Background

To improve the management of hip or knee osteoarthritis (OA), a multidisciplinary guideline-based stepped-care strategy (SCS) with recommendations regarding the appropriate non-surgical treatment modalities and optimal sequence for care has been developed. Implementation of this SCS in the general practice may be hampered by the negative attitude of general practitioners (GPs) towards the strategy. In order to develop a tailored implementation plan, we assessed the GPs’ views regarding specific recommendations in the SCS and their working procedures with regard to OA.

Methods

A survey was conducted among a random sample of Dutch GPs. Questions included the GP’s demographical characteristics and the practice setting as well as how the management of OA was organized and whether the GPs supported the SCS recommendations. In particular, we assessed GP’s views regarding the effectiveness of 14 recommended and non-recommended treatment modalities. Furthermore, we calculated their agreement with 7 statements based on the SCS recommendations regarding the sequence for care. With a linear regression model, we identified factors that seemed to influence the GPs’ agreement with the SCS recommendations.

Results

Four hundred fifty-six GPs (37%) aged 30–65 years, of whom 278 males (61%), responded. Seven of the 11 recommended modalities (i.e. oral Non-Steroidal Anti-Inflammatory Drugs, physical therapy, glucocorticoid intra-articular injections, education, lifestyle advice, acetaminophen, and tramadol) were considered effective by the majority of the GPs (varying between 95-60%). The mean agreement score, based on a 5-point scale, with the recommendations regarding the sequence for care was 2.8 (SD = 0.5). Ten percent of the variance in GPs’ agreement could be explained by the GPs’ attitudes regarding the effectiveness of the recommended and non-recommended non-surgical treatment modalities and the type of practice.

Conclusion

In general, GPs support the recommendations in the SCS. Therefore, we expect that their attitudes will not impede a successful implementation in general practice. Our results provide several starting points on which to focus implementation activities for specific SCS recommendations; those related to the prescription of pain medication and the use of X-rays. We could not identify factors that contribute substantially to GPs’ attitudes regarding the SCS recommendations regarding the sequence for care.

Background

To describe the current treatment gap in management of cardiovascular risk factors in patients with poorly controlled type 2 diabetes in general practice as well as the associated financial and therapeutic burden of pharmacological treatment.

Methods

Cross-sectional analysis of data from the Patient Engagement and Coaching for Health trial. This totalled 473 patients from 59 general practices with participants eligible if they had HbA1c > 7.5%. Main outcome measures included proportions of patients not within target risk factor levels and weighted average mean annual cost for cardiometabolic medications and factors associated with costs. Medication costs were derived from the Australian Pharmaceutical Benefits Schedule.

Results

Average age was 63 (range 27-89). Average HbA1c was 8.1% and average duration of diabetes was 10 years. 35% of patients had at least one micro or macrovascular complication and patients were taking a mean of 4 cardio-metabolic medications. The majority of participants on treatment for cardiovascular risk factors were not achieving clinical targets, with 74% and 75% of patients out of target range for blood pressure and lipids respectively. A significant proportion of those not meeting clinical targets were not on treatment at all. The weighted mean annual cost for cardiometabolic medications was AUD$1384.20 per patient (2006-07). Independent factors associated with cost included age, duration of diabetes, history of acute myocardial infarction, proteinuria, increased waist circumference and depression.

Conclusions

Treatment rates for cardiovascular risk factors in patients with type 2 diabetes in our participants are higher than those identified in earlier studies. However, rates of achieving target levels remain low despite the large ‘pill burden’ and substantial associated fiscal costs to individuals and the community. The complexities of balancing the overall benefits of treatment intensification against potential disadvantages for patients and health care systems in primary care warrants further investigation.

Background

Family history (FH) is considered an important factor to detect individuals at increased risk developing type 2 diabetes (T2D). Moreover, FH information could be used to personalise risk messages, which are assumed to increase risk-reducing behaviours. In this study, we aimed to explore Dutch health care professionals’ attitudes regarding current or future uptake of a more extensive use of FH information and the family system in diabetes prevention.

Methods

Semi-structured interviews were conducted with nineteen health care professionals from six general practices and four outpatient diabetes clinics. The use of FH information in opportunistic screening for T2D was explored, as well as the usability of a direct versus patient-mediated targeting strategy to reach persons with a FH of T2D. Three researchers analysed the interview transcripts separately.

