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The Coronavirus disease 2019 (COVID-19) outbreak impacted health care. We investigated its impact on the time to referral and diagnosis for symptomatic cancer patients in The Netherlands. We performed a national retrospective cohort study utilizing primary care records linked to The Netherlands Cancer Registry. For patients with symptomatic colorectal, lung, breast, or melanoma cancer, we manually explored free and coded texts to determine the durations of the primary care (IPC) and secondary care (ISC) diagnostic intervals during the first COVID-19 wave and pre-COVID-19. We found that the median IPC duration increased for colorectal cancer from 5 days (Interquartile Range (IQR) 1-29 days) pre-COVID-19 to 44 days (IQR 6-230, p < 0.01) during the first COVID-19 wave, and for lung cancer, the duration increased from 15 days (IQR) 3-47) to 41 days (IQR 7-102, p < 0.01). For breast cancer and melanoma, the change in IPC duration was negligible. The median ISC duration only increased for breast cancer, from 3 (IQR 2-7) to 6 days (IQR 3-9, p < 0.01). For colorectal cancer, lung cancer, and melanoma, the median ISC durations were 17.5 (IQR (9-52), 18 (IQR 7-40), and 9 (IQR 3-44) days, respectively, similar to pre-COVID-19 results. In conclusion, for colorectal and lung cancer, the time to primary care referral was substantially prolonged during the first COVID-19 wave. In such crises, targeted primary care support is needed to maintain effective cancer diagnosis.

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Introduction: In the Netherlands, the onset of the coronavirus pandemic saw shifts in primary health service provision away from physical consultations, cancer-screening programs were temporarily halted, and government messaging focused on remaining at home. In March and April 2020, weekly cancer diagnoses decreased to 73% of their pre-COVID levels, and 39% for skin cancer. This study aims to explore the effect of the COVID pandemic on patient presentations for cancer-related symptoms in primary care in The Netherlands. Methods: Retrospective cohort study using routine clinical primary care data. Monthly incidences of patient presentations for cancer-related symptoms in five clinical databases in The Netherlands were analysed from March 2018 to February 2021. Results: Data demonstrated reductions in the incidence of cancer-related symptom presentations to primary care during the first COVID wave (March-June 2020) of -34% (95% CI: -43 to -23%) for all symptoms combined. In the second wave (October 2020-February 2021) there was no change in incidence observed (-8%, 95% CI -20% to 6%). Alarm-symptoms demonstrated decreases in incidence in the first wave with subsequent incidences that continued to rise in the second wave, such as: first wave: breast lump -17% (95% CI: -27 to -6%) and haematuria -15% (95% CI -24% to -6%); and second wave: rectal bleeding +14% (95% CI: 0 to 30%) and breast lump +14% (95% CI: 2 to 27%). Presentations of common non-alarm symptom such as tiredness and naevus demonstrated decreased in-cidences in the first wave of 45% (95% CI: -55% to -33%) and 37% (95% CI -47% to -25%). In the second wave, tiredness incidence was reduced by 20% (95% CI: -33% to -3%). Subgroup analy-sis did not demonstrate difference in incidence according to sex, age groups, comorbidity status, or previous history of cancer. Conclusions: These data describe large-scale primary care avoidance that did not increase until the end of the first COVID year for many cancer-related symptoms, suggestive that substantial numbers of patients delayed presenting to primary care. For those patients who had underlying cancer, this may have had impacted the cancer stage at diagnosis, treatment, and mortality.

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Background: To describe general practitioners (GPs) experiences with the impact COVID-19 on the duration of cancer detection. Methods: Cross-sectional survey study among Dutch GPs. Results: Fifty-eight GPs participated. During the first wave, COVID-19-related delays were experienced by 88%, 52%, and 67% of GPs in the contact-seeking, primary care, and referral phases, respectively. GPs reported delays due to telehealth consultations, longer waiting times and patient's concerns of COVID infections and overburdening GPs. Conclusions: The majority of GPs experienced delays in cancer diagnostic processes during the beginning of the COVID pandemic, which was most prominent in the timeliness in which patients sought GP care.

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PURPOSE: An optimal diagnostic process in primary care is pivotal for reducing cancer-related disease burden. This study aims to explore reasons for long times to referral for Dutch colorectal cancer (CRC) patients in primary care. METHODS: A retrospective cohort study of anonymized free-text primary care records from the Julius General Practitioners' Network database, linked to the Netherlands Cancer Registry. Patients with a confirmed CRC diagnosis from 2007 through 2011 that symptomatically presented in primary care were included. Median time and interquartile ranges from presentation in primary care to referral were calculated for multiple patient and presentation characteristics. Associations of these characteristics with long time to referral (75th percentile was ≥59 days) were examined with log-binomial regression analyses. Routes to referral of patients with the longest times to referral were explored using thematic free-text analyses (90th percentile at ≥219 days). RESULTS: Among the 309 people with CRC, patients who were female, did not have a registered family history, had a history of malignancy, lacked alarm symptoms at presentation, or had hemorrhoids at physical examination were at risk for longer time to referral in univariable analyses (longer median durations and/or univariable association with the 75th percentile). Only presentation without alarm symptoms showed a statistically significant association with long duration (75th percentile) in multivariable analysis (relative risk = 1.7; 95% CI, 1.1-2.6). Thematic exploration of the diagnostic routes to referral of patients with the longest durations (90th percentile) showed 2 dominating themes: "alternative working diagnosis" and "suboptimal diagnostic strategies," and included the sub-themes "omitting to reconsider an initial diagnosis" and "lacking follow-up." CONCLUSIONS: Long time to referral for CRC in primary care is mainly related to low cancer suspicion. There is potential for reducing the longest times to referral for patients with CRC in primary care, with earlier reconsideration of the initial hypothesis and implementation of strict follow-up consultations.

