Showing papers in "Family Practice in 2006"
TL;DR: There are many different potential barriers of which some are tied to ethnic minorities, and awareness about the myriad of potential barriers is raised so that the problem of barriers to health care for different ethnic minorities becomes transparent.
Abstract: BACKGROUND: Ethnic minority patients seem to be confronted with barriers when using health services. Yet, care providers are often oblivious to these barriers, although they may share to some extent the burden of responsibility for them. In order to enlighten care providers, as to the potential pitfalls that may exist, there is a need to explore the different factors in the creation of the barriers. OBJECTIVE: Therefore, the objective of this paper is to present an overview of the potential barriers and the factors, which may restrict ethnic minority patients from using health services, according to the literature available. METHODS: Articles published from 1990 to 2003 were identified by searching electronic databases and selected through titles and abstracts. The articles were included if deemed to be relevant to study health services use by ethnic minorities, i.e. the different factors in the creation of a barrier. RESULTS: There were 54 articles reviewed. They reported on studies carried out in different countries and among different ethnic minorities. Potential barriers occurred at three different levels: patient level, provider level and system level. The barriers at patient level were related to the patient characteristics: demographic variables, social structure variables, health beliefs and attitudes, personal enabling resources, community enabling resources, perceived illness and personal health practices. The barriers at provider level were related to the provider characteristics: skills and attitudes. The barriers at system level were related to the system characteristics: the organisation of the health care system. CONCLUSION: This review has the goal of raising awareness about the myriad of potential barriers, so that the problem of barriers to health care for different ethnic minorities becomes transparent. In conclusion, there are many different potential barriers of which some are tied to ethnic minorities. The barriers are all tied to the particular situation of the individual patient and subject to constant adjustment. In other words, generalizations should not be made.
687 citations
TL;DR: Routinely collected primary care computer data, aggregated into large databases, is used for audit, quality improvement, health service planning, epidemiological study and research, but gaps exist in the literature about how to find relevant data, select appropriate research methods and ensure that the correct inferences are drawn.
Abstract: INTRODUCTION: Routinely collected primary care data has underpinned research that has helped define primary care as a specialty. In the early years of the discipline, data were collected manually, but digital data collection now makes large volumes of data readily available. Primary care informatics is emerging as an academic discipline for the scientific study of how to harness these data. This paper reviews how data are stored in primary care computer systems; current use of large primary care research databases; and, the opportunities and challenges for using routinely collected primary care data in research. OPPORTUNITIES: (1) Growing volumes of routinely recorded data. (2) Improving data quality. (3) Technological progress enabling large datasets to be processed. (4) The potential to link clinical data in family practice with other data including genetic databases. (5) An established body of know-how within the international health informatics community. CHALLENGES: (1) Research methods for working with large primary care datasets are limited. (2) How to infer meaning from data. (3) Pace of change in medicine and technology. (4) Integrating systems where there is often no reliable unique identifier and between health (person-based records) and social care (care-based records-e.g. child protection). (5) Achieving appropriate levels of information security, confidentiality, and privacy. CONCLUSION: Routinely collected primary care computer data, aggregated into large databases, is used for audit, quality improvement, health service planning, epidemiological study and research. However, gaps exist in the literature about how to find relevant data, select appropriate research methods and ensure that the correct inferences are drawn.
308 citations
TL;DR: Text messaging reminder system was effective in improving attendance rate in primary care and was more cost-effective compared with the mobile phone reminder.