Results

Dutch health care professionals considered FH an important risk factor in opportunistic screening for T2D. However, none of them used FH to promote risk-reducing behaviours. Directly targeting and educating patients known to have a FH of T2D was desirable for most primary care professionals, but not considered feasible. Findings indicated that FH information was not systematically gathered in primary care settings and electronic medical records were not equipped to retrieve persons with T2D running in their family. The idea of asking patients to pass on risk and preventive information was new to all interviewees, but was considered an acceptable strategy to reach persons with a FH of diabetes. Nevertheless, there were concerns about the accuracy of the messages delivered by the patients to their relatives. Practical barriers with regard to time, expertise, and financial reimbursement were also mentioned.

Conclusions

There is great interest among healthcare professionals in primary as well as secondary care about the use of FH to prevent T2D, but there are significant barriers against such use. The removal of these barriers would depend on evidence showing the cost-effectiveness of FH-based strategies designed to prevent T2D.

Contributing reviewers

The editors of BMC Family Practice would like to thank all the reviewers who have contributed to the journal in volume 13 (2012).

Background

Fragmentation within health care systems may negatively impact the quality of chronic disease patient care. We sought to evaluate the relationship between care management processes (CMP), integration of services, and blood pressure (BP) control among diabetic patients.

Methods

Retrospective chart reviews were performed for a random sample of adult diabetic hypertensive patients (n = 2,162) from 28 physician organizations in the United States (US). A modified version of the Physician Practice Connection Readiness Survey (PPC-RS) was completed by the chief medical officer at each site. The PPC-RS measured health system organization, delivery system redesign, decision support, clinical information systems, and self-management support, and an integration scale measured structure, functions, and financial risk. Correlations between PPC and integration scores and BP outcomes were assessed using Spearman correlation coefficients.

Results

Approximately 39.9% of diabetic patients had controlled BP. Mean total PPC score across sites was 55, with highest mean scores for health system organization (81), followed by design support (60), clinical information systems (57), self-management support (39), and delivery system redesign (39). Mean integration score was 46 (SD 27, range 4–93), and means of subscores were 64 for structure, 33 for financial risk, and 42 for function. Clinical information systems subscore was correlated with uncontrolled BP (r = −0.38, p < 0.05), while association with total PPC score was strong but not significant at p < 0.05 (r = −0.32). Total integration score and the structure subscore were significantly correlated with BP control (r = 0.38, p < 0.05, and r = 0.49, p < 0.01).

Conclusions

This study suggests that CMP and service integration may be associated with better outcomes in diabetes, though results were mixed and limited by a small number of participating sites. Primary care implementation of integrated electronic medical records may have a beneficial effect on patient outcomes for diabetes and other chronic diseases.

Background

This study updated our knowledge of UK primary care neuropathic pain incidence rates and prescribing practices.

Methods

Patients with a first diagnosis of post-herpetic neuralgia (PHN), painful diabetic neuropathy (PDN) or phantom limb pain (PLP) were identified from the General Practice Research Database (2006 – 2010) and incidence rates were calculated. Prescription records were searched for pain treatments from diagnosis of these conditions and the duration and daily dose estimated for first-line and subsequent treatment regimens. Recording of neuropathic back and post-operative pain was investigated.

Results

The study included 5,920 patients with PHN, 5,340 with PDN, and 185 with PLP. The incidence per 10,000 person-years was 3.4 (95% CI 3.4, 3.5) for PHN; and 0.11 (95% CI 0.09, 0.12) for PLP. Validation of the PDN case definition suggested that was not sensitive. Incident PHN increased over the study period. The most common first-line treatments were amitriptyline or gabapentin in the PDN and PLP cohorts, and amitriptyline or co-codamol (codeine-paracetamol) in PHN. Paracetamol, co-dydramol (paracetamol-dihydrocodeine) and capsaicin were also often prescribed in one or more condition. Most first-line treatments comprised only one therapeutic class. Use of antiepileptics licensed for neuropathic pain treatment had increased since 2002–2005. Amitriptyline was the only antidepressant prescribed commonly as a first-line treatment.

Conclusion

The UK incidence of diagnosed PHN has increased with the incidence of back-pain and post-operative pain unclear. While use of licenced antiepileptics increased, prescribing of therapy with little evidence of efficacy in neuropathic pain is still common and consequently treatment was often not in-line with current guidance.

Background

An important consideration in health service delivery is ensuring that services meet consumer needs and that consumers are satisfied with service delivery. Patient satisfaction can impact on compliance with suggested treatments and therefore impact on health outcomes. Comparatively few studies have explored consumer satisfaction with nurses in general practice.