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BACKGROUND & AIM: Reducing the duration of the diagnostic cancer care pathway is intensively pursued. The aim of this study was to chart the diagnostic pathway for the five most common cancers in the Netherlands. METHODS: A retrospective cohort study using cancer patients' anonymised primary care data (free text and coded) linked to the Netherlands Cancer Registry. We determined the median duration of the following: 1. Primary care intervals (IPCs): the first cancer-related general practitioner consultation to referral, 2. Referral intervals (IRs): referral to diagnosis, 3. Treatment intervals (ITs): diagnosis to treatment and the overarching intervals, 4. Diagnostic intervals (IDs): IPC and IR combined and 5. Health care intervals (IHCs): IPC, IR and IT combined. RESULTS: For 465, 309, 197, 237 and 149 patients diagnosed with breast-, colorectal-, lung-, prostate cancer and melanoma, respectively; median IPC, IR and ID durations were shortest for breast cancer and melanoma (ID duration 7 and 21 days, respectively), intermediate for lung- and colon cancer (ID duration 49 and 54 days) and the longest for prostate cancer (ID duration 137 days). For all cancers, the duration of intervals increased steeply for the 10-25% with longest durations. For colorectal cancer, increasing ID durations showed increasing proportions of time attributable to primary care (IPC). CONCLUSION: Approximately 10-25% of cancer patients show substantially long duration of diagnostic intervals. Reducing primary care delay seems particularly relevant for colorectal cancer.

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OBJECTIVE: The aim of this study was to gain better insight into the quality of patient participation in the development of clinical practice guidelines and to contribute to approaches for the monitoring and evaluation of such initiatives. In addition, we explore the potential of a dialogue-based approach for reconciliation of preferences of patients and professionals in the guideline development processes. METHODS: The development of the Multidisciplinary Guideline for Employment and Severe Mental Illness in the Netherlands served as a case study. Methods for patient involvement in guideline development included the following: four patient representatives in the development group and advisory committee, two focus group discussions with patients, a dialogue session and eight case studies. To evaluate the quality of patient involvement, we developed a monitoring and evaluation framework including both process and outcome criteria. Data collection included observations, document analysis and semi-structured interviews (n = 26). RESULTS: The quality of patient involvement was enhanced using different methods, reflection of patient input in the guideline text, a supportive attitude among professionals and attention to patient involvement throughout the process. The quality was lower with respect to representing the diversity of the target group, articulation of the patient perspective in the GDG, and clarity and transparency concerning methods of involvement. CONCLUSIONS: The monitoring and evaluation framework was useful in providing detailed insights into patient involvement in guideline development. Patient involvement was evaluated as being of good quality. The dialogue-based approach appears to be a promising method for obtaining integrated stakeholder input in a multidisciplinary setting.

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BACKGROUND: In acute cough patients, impaired lung function as present in chronic lung conditions like asthma and chronic obstructive pulmonary disease (COPD) are often thought to negatively influence course of disease, but clear evidence is lacking. AIMS: To investigate the influence of lung function abnormalities on course of disease and response to antibiotic therapy in primary care patients with acute cough. METHODS: A total of 3,104 patients with acute cough (⩽28 days) were included in a prospective observational study with a within-nested trial, of which 2,427 underwent spirometry 28-35 days after inclusion. Influence of the lung function abnormalities fixed obstruction (forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) ratio <0.7) and bronchodilator responsiveness (FEV1 increase of ⩾12% or 200 ml after 400 µg salbutamol) on symptom severity, duration and worsening were evaluated using uni- and multivariable regression models. Antibiotic use was defined as the reported use of antibiotics ⩾5 days in the first week. Interaction terms were calculated to investigate modifying effects of lung function on antibiotic effect. RESULTS: The only significant association was the effect of severe airway obstruction on symptom severity on days 2-4 (difference=0.31, 95% confidence interval (CI)=0.03-0.60, P=0.03). No evidence of a differential effect of lung function on the effect of antibiotics was found. Prior use of inhaled steroids was associated with a 30% slower resolution of symptoms rated 'moderately bad' or worse (hazard ratio=0.75, 95% CI=0.63-0.90, P=0.00). CONCLUSIONS: In adult patients with acute cough, lung function abnormalities were neither significantly associated with course of disease nor did they modify the effect of antibiotics.

