CI 0.02 to 0.08), fasting glucose of 0.01 mmol/L (95 % CI 0.00 to 0.02) and weight of 0.04 kg (CI 0.01 to 0.06). CONCLUSION:Following an FMD programme for 5-consecutive days per month for twelve months reduces both liver PDFF and cT1 MRI-derived biomarkers in patients with type 2 diabetes, indicating a reduction in liver fat and liver inflammation/fibrosis. Decreases in PDFF and cT1 are associated with decreases in HbA1c, fasting glucose, triglycerides and weight. Decrease in PDFF was also associated with a decrease in total cholesterol. Monthly cycles of an FMD appear to be a valuable adjunct to regular treatment of type 2 diabetes. TRIAL REGISTRATION:ClinicalTrials.gov: NCT03811587.

Routine body mass index (BMI) recording in electronic health records (EHR) could support general practitioners (GPs) in managing patients with obesity. This study aimed to evaluate recording practices of BMI, overweight, and obesity in adults including subgroup analysis of age, sex, and comorbidities in primary care in the Netherlands. An observational study of individuals aged ≥ 18 years and registered between 2007 and 2023, using routine healthcare data from the Extramural LUMC Academic Network (ELAN) in the Netherlands. Outcomes were (i) incidence rates of a recorded BMIs per 1000 person-years for sex and ten-year age categories (ii) proportions of recorded BMIs for different comorbidities and (iii) proportions of diagnosis of overweight (BMI between 25 and 30 kg/m2) and/or obesity (BMI ≥ 30 kg/m2) for a corresponding recorded BMI. Approximately 30

Previous studies indicate that 40% of patients with advanced chronic kidney disease (CKD), a proportion that increases with age, are managed in primary care despite meeting referral criteria. Older patients are more likely to have stable kidney function or may find hospital visits burdensome. We aimed to describe the proportion of older patients with advanced CKD receiving guideline-adherent care in primary and nephrology care, and describe how clinical characteristics and social determinants of health are associated with guideline adherence. Ultimately, we aim to assess whether primary care can be a suitable setting for managing subgroups of older CKD patients and adequately addressing their needs. This dynamic, population-based cohort study, used routine health care data of general practitioner (GP) practices and hospitals within the Extramural Leiden University Medical Center Academic Network (ELAN), linked to individual-level registry data from Statistics Netherlands. We included adults aged ≥65 years with incident or prevalent CKD (eGFR ≤30 ml/min/1.73 m2, confirmed by two measurements taken ≥90 days apart) between 2015 and 2023. Follow-up continued until death, kidney replacement therapy initiation, end of study (01-01-2023) or deregistration from a participating GP. Patients were categorized as managed in primary or nephrology care based on diagnosis-treatment combinations. We used descriptive statistics to assess the proportion of patients in each care setting and adherence to CKD guidelines, stratified by clinical characteristics and social determinants of health. We enrolled 1647 patients, with a median follow-up of 2.25 years; 1194 were managed exclusively in primary care and 453 (part of) follow-up in nephrology care. The mean age was 82 ± 9 years (83 ± 9 in primary care vs 79 ± 8 in nephrology care), with a median eGFR of 26 [22; 28] ml/min/1.73 m2. Of these, 973 patients had at least 15 months of follow-up in primary or nephrology care, allowing for guideline-adherence assessment. Patients with shorter follow-up were more likely to be female (55% vs 46%), older (83 ± 9 vs 81 ± 8 years), and classified as frail (30% vs 21%). Differences in adherence to quality indicators were observed between the care settings (see Fig. 1), with nephrology care showing higher adherence to kidney function monitoring (≥2 measurements per year: 68% vs 83%), annual testing of albuminuria (45% vs 65%), hemoglobin (74% vs 87%), LDL (49% vs 60%), and HbA1c (50% vs 65%), as well as higher prescription rates of renin-angiotensin-aldosterone system inhibitor (RAASi) (72% vs 77%). Annual blood pressure measurement and avoidance of NSAIDs were similar across care settings (60% vs 57% and 94% vs 94%, respectively). In both care settings, we observed lower guideline adherence for women across all indicators and a decrease in adherence with age, except for eGFR monitoring in nephrology care and blood pressure monitoring in both care settings. In primary care, patients with diabetes mellitus were more likely to receive guideline-adherent care compared to those without diabetes, with a similar trend observed for patients with hypertension, albeit to a lesser extent. No differences were found between ethnic and socioeconomic groups, or in relation to eGFR and frailty. The majority of older patients with advanced CKD are managed in primary care, where guideline adherence is generally acceptable, but less strictly followed than in nephrology care. Among patients with diabetes or hypertension, who are treated in structured care pathways, adherence is higher, suggesting that similar proactive and structured approaches could enhance CKD care. Given the life expectancy and treatment goals of older patients, CKD management should prioritize individual needs and quality of life over strict guideline adherence. Future research should explore whether outcomes, including CKD progression, quality of life and healthcare costs, differ between patients managed in primary and nephrology care.