Abstract: Background. Non-attendance is common in primary care and previous studies have reported that reminders were useful in reducing broken appointments. Objective. To determine the effectiveness of a text messaging reminder in improving attendance in primary care. Design. Multicentre three-arm randomized controlled trial. Setting. Seven primary care clinics in Malaysia. Participants. Patients (or their caregivers) who required follow-up at the clinics between 48 hours and 3 months from the recruitment date. Interventions. Two intervention arms consisted of text messaging and mobile phone reminders 24-48 hours prior to scheduled appointments. Control group did not receive any intervention. Outcome measures. Attendance rates and costs of interventions. Results. A total of 993 participants were eligible for analysis. Attendance rates of control, text messaging and mobile phone reminder groups were 48.1, 59.0 and 59.6, respectively. The attendance rate of the text messaging reminder group was significantly higher compared with that of the control group (odds ratio 1.59, 95 confidence interval 1.17 to 2.17, P = 0.005). There was no statistically significant difference in attendance rates between text messaging and mobile phone reminder groups. The cost of text messaging reminder (RM 0.45 per attendance) was lower than mobile phone reminder (RM 0.82 per attendance). Conclusions. Text messaging reminder system was effective in improving attendance rate in primary care. It was more cost-effective compared with the mobile phone reminder.
291 citations
TL;DR: A need for the development of evidence-based provision for older people with depression within primary care, but also a need for elderly patients to be made aware of the legitimacy of presenting low mood and misery to their primary care professional.
Abstract: Background: Depression is the commonest mental health problem in elderly people and continues to be underdiagnosed and undertreated.
Aim: To explore the ways that primary care professionals and patients view the causes and management of late-life depression.
Design: A qualitative study using semistructured interviews.
Setting: One Primary Care Trust in North West England.
Participants: Fifteen primary care practitioners comprising nine GPs, three practice nurses, two district nurses and one community nurse; twenty patients who were over the age of 60 and who were participating in a feasibility study of a new model of care for late-life depression [PRIDE Trial: PRimary care Intervention for Depression in the Elderly (a feasibility study in Central Manchester funded by the Department of Health)].
Results: Primary care practitioners conceptualized late-life depression as a problem of their everyday work, rather than as an objective diagnostic category. They described depression as part of a spectrum including loneliness, lack of social network, reduction in function and viewed depression as 'understandable' and 'justifiable'. This view was shared by patients. Therapeutic nihilism, the feeling that nothing could be done for this group of patients, was a feature of all primary care professionals' interviews. Patients' views were characterized by passivity and limited expectations of treatment. Depression was not viewed as a legitimate illness to be taken to the GP. Primary care professionals recognized that managing late-life depression did fall within their remit, but identified limitations in their own skills and capabilities in this area, as well as a lack of other resources to which they could refer patients.
Conclusion: This study highlights the complicated nature of the diagnosis and management of late-life depression. Protocols for the diagnosis and treatment of depression emphasis the biomedical model which does not fit with the everyday experience of GPs or elderly patients who share the views of primary care professionals that depression is a consequence of social and contextual issues. There is a need for the development of evidence-based provision for older people with depression within primary care, but also a need for elderly patients to be made aware of the legitimacy of presenting low mood and misery to their primary care professional.
210 citations
TL;DR: This older general practice population in Germany is among the top pharmaceutical user group of European study samples and GPs should be aware that low subjective health and medication disagreement are independent predictors of polypharmacy.
Abstract: Background Older people consume an increasing amount of medication. Polypharmacy is associated with an elevated risk of adverse health outcomes resulting in hospitalizations and sometimes death. Objectives To describe the prevalence of prescribed and over-the-counter (OTC) medications among older general practice patients living in the community. To determine predictors of polypharmacy (five or more prescribed drugs) from a variety of patient- and doctor-related factors. Methods Sixty-seven randomly selected practices in two areas of Germany and 466 of their older patients (70+ years) were recruited for a geriatric assessment study. A cross-sectional analysis of health problems, GPs' awareness and their interventions was conducted. In this post hoc analysis, we assessed the medication use as reported by older patients and compared it with doctors' perceived medication regimens for their respective patients. The detailed assessment of patients' health and well-being enabled us to explore a variety of predictors of polypharmacy using logistic regression analysis with forward selection. Results Study participants consumed an average of 3.7 prescribed medicines and an additional 1.4 OTC drugs. In all, 26.7% of patients used five and more chronically prescribed drugs. A set of five determinants predicted polypharmacy best: breathlessness, hypertension, dependency on instrumental activities of daily living, low subjective health and medication disagreement between doctors and patients. Conclusion This older general practice population in Germany is among the top pharmaceutical user group of European study samples. Apart from disease-specific determinants, GPs should be aware that low subjective health and medication disagreement are independent predictors of polypharmacy.
