Innovations in diagnosing patients with acute abdominal pain in primary care.

Abdominal pain is one of the most common complaints of patients in primary care, accounting for 10% of all presentations in general practice. Abdominal pain can be caused by a variety of conditions, ranging from acutely life-threatening to benign and self-limiting, most frequently acute gastro-enteritis, appendicitis, choledocholithiasis, acute pancreatitis and neoplasms. Overall mortality rates are approximately 3% in general practice. Physicians working in primary care deal with high patient volumes and have to make decisions amid uncertainty. The diagnostic process is complicated by low prevalence of serious disease, undifferentiated symptoms, a high degree of symptom overlap between serious and benign conditions, patients presenting with multiple complaints, and psychological or social distress manifesting somatically, resulting in missed, delayed or wrong diagnoses. Abdominal pain is the most common reason for referral from primary to secondary care. In the process of diagnosing patients in primary care, additional tests such as imaging or lab-based blood tests do not provide results quickly enough to influence acute clinical decision making. In contrast, point-of-care tests provide immediate diagnostic information. The most widely studied point-of-care test is C-reactive protein, which has been shown to be able to rule out serious infections in children and can be used to safely decrease antibiotic prescribing. In patients with abdominal pain, CRP has diagnostic value for appendicitis and diverticulitis. In addition there is a growing interest in point-of-care ultrasound in primary care. Technological advances make it more accurate, cheaper and more accessible for use in primary care. Preliminary evidence suggests that POCUS could be an important tool for primary care physicians and may possibly reduce health care costs. Adding POCUS to the examination of selected patients leads to improved and earlier diagnosis in emergency departments. Throughout this PhD we will investigate and aim to strengthen the diagnostic process of patients presenting with abdominal pain to primary care physicians. We will assess the diagnostic accuracy of clinical features and diagnostic tests for diagnosing acute abdominal pain currently used in primary care. In addition, due to this growing interest in point-of-care tests, we aim to assess indications, impact, barriers and facilitating factors of point-of-care ultrasound in primary care. Self-evidently focusing on implementation of point-of-care ultrasound in patients with acute abdominal pain in primary care. Finally we aim to develop a diagnostic model for patients with acute abdominal pain in presenting to primary care, i.e. a clinical prediction rule, designed to excludes serious conditions and therefore decreases inappropriate referrals. Assessing the diagnostic value of promising diagnostic tests gathered throughout obtaining the previous described research goals, for instance POCUS, point-of-care CRP, and specific signs, symptoms, imaging tests and lab-based blood tests.