Methods

A sub-group of 18 consumers from a larger quantitative evaluation of consumer satisfaction with New Zealand general practice nurses participated in semi-structured telephone interviews. Interview data was analysed using thematic analysis.

Results

Four major themes emerged from the data. These themes highlighted that, despite confusion experienced by some consumers regarding the practice nurse role, consumers were happy with the level of care provided by them. Consumers felt valued by Practice Nurses and considered them competent and highly knowledgeable. Findings also convey that consumers appreciate the accessibility and financial benefits of utilising the services of practice nurses.

Conclusions

Consumers are highly satisfied with practice nurse service delivery and value their relationships with these health professionals. Consumers revealed that greater clarity around the practice nurse role and their scope of practice may enhance their utilisation. Spreading the message of practice nurses being the right person to deliver care, within their scope of practice, at the right time may have the potential to provide more timely care within the primary care setting.

Background

Family Physician (FP) trainees are expected to be provided with high quality training in well organized practice settings. This study examines differences between FP trainers and non-trainers and their practices to see whether there are differences in trainers and non-trainers and in how their practices are organized and their services are delivered.

Method

203 practices (88 non-training and 115 training) with 512 FPs (335 non-trainers and 177 trainers) were assessed using the “Visit Instrument Practice organization (VIP)” on 369 items (142 FP-level; 227 Practice level). Analyses (ANOVA, ANCOVA) were conducted for each level by calculating differences between FP trainees and non-trainees and their host practices.

Results

Trainers scored higher on all but one of the items, and significantly higher on 47 items, of which 13 remained significant after correcting for covariates. Training practices scored higher on all items and significantly higher on 61 items, of which 23 remained significant after correcting for covariates. Trainers (and training practices) provided more diagnostic and therapeutic services, made better use of team skills and scored higher on practice organization, chronic care services and quality management than non-training practices. Trainers reported more job satisfaction and commitment and less job stress than non-trainers.

Discussion

There are positive differences between FP trainers and non-trainers in both the level and the quality of services provided by their host practices. Training institutions can use this information to promote the advantages of becoming a FP trainer and training practice as well as to improve the quality of training settings for FPs.

Background

Pulmonary Rehabilitation for moderate Chronic Obstructive Pulmonary Disease in primary care could improve patients’ quality of life.

Methods

This study aimed to assess the efficacy of a 3-month Pulmonary Rehabilitation (PR) program with a further 9 months of maintenance (RHBM group) compared with both PR for 3 months without further maintenance (RHB group) and usual care in improving the quality of life of patients with moderate COPD.

We conducted a parallel-group, randomized clinical trial in Majorca primary health care in which 97 patients with moderate COPD were assigned to the 3 groups. Health outcomes were quality of life, exercise capacity, pulmonary function and exacerbations.

Results

We found statistically and clinically significant differences in the three groups at 3 months in the emotion dimension (0.53; 95%CI0.06-1.01) in the usual care group, (0.72; 95%CI0.26-1.18) the RHB group (0.87; 95%CI 0.44-1.30) and the RHBM group as well as in fatigue (0.47; 95%CI 0.17-0.78) in the RHBM group. After 1 year, these differences favored the long-term rehabilitation group in the domains of fatigue (0.56; 95%CI 0.22-0.91), mastery (0.79; 95%CI 0.03-1.55) and emotion (0.75; 95%CI 0.17-1.33). Between-group analysis only showed statistically and clinically significant differences between the RHB group and control group in the dyspnea dimension (0.79 95%CI 0.05-1.52). No differences were found for exacerbations, pulmonary function or exercise capacity.

Conclusions

We found that patients with moderate COPD and low level of impairment did not show meaningful changes in QoL, exercise tolerance, pulmonary function or exacerbation after a one-year, community based rehabilitation program. However, long-term improvements in the emotional, fatigue and mastery dimensions (within intervention groups) were identified.

Trial registration

ISRCTN94514482

Background

The number of chronically ill patients increases every year. This is partly due to an unhealthy lifestyle. However, the frequency and quality of (evidence-based) health promotion activities conducted by Dutch general practitioners (GPs) and practice nurses (PNs) are limited. The aim of this pilot study was to explore which lifestyle interventions Dutch GPs and PNs carry out in primary care, which barriers and facilitators can be identified and what main topics are with respect to attitudes towards health promoting activities. These topic areas will be identified for a future, larger scale study.

Method

This qualitative study consisted of 25 semi-structured interviews with sixteen GPs and nine PNs. ATLAS.ti was used to analyse the transcripts of the interviews.