203 citations
TL;DR: Although 25-50% of all reasons for visit to a GP concern symptoms that are not medically explained, the frequent presentation of such symptoms is much more rare, and is most common among elderly women with a lower socio-economic status.
Abstract: OBJECTIVES: To estimate the prevalence of persistent presentation of medically unexplained physical symptoms (MUPS) in general practice. To assess socio-demographic characteristics, health status and use of health services of patients who frequently present MUPS, compared with reference groups. DESIGN: One-year, nationwide, representative survey of morbidity in general practice in the Netherlands, including 400 000 enlisted patients in 104 general practices. RESULTS: Of all patients (age: 18 years and older), 2.45% who visited their GP at least once a year, presented at least 4 times in 1 year with symptoms which are commonly considered medically unexplained without getting a medical diagnosis during that period, that might explain the symptoms. These patients are significantly older, more often female, less educated, more frequently unemployed and more frequently from a non-Western origin than 'average' patients or patients with a medical diagnosis. CONCLUSION: Although 25-50% of all reasons for visit to a GP concern symptoms that are not medically explained, the frequent presentation of such symptoms is much more rare. Frequent attendance because of MUPS is most common among elderly women with a lower socio-economic status. (aut.ref.)
199 citations
TL;DR: Patients with a diagnosis of schizophrenia are less likely to receive some important general health checks than patients without schizophrenia.
Abstract: BACKGROUND: Excess morbidity and mortality associated with schizophrenia is well established. Despite this, no previous multi-centre study has investigated whether patients with schizophrenia receive equitable physical healthcare within primary care. OBJECTIVE: To determine whether patients with a diagnosis of schizophrenia receive the same levels of physical health care from primary care practitioners as patients without schizophrenia. METHODS: Design: Case-matched retrospective case note review. Setting: Twenty-two general practices in the Birmingham area (UK). Subjects: 195 patients with a diagnosis of schizophrenia, 390 matched controls with a diagnosis of asthma and 390 general control patients. Main outcome measures: Proportions of patients within each group having received six pre-defined routine health checks in a 3 year period. Conditional logistic regression models were used to identify differences between groups. RESULTS: Patients with schizophrenia were half as likely as asthma controls to have blood pressure and cholesterol levels recorded (odds ratio 0.51; 95% confidence interval (CI) 0.35-0.73 and 0.50; 0.31-0.82, respectively) and were also less likely to have smoking status noted (0.60; 0.41-0.85). Similarly, patients with schizophrenia were significantly less likely than general population controls to have either blood pressure or cholesterol recorded (0.68; 0.47-0.97 and 0.58; 0.35-0.95). The significant differences observed were maintained after adjusting for potential confounders with the exception of cholesterol recording between the asthma and schizophrenia groups (0.57; 0.30-1.05). CONCLUSIONS: Patients with a diagnosis of schizophrenia are less likely to receive some important general health checks than patients without schizophrenia.
170 citations
TL;DR: To examine the views of primary care patients with OA knee towards exercise, factors that determine the acceptability and motivation to exercise are explored, and barriers that limit its use are identified.