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OBJECTIVE: To assess the diagnostic value of fever and facial and dental pain in adults suspected of acute bacterial rhinosinusitis. DATA SOURCES: PubMed, EMBASE, and the Cochrane Library. REVIEW METHODS: A comprehensive systematic search was performed on March 18, 2013. We included articles reporting studies on the diagnostic value of fever or facial and dental pain in patients suspected of acute bacterial rhinosinusitis. For included articles, the reported study design was assessed for directness of evidence and risk of bias. Prevalences, positive predictive values, and negative predictive values were extracted. RESULTS: Of 3171 unique records, we included 1 study with a high directness of evidence and a moderate risk of bias. The prior probability of bacterial rhinosinusitis was 0.29 (95% confidence interval: 0.24 to 0.35). We could not extract posterior probabilities with accompanying positive and negative predictive values. The study reported an odds ratio from univariate analysis for fever of 1.02 (0.52 to 2.00) and 1.65 (0.83 to 3.28) for facial and dental pain. In subsequent multivariate analysis, the odds ratio of facial and dental pain was 1.86 (1.06 to 3.29). CONCLUSION AND RECOMMENDATION: There is 1 study with moderate risk of bias, reporting data in such a manner that we could not assess the value of fever and facial and dental pain in adults suspected of an acute bacterial rhinosinusitis. Therefore, these symptoms should not be used in clinical practice to distinguish between a bacterial and viral source of acute rhinosinusitis or for decision making about prescribing antibiotic treatment.

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This retrospective study evaluates the impact of postoperative antiepileptic drug (AED) withdrawal on psychomotor speed in seizure-free children, operated for medically refractory epilepsy. Post-surgical medication policy and neuropsychological assessments (performed shortly before and 6, 12 and 24 months after surgery), were evaluated in 57 children (32 female, median age at surgery 13 years). Patients were divided into a withdrawal (n=29) and a no-withdrawal group (n=28). Scores of four psychomotor tests performed at 12 and 24 months after surgery were compared with those of postoperative baseline measurements, performed 6 months after surgery. At 24 months, the withdrawal group had improved significantly more than the no-withdrawal group on three of four tests; reaction time to light (p=0.031), reaction time to sound (p=0.045) and tapping (p=0.003). At 12 months, a non-significant tendency in the same direction was found for both reaction time tests. Drug withdrawal after surgery improves psychomotor speed and may unleash the potential for cognitive improvement.

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OBJECTIVE: This article describes the results of a qualitative study on the training and employment of consumer provider employees in Dutch mental health care. METHODS: The authors used semi-structured interviews with students, graduates/employees, teachers, team managers, colleagues and clients to assess their experiences with the college program. RESULTS: The college program succeeds in preparing the consumer students for their role as consumer provider employees in mental health teams. In the peer support and recovery program and supervision, students learn to develop their recovery story, to apply their experiences in practice, and to deal with challenges. CONCLUSIONS: Coaching and supervision are essential to help consumer providers in their specific role, to deal with dilemmas and to facilitate open dialogue. Teams need to be adequately prepared by informing them on the requirements of the college program and the role of consumer providers.

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OBJECTIVE: This brief report addresses the systematic implementation of skills training modules for persons with schizophrenia or related disorders in three Dutch mental health agencies. METHODS: Information on barriers, strategies and integration into routine daily practice was gathered at 0, 12 and 24 months through interviews with managers, program leaders, trainers, practitioners and clients. RESULTS: Overall implementation of the skills training modules for 74% of the persons with schizophrenia or related disorders was not feasible. Implementation was impeded by an incapable program leader, organizational changes, disappointing referrals and loss of trainers. The agencies made important steps forward to integrate the modules into routine daily practice. CONCLUSIONS: A reach percentage of 74% in two years time is too ambitious and needs to be adjusted. Systematic integration of the modules into routine daily practice is feasible, but requires solid program management and continuous effort to involve clients and practitioners.

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OBJECTIVE: This article reports on the implementation of the individual placement and support model of supported employment in four Dutch regions. METHODS: The authors used structured site visits, employment data, and semistructured interviews to assess fidelity, employment outcomes, and facilitators of and barriers to successful implementation. RESULTS: At 24 months, the four sites reached a mean+/-SD fidelity score of 4.1+/-.3 (possible scores range from 1 to 5, with higher scores indicating closer adherence to the model). Of the 316 persons with mental illnesses, 57 (18%) obtained competitive jobs. Barriers to implementation included lack of organizational standards, loss of vocational staff, funding problems, insufficient time for program leaders, and inadequate cooperation between the involved organizations. Important facilitators were the skills and commitment of the vocational team members and the integration of vocational and mental health staff. CONCLUSIONS: To implement evidence-based supported employment in the Netherlands will require changes in financing, organizational structures, attitudes, cultural beliefs, and labor and disability regulations.

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