Results

All GPs and PNs said they discuss lifestyle with their patients. Next to this, GPs and PNs counsel patients, and/or refer them to other disciplines. Only few said they refer patients to specific lifestyle programs or interventions in their own practice or in the neighbourhood. Several barriers and facilitators were identified. The main topics as barriers are: a lack of patients’ motivation to make lifestyle changes, insufficient reimbursement, a lack of proven effectiveness of interventions and a lack of overview of health promoting programs in their neighbourhood. The most cited facilitators are availability of a PN, collaboration with other disciplines and availability of interventions in their own practice. With respect to attitudes, six different types of GPs were identified reflecting the main topics that relate to attitudes, varying from ‘ignorer’ to ‘nurturer’. The topics relating to PNs attitudes towards health promotion activities, were almost unanimously positive.

Conclusion

GPs and PNs all say they discuss lifestyle issues with their patients, but the health promotion activities that are organized in their practice vary. Main topics that hinder or facilitate implementation are identified, including those that relate to attitudes of GPs and PNs.

Background

Identification of pregnant women susceptible to rubella is important as vaccination can be given postpartum to prevent future risks of congenital rubella syndrome. However, in Malaysia, rubella antibody screening is not offered routinely to pregnant women in public funded health clinics due to cost constraint. Instead, a history of rubella vaccination is asked to be provided to establish the women’s risk for rubella infection. The usefulness of this history, however, is not established. Thus, this paper aimed to determine the usefulness of a history of rubella vaccination in determining rubella susceptibility in pregnant women.

Methods

A cross-sectional study was conducted on 500 pregnant women attending a public funded health clinic. Face-to-face interviews were conducted, and demographic data and history of rubella vaccination were obtained. Anti-rubella IgG test was performed.

Results

A majority of the women (66.6%) had a positive vaccination history. Of these, 92.2% women were immune. A third (33.4%) of the women had a negative or unknown vaccination history, but 81.4% of them were immune to rubella. The sensitivity and specificity of a history of rubella vaccination in identifying disease susceptibility was 54.4% (95% CI: 40.7, 67.4%) and 69.3% (95% CI: 64.7, 73.5%) respectively; the positive predictive value was 18.6% (95% CI: 13.1, 25.5%) and the negative predictive value was 92.2% (95% CI: 88.6, 94.7%).

Conclusions

A vaccination history of rubella had a poor diagnostic value in predicting rubella susceptibility. However, obtaining a vaccination history is inexpensive compared with performing a serological test. A cost-utility analysis would be useful in determining which test (history versus serological test) is more cost-effective in a country with resource constraint.

Background

Hypertension prevalence is high in China, while patients’ levels of hypertension awareness, treatment and control are low. General practitioners’ knowledge and training relating to hypertension prevention may be an important related factor. We aimed to investigate general practitioners’ knowledge of hypertension prevention and potential training needs.

Methods

A questionnaire survey was conducted among all general practitioners at five community health service centers selected by convenience sampling. A total of 160 questionnaires were distributed and 147 were returned (response rate 91.9%) The questionnaire included general information; 12 subjective questions on health promotion, education and training needs; and 19 objective questions in 5 domains (epidemiology, diagnosis, treatment, referral and community management) measuring knowledge of hypertension prevention and treatment.

Results

The major difficulties in health education practice for general practitioners were poor patient compliance (77.6%) and lack of medical consultation time (49.0%). The average accuracy rate of hypertension prevention knowledge was 49.2%, ranging from 10.5% to 94.7%. The factors associated with accuracy rate were physician’s education level (medical university vs. professional school, β = 13.3, P = 0.003), and type of center (training base vs. community healthcare center, β = 12.3, P < 0.0001). Most physicians (87.8%) reported being willing to attend training courses regularly and the preferred frequency was once every 2 ~ 3 months (53.5%). The preferred course was medical treatment of hypertension (82.3%) and the most favored training approach was expert lectures (80.3%).

Conclusions

The knowledge level of hypertension prevention is low among general practitioners in urban settings. Physicians working in community clinics where they participate in a series of teaching, assessing and evaluating systems for hypertension prevention perform better than those in general healthcare centers who lack specific training. Continuing hypertension education is urgently needed to ensure that physicians in general practice are aware of and adhere to the national hypertension prevention guidelines.

Background

Refugees are a particularly vulnerable group in relation to the development of mental illness and many may have been subjected to torture or other traumatic experiences. General practitioners are gatekeepers for access to several parts of the psychiatric system and knowledge of their patients’ refugee background is crucial to secure adequate care. The aim of this study is to investigate how general practitioners experience providing care to refugees with mental health problems.