Abstract: Background Osteoarthritis (OA) of the knee is common and disabling. Exercise is effective in reducing pain and disability, but long-term adherence to exercise regimens is disappointing, and motivation to exercise in those with OA knee is poorly understood. Objectives To examine the views of primary care patients with OA knee towards exercise, explore factors that determine the acceptability and motivation to exercise, and to identify barriers that limit its use. Method Semi-structured interviews were conducted with 22 primary care patients with OA knee, six of whom also participated in a focus group for triangulation. Transcripts were coded into categories and themes to develop a conceptual framework and typology of exercise behaviour. Results Exercise behaviour depended upon physical capacity to exercise; exercise beliefs and other factors such as enjoyment, social support, priority setting and context. Four types of patients were identified: 'long-term sedentary' who had never exercised; 'long-term active' who continued to exercise; 'exercise retired' who used to exercise, but had stopped because of their symptoms, and because they believed that exercise was damaging their joints; and 'exercise converted' who recently started to exercise, and preferred a gym because of the supervision and social support they received there. Conclusions Several physical, cognitive and contextual factors, and a typology of exercise behaviour were identified that could be addressed in primary care consultations. The importance of gyms and GP referral schemes for people who are exercising for the first time, and the high level of patient satisfaction associated with these were highlighted.
162 citations
TL;DR: Some causes of chest pain are underdiagnosed in primary care, and this is of particular consequence for the minority ofchest pain patients with cardiac disease.
Abstract: Background. Chest pain is a common symptom that presents the primary care physician with a complex diagnostic and therapeutic challenge. Aims. To evaluate the natural history and management of patients diagnosed with chest pain of unspecified type or origin in primary care. Design. Population-based case-control study. Methods. The study included 13 740 patients with a first diagnosis of unspecified chest pain and 20 000 age- and sex-matched controls identified from the UK General Practice Research Database. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed using unconditional logistic regression. Risk estimates were adjusted for age, sex and number of physician visits. Results. The incidence of a new diagnosis of chest pain was 15.5 per 1000 person-years and increased with age, particularly in men. The risk of a chest pain diagnosis was greatest in patients with prior diagnoses of coronary heart disease (OR: 7.1; 95% CI: 6.1-8.2) and gastroesophageal reflux disease (OR: 2.0; 95% CI: 1.7-2.3). In the year after diagnosis, chest pain patients were more likely than controls to be newly diagnosed with coronary heart disease (OR: 14.9; 95% CI: 12.7-17.4) and heart failure (OR: 4.7; 95% CI: 3.6-6.1). A new diagnosis of chest pain was associated with an increased risk of death in the following year (RR: 2.3; 95% CI: 1.9-2.8). Conclusions. Some causes of chest pain are underdiagnosed in primary care. This is of particular consequence for the minority of chest pain patients with cardiac disease.
159 citations
TL;DR: The evidence derived from these limited studies suggests that 2000 microg doses of oral vitamin B(12) daily and 1000microg doses initially daily and thereafter weekly and then monthly may be as effective as intramuscular administration in obtaining short-term haematological and neurological responses in vitamin B (12)-deficient patients.
Abstract: Background. Vitamin B12 deficiency is common, increasing with age. Most people are treated in primary care with intramuscular vitamin B12. Several studies have reported equal efficacy of oral administration of vitamin B12.
Objectives. We set out to identify randomized controlled trial (RCT) evidence for the effectiveness of oral versus intramuscular vitamin B12 to treat vitamin B12 deficiency.
Methods. We conducted a systematic review searching databases for relevant RCTs. Outcomes included levels of serum vitamin B12, total serum homocysteine and methylmalonic acid, haemoglobin and signs and symptoms of vitamin B12 deficiency.
Results. Two RCTs comparing oral with intramuscular administration of vitamin B12 met our inclusion criteria. The trials recruited a total of 108 participants and followed up 93 of these from 90 days to 4 months. In one of the studies, mean serum vitamin B12 levels were significantly higher in the oral (643 ± 328 pg/ml; n = 18) compared with the intramuscular group (306 ± 118 pg/ml; n = 15) at 2 months (P < 0.001) and 4 months (1005 ± 595 versus 325 ± 165 pg/ml; P < 0.0005) and both groups had neurological responses. In the other study, serum vitamin B12 levels increased significantly in those receiving oral vitamin B12 and intramuscular vitamin B12 (P < 0.001).
Conclusions. The evidence derived from these limited studies suggests that 2000 µg doses of oral vitamin B12 daily and 1000 µg doses initially daily and thereafter weekly and then monthly may be as effective as intramuscular administration in obtaining short-term haematological and neurological responses in vitamin B12-deficient patients.
