N MANY COUNTRIES, THE NUMBER OF diagnostic tests ordered by primary care physicians is growing, while according to established evidence-based guidelines, many of these tests are seen as unnecessary. [1][2][3] Possible explanations are test ordering routines that are difficult to change, a more defensive attitude among primary care physicians out of fear of medical errors, or a lack of knowledge about the appropriate use of tests. [4][5][6][7] Moreover, patients more actively ask for tests and often attach greater value to test results than is justified by the facts. 8,9 Unfortunately, little is yet known about the negative effects of performing such tests, in terms of, for example, unnecessary exposure to radiation or false-positive results, that may induce fear and anxiety in patients or may result in a cascade of unnecessary further testing.Given these problems it is challenging to learn how to change test ordering performance effectively and bring it into line with existing evidence or guidelines on optimal testing. Many such attempts have been made with mixed results, showing that successful strategies require a well-balanced Author Affiliations are listed at the end of this article.

Lucas AEM, Smeenk FWJM, Smeele IJ and van Schayck CP. Overtreatment with inhaled corticosteroids and diagnostic problems in primary care patients, an exploratory study. Family Practice 2008; 25: 86-91.Background. Underdiagnosis and undertreatment of patients with asthma or chronic obstructive pulmonary disease are widely discussed in the literature. Not much is known about the possible overdiagnosis and consequently the overtreatment with inhaled corticosteroids (ICS). Aim. This study investigates how often ICS are prescribed without a proper indication and how big the diagnostic problem is caused by inappropriate prescription and use of ICS.Methods. All patients referred to a primary care diagnostic centre during 6 months who used ICS without a clear indication were included. Their GPs were questioned about the reasons for prescribing ICS. If still no diagnosis could be assessed, GPs were advised to stop ICS and renew spirometry after a steroid-free period of at least 3 months. After 1 year, the use of ICS was evaluated and the diagnoses were reassessed.Results. Of all referred patients (2271), 1171 used ICS, 505 (30%) without a clear indication. After 1 year, final results showed that 11% of all patients originally using ICS had no indication to use ICS and had successfully ceased using this mediation. For 15%, the reasons for using ICS remained unclear.Conclusions. Overtreatment with ICS in primary care seems to be considerable, which falsely labels patients as asthmatic and which generates unnecessary costs and possible side effects. The awareness of GPs of the need for proper diagnostic testing before prescribing ICS needs to be improved. Overtreatment with ICS in primary care patients can be diminished by systematically supporting the GP in the diagnostic procedures and decision making.

The aim of the present study was to establish the agreement between two recommended definitions of airflow obstruction in symptomatic adults referred for spirometry by their general practitioner, and investigate how rates of airflow obstruction change when prebronchodilator instead of post-bronchodilator spirometry is performed.The diagnostic spirometric results of 14,056 adults with respiratory obstruction were analysed. Differences in interpretation between a fixed 0.70 forced expiratory volume in one second (FEV1)/ forced vital capacity (FVC) cut-off point and a sex-and age-specific lower limit of normal cut-off point for this ratio were investigated.Of the subjects, 53% were female and 69% were current or ex-smokers. The mean postbronchodilator FEV1/FVC was 0.73 in males and 0.78 in females. The sensitivity of the fixed relative to the lower limit of normal cut-off point definition was 97.9%, with a specificity of 91.2%, positive predictive value of 72.0% and negative predictive value of 99.5%. For the subgroup of current or ex-smokers aged o50 yrs, these values were 100, 82.0, 69.2 and 100%, respectively. The proportion of false positive diagnoses using the fixed cut-off point increased with age. The positive predictive value of pre-bronchodilator airflow obstruction was 74.7% among current or ex-smokers aged o50 yrs.The current clinical guideline-recommended fixed 0.70 forced expiratory volume in one second/ forced vital capacity cut-off point leads to substantial overdiagnosis of obstruction in middle-aged and elderly patients in primary care. Using pre-bronchodilator spirometry leads to a high rate of false positive interpretations of obstruction in primary care.KEYWORDS: Chronic obstructive pulmonary disease, diagnostics, lung function measurements, primary care C hronic obstructive pulmonary disease (COPD) is a respiratory condition that is predominantly caused by smoking, and is characterised by airflow obstruction that is progressive in nature and not fully reversible [1]. Recent estimates for the population prevalence of COPD in adults aged .40 yrs range 11-26% for countries throughout the world [2]. As the majority of patients with COPD are diagnosed and managed in primary care, timely diagnosis and subsequent staging both require primary care spirometry in order to confirm the presence and severity of airflow obstruction [3].Airflow obstruction in COPD is present when a patient shows a disproportionate reduction in the maximal airflow from the lungs in relation to the maximal volume that can be displaced from the lungs [4]. According to current COPD guideline recommendations for primary [5,6] and secondary care [1,7,8], this is determined by measuring the forced expiratory volume in one second (FEV1)/forced vital capacity (FVC) ratio. Without exception, the guidelines recommend a fixed 0.70 cut-off point for FEV1/FVC in deciding whether or not airflow obstruction is present, regardless of the sex and age of the subject involved. However, it is well documented that ageing is associated wi...

ObjectivesHealthcare costs and usage are rising. Evidence-based online health information may reduce healthcare usage, but the evidence is scarce. The objective of this study was to determine whether the release of a nationwide evidence-based health website was associated with a reduction in healthcare usage.DesignInterrupted time series analysis of observational primary care data of healthcare use in the Netherlands from 2009 to 2014.SettingGeneral community primary care.Population912 000 patients who visited their general practitioners 18.1 million times during the study period.InterventionIn March 2012, an evidence-based health information website was launched by the Dutch College of General Practitioners. It was easily accessible and understandable using plain language. At the end of the study period, the website had 2.9 million unique page views per month.Main outcomes measuresPrimary outcome was the change in consultation rate (consultations/1000 patients/month) before and after the release of the website. Additionally, a reference group was created by including consultations about topics not being viewed at the website. Subgroup analyses were performed for type of consultations, sex, age and socioeconomic status.ResultsAfter launch of the website, the trend in consultation rate decreased with 1.620 consultations/1000 patients/month (p<0.001). This corresponds to a 12% decline in consultations 2 years after launch of the website. The trend in consultation rate of the reference group showed no change. The subgroup analyses showed a specific decline for consultations by phone and were significant for all other subgroups, except for the youngest age group.ConclusionsHealthcare usage decreased by 12% after providing high-quality evidence-based online health information. These findings show that e-Health can be effective to improve self-management and reduce healthcare usage in times of increasing healthcare costs.

Our hypothesis that COPD patients on the mild side of the severity spectrum differ from patients on the severe side regarding the association between their bronchodilator flow and volume responses was confirmed. The difference is probably explained by the higher degree of loss of lung elastic recoil and/or compression of the smaller airways due to enlarged air spaces that accompanies the progression of COPD to the more severe stages.