Methods

The study was conducted as part of an EU project on European Best Practices in Access, Quality and Appropriateness of Health Services for Immigrants in Europe (EUGATE). Semi-structured interviews were carried out with nine general practitioners in the vicinity of Copenhagen purposively selected from areas with a high proportion of immigrants. The analysis of the interviews is inspired by qualitative content analysis.

Results

One of the main themes identified in the analysis is communication. This includes the use of professional interpreters and that communication entails more than sharing a common language. Quality of care is another theme that emerges and includes awareness of possible trauma history, limited possibilities for refugees to participate in certain treatments due to language barriers and feelings of hopelessness in the general practitioners. The general practitioners may also choose different referral pathways for refugees and they report that their patients lack understanding regarding the differences between psychological problems and physical symptoms.

Conclusion

General practitioners experience that providing care to refugees differs from providing care for patients from the majority population. The different strategies employed by the general practitioners in the health care treatment of refugees may be the result of the great diversity in the organisation of general practice in Denmark and the lack of a national strategy in the health care management of refugees. The findings from this study suggest that the development of conversational models for general practitioners including points to be aware of in the treatment of refugee patients may serve as a support in the management of refugee patients in primary care.

Background

There is little information regarding lay-people's representations of influenza and influenza-like illness in their day-to-day lives. An insight into these views may aid our understanding of community attitudes regarding official recommendations for its prevention.

Methods

This was a qualitative research. Semi-structured face-to-face interviews were conducted with 40 French participants from the community, and from five different locations. Questions elicited the participants' representations of onset of flu and influenza-like illness, as well as their views on what can/should be done to deal with symptoms and their personal experience with flu and flu-like symptoms.

Results

Thematic content analyses allowed us to identify five main themes: the presence of a clear continuum between influenza-like illness and flu; a description of flu as a very contagious disease; flu as being benign, except in "frail people", which the respondents never considered themselves to be; interruption of daily activities, which could be considered pathognomonic for influenza for most subjects; self-medication as the main current practice, and requests for healthcare mainly to confirm an auto-diagnosis.

Conclusions

There was a large homogeneity in the representation of flu. There was also a gap between people's representations (i.e., a continuum from having a "cold" to having "influenza") and scientific knowledge (i.e., a distinction between "true" influenza and influenza-like illnesses based on the existence of a confirmatory virological diagnosis). This gap raises issues for current campaigns for flu prevention, as these may not be congruent with the representation of flu being responsible for interrupting daily activities while also being seen as a non-severe disease, as well as the perception that flu is only a risk to "frail people" though no participants considered themselves to be "frail".

Background

Substitute decision-makers are integral to the care of dying patients and make many healthcare decisions for patients. Unfortunately, conflict between physicians and surrogate decision-makers is not uncommon in end-of-life care and this could contribute to a “bad death” experience for the patient and family. We aim to describe Canadian family physicians’ experiences of conflict with substitute decision-makers of dying patients to identify factors that may facilitate or hinder the end-of-life decision-making process. This insight will help determine how to best manage these complex situations, ultimately improving the overall care of dying patients.

Methods

Grounded Theory methodology was used with semi-structured interviews of family physicians in Edmonton, Canada, who experienced conflict with substitute decision-makers of dying patients. Purposeful sampling included maximum variation and theoretical sampling strategies. Interviews were audio-taped, and transcribed verbatim. Transcripts, field notes and memos were coded using the constant-comparative method to identify key concepts until saturation was achieved and a theoretical framework emerged.

Results

Eleven family physicians with a range of 3 to 40 years in clinical practice participated.

The family physicians expressed a desire to achieve a “good death” and described their role in positively influencing the experience of death.

Finding Common Ground to Achieve a “Good Death” for the Patient emerged as an important process which includes 1) Building Mutual Trust and Rapport through identifying key players and delivering manageable amounts of information, 2) Understanding One Another through active listening and ultimately, and 3) Making Informed, Shared Decisions. Facilitators and barriers to achieving Common Ground were identified. Barriers were linked to conflict. The inability to resolve an overt conflict may lead to an impasse at any point. A process for Resolving an Impasse is described.

Conclusions

A novel framework for developing Common Ground to manage conflicts during end-of-life decision-making discussions may assist in achieving a “good death”. These results could aid in educating physicians, learners, and the public on how to achieve productive collaborative relationships during end-of-life decision-making for dying patients, and ultimately improve their deaths.