159 citations
TL;DR: There was evidence of relationships between the attributes of FM and the service outcomes measured by indicators of satisfaction, health and cost.
Abstract: Objective To identify, from a systematic review of the literature, the attributes of Family Medicine (FM) that influence the primary health care outcome as measured by users' satisfaction, improvement in patient health and in costs Data sources Literature search of Medline and the Cochrane library using MeSH terms 'Primary Health' or 'Family Practice' or 'Family Physicians' and 'Outcome Assessment' or 'Process Assessment' Papers were excluded if they lacked a based on primary data, if no single component of FM was assessed; if indicators of evaluation were not related to health, satisfaction or costs Results A total of 356 articles were initially identified and 19 finally met the inclusion criteria Study methods were a systematic review of randomized control trials, a double-blind randomized trial, 4 systematic reviews of observational studies, 2 cohort studies and 12 descriptive cross-sectional studies Conclusions There was evidence of relationships between the attributes of FM and the service outcomes measured by indicators of satisfaction, health and cost User satisfaction was associated with accessibility, continuity of care, consultation time and the doctor-patient relationship Improvement in patient's health was related to continuity, consultation time, doctor-patient relationship and the implementation of preventive activities Coordination of care showed mixed results with health outcomes Continuity, consultation time, doctor-patient communication and prevention were cost-effective in the primary care setting
TL;DR: Provider-related factors including perceived gay-positivity and inquiry about sexual orientation are strongly associated with disclosure of sexual orientation, which, along with health status, predicted regular health care use.
Abstract: Methods. A path analysis using community survey data from 489 lesbian respondents. Results. 78.5% [95% confidence interval (CI): 74.7–82.0] of women reported regular health service use; 75.8% (95% CI: 72.2–79.8) of women had disclosed their sexual orientation to their provider; and 24.4% (95% CI: 20.6–28.2) of women had been asked about their sexual orientation by their provider. Of those women whose physicians had inquired about their sexual orientation, 100% (95% CI: 97.5–100.0) had disclosed. In the final path analysis, perceived provider gay-positivity and level of patient outness predicted disclosure, which, along with health status predicted regular health care use. All paths were significant at P < 0.05. Conclusions. Provider-related factors including perceived gay-positivity and inquiry about sexual orientation are strongly associated with disclosure of sexual orientation. Disclosure is associated with regular health care use. Minor changes to practice could improve access to health services for lesbians.
TL;DR: Better health professional guidance on appropriate physical activity, its health benefits and its safety is needed for this highly at-risk group of South Asian women with CHD and diabetes.
Abstract: Background People of South Asian origin have higher mortality and morbidity from coronary heart disease (CHD) and diabetes than those of European origin. However, physical activity, of established value in primary and secondary prevention, appears lower among South Asians. Objective To explore influences on, and attitudes towards, physical activity among South Asian women with CHD and diabetes to inform secondary prevention strategies. Methods Exploratory qualitative study with women aged 26-70 years of varying South Asian ethnicity, religion and socio-economic background with CHD and/or non-insulin-dependent diabetes were recruited from primary care practices in the UK. Results The beneficial use of physical activity to improve and limit progression of their disease was largely unrecognized by the women interviewed. They were uncertain what type and level of physical activity was appropriate and safe for them. They operated their own threshold for physical activity in relation to their condition, which they were afraid to exceed. Specific guidance from health professionals was lacking. Respondents emphasized the cultural importance of being active day to day, rather than the 'Western' concepts of organized exercise. However, women's principal motivations and attitudes towards physical activity, to loose weight, socialize and maintain independence, were culturally similar to 'majority' populations. Conclusions Better health professional guidance on appropriate physical activity, its health benefits and its safety is needed for this highly at-risk group. Promoting informal moderate-intensity physical activity may help. Strategies should avoid any tendency to overemphasize cultural barriers noting greater similarities than differences between cultural groups.
TL;DR: Better methods of providing information for long-term survivors of stroke, and for addressing their emotional and psychological needs are required, and primary care could be a key setting for helping to provide more inclusive services for both patient and carer.
Abstract: Background. Previous research has focused on the longer term needs of 'new' stroke patients at fixed time intervals after the event, but neglected those of stroke patients who may have had the event many years earlier. Objective. To identify the long-term support needs of patients with prevalent stroke, and their carers identified from practice stroke registers. Design of study. Patients and their carers were invited to attend focus groups at the university, a nursing home or in the community. Setting. Seven practices in South Birmingham. Adults (18+) with a validated record of stroke. Methods. Focus groups were audio-taped and data analysed using a constant comparison method. Results. Twenty-seven patients and six carers participated in the study. Three major themes emerged: emotional and psychological problems; lack of information available for patients and their families; the importance of Primary Care as the first point of contact for information or problems, even if these were non medical. Conclusions. Better methods of providing information for long-term survivors of stroke, and for addressing their emotional and psychological needs are required. Primary care could be a key setting for helping to provide more inclusive services for both patient and carer. © The Author (2005). Published by Oxford University Press. All rights reserved.
TL;DR: This study successfully brought patient, carer and professional perspectives to the development of a care framework for primary care for cancer care in primary care in the south of Scotland.
Abstract: Results. Patients with cancer and their carers identified five key times in the cancer journey as being especially significant from their perspective: around diagnosis, during treatment, after discharge, at recurrence and the final weeks. At each key time, there were five major issues of concern: information, communication, equity, a holistic approach and patient-centred care. Using these, the group members developed a checklist of recommended interventions for each stage in the illness trajectory and suggested how they might be implemented in primary care. Proactive and ongoing contact, if wished by the patient, was considered the central plank of cancer care in the community. Conclusions. Patients with cancer and their carers believe that there is an important and unique role for primary care in offering continuity of care and information that is patientcentred and holistic, throughout the cancer trajectory, from first presentation. This study successfully brought patient, carer and professional perspectives to the development of a care framework for primary care.
TL;DR: The EPA instrument provides feedback to practices that facilitates quality improvement and can compare primary care practices on a national and an international level.
Abstract: Background. Effective practice management is an important prerequisite for offering good clinical care. Internationally valid, reliable and feasible indicators and instruments are needed to describe and compare the management of primary care practices in Europe.
Objective. This paper describes development and evaluation of the European Practice Assessment instrument and indicators (Engels Y, Campbell S, Dautzenberg M et al. Developing a framework of, and quality indicators for, general practice management in Europe. Fam Pract 2005; 22(2): 215–22).
Methods. The study design was a validation and feasibility study set in 273 general practices in Austria, Belgium, France, Germany, Israel, The Netherlands, Slovenia, Switzerland and the UK. Use was made of a set of 62 valid quality indicators derived previously from an international Delphi procedure. The EPA instrument, based on this set of indicators, was used to collect data in the 273 practices. This instrument consists of self-completed questionnaires for doctors, staff managers and patients. In addition, there is an interview schedule for use by an outreach visitor, to be held with the lead GP or manager, and a visitor checklist. The instrument was analysed using expert review by the project partners, factor and reliability analyses, ANOVA analyses and by determining intraclass correlations.
Results. Fifty-seven indicators were found to be valid, feasible, reliable and discriminative in all participating countries. The instrument was able to determine differences in practice management within and between countries. All (but one) practices completed the assessment procedure. The data collection method appeared to be feasible, although some aspects can be improved.
Conclusion. The EPA instrument provides feedback to practices that facilitates quality improvement and can compare primary care practices on a national and an international level.
TL;DR: The foundations that underpin the value of personal care from the patients' perspective could be based on categories found in this study, which was based on four main categories or core foundations.