Background

Calculation of individual risk is the cornerstone of effective cardiovascular prevention. arriba is a software to estimate the individual risk to suffer a cardiovascular event in 10 years. Prognosis and the absolute effects of pharmacological and lifestyle interventions help the patient make a well-informed decision. The risk calculation algorithm currently used in arriba is based on the Framingham risk algorithm calibrated to the German setting. The objective of this study is to evaluate and adapt the algorithm for the target population in primary care in Germany.

Methods/design

arriba-pro will be conducted within the primary care scheme provided by a large health care insurer in Baden-Württemberg, Germany. Patients who are counseled with arriba by their general practitioners (GPs) will be included in the arriba-pro cohort. Exposure data from the consultation with arriba such as demographic data and risk factors will be recorded automatically by the practice software and transferred to the study centre. Information on relevant prescription drugs (effect modifiers) and cardiovascular events (outcomes) will be derived from administrative sources.

Discussion

The study is unique in simulating a therapy naïve cohort, matching exactly research and application setting, using a robust administrative data base, and, finally, including patients with known cardiovascular disease who have been excluded from previous studies.

Trial registration

The study is registered with Deutsches Register Klinischer Studien (DRKS00004633).

Background

Nurse led self-help treatments for people with chronic fatigue syndrome/myalgic encephalitis (CFS/ME) have been shown to be effective in reducing fatigue but their cost-effectiveness is unknown.

Methods

Cost-effectiveness analysis conducted alongside a single blind randomised controlled trial comparing pragmatic rehabilitation (PR) and supportive listening (SL) delivered by primary care nurses, and treatment as usual (TAU) delivered by the general practitioner (GP) in North West England. A within trial analysis was conducted comparing the costs and quality adjusted life years (QALYs) measured within the time frame of the trial. 296 patients aged 18 and over with CFS/ME diagnosed using the Oxford criteria were included in the cost-effectiveness analysis.

Results

Treatment as usual is less expensive and leads to better patient outcomes compared with Supportive Listening. Treatment as usual is also less expensive than Pragmatic Rehabilitation. PR was effective at reducing fatigue in the short term, but the impact of the intervention on QALYs was uncertain. However, based on the results of this trial, PR is unlikely to be cost-effective in this patient population.

Conclusions

This analysis does not support the introduction of SL. Any benefits generated by PR are unlikely to be of sufficient magnitude to warrant recommending PR for this patient group on cost-effectiveness grounds alone. However, dissatisfaction with current treatment options means simply continuing with ‘treatment as usual’ in primary care is unlikely to be acceptable to patients and practitioners.

Trial registration

The trial registration number is IRCTN74156610

Background

Midwives and obstetricians are the key providers of care during pregnancy and postpartum. Information about the consultations with a general practitioner (GP) during this period is generally lacking.

The aim of this study is to compare consultation rates, diagnoses and GP management of pregnant women with those of non-pregnant women.

Methods

Data were retrieved from the Netherlands Information Network of General Practice (LINH), a nationally representative register. This register holds longitudinal data on consultations, prescriptions and the referrals of all patients listed at 84 practices in the Netherlands in 2007–2009, including 15,123 pregnant women and 102,564 non-pregnant women in the same age-range (15 to 45 years). We compared consultation rates (including all contacts with the practice), diagnoses (ICPC-1 coded), medication prescriptions (coded according to the Anatomical Therapeutic Chemical classification system), and rate and type of referrals from the start of the pregnancy until six weeks postpartum (336 days).

Results

Pregnant women contacted their GP on average 3.6 times, compared to 2.2 times for non-pregnant women. The most frequently recorded diagnoses for pregnant women were ‘pregnancy’ and ‘cystitis/urinary infection’, and ‘cystitis/urinary infection’ and ‘general disease not otherwise specified’ for non-pregnant women. The mean number of prescribed medications was lower in pregnant women (2.1 against 4.4). For pregnant women, the most frequent referral indication concerned obstetric care, for non-pregnant women this concerned physiotherapy.

Conclusions

GP consultation rates in pregnancy and postpartum shows that GPs are important providers of care for pregnant women. Therefore, the involvement of GPs in collaborative care during pregnancy and postpartum should be reinforced.

Background

Chronic obstructive pulmonary disease (COPD) is frequent and often coexists with other diseases. The aim of this study was to quantify the prevalence of COPD and related chronic comorbidity among patients aged over 40 years visiting family practices in an area of Madrid.