Abstract: Method. In this qualitative study, 14 chronically ill patients at three primary health care centres were strategically selected. The centres were selected to include patients with experiences from both long-term and short-term doctors. The patients were asked about their views on having a personal doctor in a continuing doctor–patient relationship in primary care compared with having different short-term doctors. Sixteen health care professionals were interviewed about what chronically ill patients convey to them about having a personal doctor in contrast to seeing different short-term locum doctors. The in-depth interviews were transcribed verbatim and analysed by qualitative content analysis. Results. The core category, i.e. a universal concept that many patients used to describe the impact of having access to a personal doctor, was a sense of security. This was based on four main categories or core foundations which were: feelings of coherence, confidence in care, a trusting relationship and accessibility. In turn, the four main categories emerged from two to four of subcategories. Conclusion. The foundations that underpin the value of personal care from the patients’ perspective could be based on categories found in this study.
TL;DR: Factors influencing perceptions of family history may vary between individuals and between diseases, and to use the family history as a tool in preventive healthcare the authors will need to consider the individual's personal understanding of disease risk and their ideas about cause and controllability of the familial illness.
Abstract: Results. People with a family history of cancer had a greater sense of personal vulnerability than people with a family history of heart disease: family history of diabetes was generally viewed as the least threatening. Using the CSM constructs we identified factors which determine individual perceptions of family history. Beliefs about consequences and timeline were influenced by witnessing painful, lingering or sudden familial death; people who felt their risk was determined by inheritance were more likely to feel vulnerable and have less control, while those who felt able to change lifestyle or behaviour felt more able to control their perceived risk. Conclusion. Factors influencing perceptions of family history may vary between individuals and between diseases. To use the family history as a tool in preventive healthcare we will need to consider the individual’s personal understanding of disease risk and their ideas about cause and controllability of the familial illness. Perceived risk may then be used to motivate preventive health behaviours.
TL;DR: It is suggested that Internet gambling is linked to pathological gambling and is independently associated with poor health, and family practice physicians should consider referring patients who gamble on the Internet for further treatment.
Abstract: Background Gambling problems are rarely brought to the attention of family practice physicians, but pathological gambling can be associated with poor emotional and physical health. Recent availability and easy accessibility of Internet gambling may be associated with pathological gambling status, and Internet gambling may confer health risks. Objective This study evaluated the prevalence of Internet gambling, its association with pathological gambling, and the relationship between Internet gambling and health status among patients attending medical and dental clinics. Methods The South Oaks Gambling Screen and Short Form 12 were administered to 1414 adults in waiting areas of clinics. Results Only 6.9% of respondents reported ever gambling on the Internet, with 2.8% indicating frequent Internet wagering. Almost two-thirds (65.9%) of regular Internet gamblers were classified as probable pathological gamblers, compared with 29.8% of ever-Internet gamblers and 7.6% of non-Internet gamblers. Internet gambling was associated with poor mental and physical health, and this association remained significant even after controlling for age, gender, site and pathological gambling status. Conclusions These data suggest that Internet gambling is linked to pathological gambling and is independently associated with poor health. Family practice physicians should consider referring patients who gamble on the Internet for further treatment.
TL;DR: Assessment of general practice preparedness to respond to pandemic influenza and to identify issues that need to be addressed to enhance preparedness for the next pandemic.
Abstract: Background. Current pandemic influenza plans to place GPs at the front line of a pandemic influenza response. However, little is known about GPs' perceptions of their role and preparedness in the event of a pandemic occurring.
Objective. Our aim was to assess general practice preparedness to respond to pandemic influenza and to identify issues that need to be addressed to enhance preparedness for the next pandemic.
Methods. We conducted a series of semi-structured interviews to explore GPs' views regarding their role in responding to pandemic influenza, practice preparedness and planning issues, and the expectations and requirements of GPs for provision of professional services during a pandemic. The subjects were 60 Australian GPs, purposively selected to maximize diversity within the sample.