Methods

An observational, descriptive, cross-sectional study was conducted in a health area of the Madrid Autonomous Region (Comunidad Autónoma de Madrid). The practice population totalled 198,670 persons attended by 129 Family Physicians (FPs), and the study population was made up of persons over the age of 40 years drawn from this practice population. Patients were deemed to have COPD if this diagnosis appeared on their clinical histories. Prevalence of COPD; prevalence of a further 25 chronic diseases in patients with COPD; and standardised prevalence ratios, were calculated.

Results

Prevalence of COPD in family medicine was 3.2% (95% CI 3.0–3.3) overall, 5.3% among men and 1.4% among women; 90% of patients presented with comorbidity, with a mean of 4 ± 2.04 chronic diseases per patient, with the most prevalent related diseases being arterial hypertension (52%), disorders of lipid metabolism (34%), obesity (25%), diabetes (20%) and arrhythmia (15%). After controlling for age and sex, the observed prevalence of the following ten chronic diseases was higher than expected: heart failure; chronic liver disease; asthma; generalised artherosclerosis; osteoporosis; ischaemic heart disease; thyroid disease; anxiety/depression; arrhythmia; and obesity.

Conclusions

Patients with COPD, who are frequent in family practice, have a complex profile and pose a clinical and organisational challenge to FPs.

Background

Though general antibiotic consumption data is available, information on the actual patterns of prescribing antibiotics locally is difficult to obtain. An easy to use methodology was designed to assess ambulatory management of infections by Latvian general practitioners (GPs).

Methods

GPs were asked to record data in a patient data collection form for every patient that received antibiotics. Study period – (7 days) one week in November, 2008. Data recorded included the following details: an antibiotic, the prescribed dose, dosing interval, route of administration combined with the demographic factors of the patient and clinical diagnosis based on a pre-defined list.

Results

Two hundred forty eight forms out of the 600 (41%) were returned by post. Antibiotics were prescribed in 6.4% (1711/26803) of outpatient consultations. In total, 1763 antibiotics were prescribed during the study period. Ninety seven percent of the patients received monotherapy and only 47 (2.7%) patients were prescribed two antibiotics. The most commonly prescribed antibiotics were amoxicillin (33.9% of prescribed), amoxicillin/clavulanate (18,7%) and clarithromycin (7.6%). The most commonly treated indications were pharyngitis (29.8%), acute bronchitis (25.3%) and rhinosinusitis (10.2%). Pneumonia was mostly treated with amoxicillin/clavulanate (25,7%), amoxicillin (15.7%) and clarithromycin (19.3%).

Conclusions

Methodology employed provided useful additional information on ambulatory practice of prescribing antibiotics and could be used in further assessment studies. Educational interventions should be focused on treatment of acute pharyngitis and bronchitis in children and unnecessary use of quinolones in adults for uncomplicated urinary tract infection.

Background

Family physicians frequently interact with people affected by chronic diseases, placing them in a privileged position to enable patients to gain control over and improve their health. Soliciting patients’ perceptions about how their family physician can help them in this process is an essential step to promoting enabling attitudes among these health professionals. In this study, we aimed to identify family physician enabling attitudes and behaviours from the perspective of patients with chronic diseases.

Methods

We conducted a descriptive qualitative study with 30 patients, 35 to 75 years of age presenting at least one common chronic disease, recruited in primary care clinics in two regions of Quebec, Canada. Data were collected through in-depth interviews and were analyzed using thematic analysis.

Results

Family physician involvement in a partnership was perceived by participants as the main attribute of enablement. Promoting patient interests in the health care system was also important. Participants considered that having their situation taken into account maximized the impact of their physician’s interventions and allowed the legitimization of their feelings. They found their family physician to be in a good position to acknowledge and promote their expertise, and to help them maintain hope.

Conclusions

From the patient’s perspective, their partnership with their family physician is the most important aspect of enablement.

Background

Inappropriate use of antidepressants (AD), defined as either continuation in the absence of a proper indication or continuation despite the lack of therapeutic efficacy, applies to approximately half of all long term AD users.

Methods/design

We have designed a cluster randomized controlled clinical trial to assess the (cost-) effectiveness of an antidepressant cessation advice in the absence of a proper indication for maintenance treatment with antidepressants in primary care.

We will select all patients using antidepressants for over 9 months from 45 general practices. Patients will be diagnosed using the Composite International Diagnostic Interview (CIDI) version 3.0, extended with questions about the psychiatric history and previous treatment strategies. General practices will be randomized to either the intervention or the control group. In case of overtreatment, defined as the absence of a proper indication according to current guidelines, a cessation advice is given to the general practitioner. In the control groups no specific information is given. The primary outcome measure will be the proportion of patients that successfully discontinue their antidepressants at one-year follow-up. Secondary outcomes are dimensional measures of psychopathology and costs.

Discussion

This study protocol provides a detailed overview of the design of the trial. Study results will be of importance for refining current guidelines. If the intervention is effective it can be used in managed care programs.

Trial registration

NTR2032

Background

In many countries, general practitioner (GP) care of acute low back pain often does not adhere to evidence-based clinical guidelines. There has been little exploration of this deviation from evidence-based care from the patients’ perspective, particularly in relation to patients’ care expectations. The aim of this study was to explore the care expectations in patients who present to their GP with acute low back pain, influences on expectation development, and congruence of these expectations with clinical guideline recommendations.

Methods

Qualitative study in an inner urban general practice in Brisbane, Australia. Semi-structured interviews were conducted with 11 patients who presented to their GP with acute low back pain.

Results

Patients had a biomechanical understanding of back pain, how it should be tested and treated, and a poor understanding of its natural history. Most expected x-rays, believing they were necessary to identify the “cause of the pain” without belief of any downsides to x-rays. Patients’ expectations were primarily influenced by the experiences of family and friends, their own previous experiences of low back pain care, and comments from other health professionals they were consulting. The GP-patient relationship was important in influencing patient satisfaction of care provided. Most patient expectations, and some of the care that they reported receiving, were incongruent with guideline recommendations.

Conclusions

A biomechanical approach to management rather than an awareness of empirical evidence was evident in patients’ expectations. Communication and education by the GP that includes specifically enquiring about patients’ expectations, provides an opportunity to correct misperceptions, explain acute low back pain natural history, and the rationale for test and treatment recommendations.

Background

People with Type 2 diabetes face various psycho-social, self-management and clinical care issues and evidence is mixed whether support from others with diabetes, ‘peer support’, can help. We now describe a 2 month pilot study of different peer support interventions.

Methods

The intervention was informed by formative evaluation using semi-structured interviews with health professionals, community support groups and observation of diabetes education and support groups. Invitations to participate were mailed from 4 general practices and included a survey of barriers to care. Participants were randomized by practice to receive individual, group, combined (both individual and group) or no peer support. Evaluation included ethnographic observation, semi-structured interviews and questionnaires at baseline and post-intervention.

Results

Of 1,101 invited, 15% expressed an interest in participating in the pilot. Sufficient numbers volunteered to become peer supporters, although 50% of these (8/16) withdrew. Those in the pilot were similar to other patients, but were less likely to feel they knew enough about diabetes (60.8% vs 44.6% p = 0.035) and less likely to be happy with the diabetes education/care to date (75.4% vs 55.4% p = 0.013). Key issues identified were the need to recruit peer supporters directly rather than through clinicians, to address participant diabetes educational needs early and the potential for group sessions to have lower participation rates than 1:1 sessions.

Conclusions

Recruitment to a full trial of peer support within the existing study design is feasible with some amendments. Attendance emerged as a key issue needing close monitoring and additional intervention during the trial.

Background

Children’s emergency admissions in England are increasing. Community Children’s Nursing Teams (CCNTs) have developed services to manage acutely ill children at home to reduce demand for unscheduled care. Referral between General Practitioners (GPs) and CCNTs may reduce avoidable admissions and minimise the psychosocial and financial impact of hospitalisation on children, families and the NHS. However, facilitators of GP referral to CCNTs are not known. The aim of this study was to identify facilitators of GP referral to CCNTs.

Methods

Semi-structured interviews with 39 health professionals were conducted between June 2009 and February 2010 in three Primary Care Trusts served by CCNTs in North West England. Interviewees included GPs, Community Children’s Nurses (CCNs), consultant paediatricians, commissioners, and service managers. Qualitative data were analysed thematically using the Framework approach in NVivo 8.

Results

Five facilitators were identified: 1) CCN/CCNT visibility; 2) clear clinical governance procedures; 3) financial and organisational investment in the role of CCNTs in acute care pathways; 4) access and out of hours availability; 5) facilitative financial frameworks.

Conclusion

GPs required confidence in CCNs’ competence to safely manage acutely ill children at home and secure rapid referral if a child’s condition deteriorated. Incremental approaches to developing GP referral to CCNTs underpinned by clear clinical governance protocols are likely to be most effective in building GP confidence and avoiding inappropriate admission.