Results. GPs in this study expressed a willingness to provide professional services in a pandemic. The motivation for this was largely altruistic and was in the context of high personal risk of becoming infected. Participants did not have stockpiles of antivirals or personal protective equipment within their practices and felt that government had a duty of care to stockpile on behalf of the general practice workforce. Participants were enthusiastic about receiving further information and training in pandemic preparedness. The most appropriate setting for this was within practices.
Conclusions. GPs were willing to provide clinical services in a pandemic. However, appropriate education, training and supply of equipment were necessary to support them in this role. This information will inform further planning for the public health response to pandemic influenza.
TL;DR: This paper explores alternative perspectives and methodological opportunities that arise from viewing health service as a complex non-linear system and may help to explain the limitations of current analytical techniques.
Abstract: Despite a recognition that health service research has failed to make its full contribution to health service improvement, the fact that evidence is not widely accommodated into practice is seen as a failure of communication rather than the inappropriate application of a particular form of investigation. Dominant theoretical frameworks still retain the fundamental idea that order needs to be somehow created by external forces and that organizational issues will inevitably yield to more collection of data and the application of increasingly sophisticated analytical techniques. This paper explores alternative perspectives and methodological opportunities that arise from viewing health service as a complex non-linear system. This approach may offer new research insights that more accurately reflect underlying mechanisms and may help to explain the limitations of current analytical techniques.
TL;DR: The values that doctors working in general practice attach to continuity of patient care are explored and how these values are applied in practice are outlined to outline how the same benefits can be achieved within teams.
Abstract: Background. Continuity is thought to be important to GPs but the values behind this are unknown.Objectives. To explore the values that doctors working in general practice attach to continuity of patient care and to outline how these values are applied in practice.Methods. In-depth qualitative interview with 24 GPs in England. Participants were purposefully sampled according to personal and practice characteristics. Analysis was thematic, drawing on the constant comparative method.Results. The majority of doctors valued doctor-patient, or personal, continuity in their everyday work. It was most valued in patients with serious, complex or psychological problems. GPs believed that through their personal knowledge of the patient and the doctor-patient relationship, personal continuity enabled them to provide higher quality care. However, the benefits of personal continuity were balanced against problems, and GPs identified personal, professional and external constraints that limited its provision. GPs seemed to have resolved the tension between the benefits, limits and constraints they described by accepting an increased reliance on continuity being provided within teams.Conclusion. Personal continuity may offer important benefits to doctors and patients, but we do not know how unique its values are. In particular, it is not clear whether the same benefits can be achieved within teams, the level at which continuity is increasingly being provided. The relative advantages and limits of the different means of delivering continuity need to be better understood, before further policy changes that affect personal continuity are introduced.
TL;DR: The combined use of TCM and WHS is common among elderly Chinese immigrants and the predictors identified should help physicians to recognize who among the elderlyChinese immigrants are more likely to use TCM so that a more in-depth understanding toward their health practices and needs can be achieved.
Abstract: Results. The response rate was 77%. Over two-thirds of the older Chinese immigrants reported using TCM in combination with WHS. About half (50.3%) of the older Chinese immigrants used Chinese herbs, 48.7% used Chinese herbal formulas, and 23.8% consulted a Chinese herbalist. Although separate analysis was conducted, similar predictors were identified. Country of origin, Chinese health beliefs, social support, city of residency, and health variables were the common predictors of using a form of TCM. Conclusion. The combined use of TCM and WHS is common among elderly Chinese immigrants. Culture-related variables are important in determining use of TCM. The predictors identified should help physicians to recognize who among the elderly Chinese immigrants are more likely to use TCM so that a more in-depth understanding toward their health practices and needs can be achieved.
TL;DR: A long-term programme is needed incorporating mutual support and sharing with regular (not necessarily frequent) input from practitioners of information, advice and reassurance, as a support strategy for lifestyle change.
Abstract: Gregory S, Bostock Y and Backett-Milburn K. Recovering from a heart attack: a qualitative study into lay experiences and the struggle to make lifestyle changes. Family Practice 2006; 23: 220–225. Background. The adoption of healthy living advice by people with heart disease is known to be poor even in targeted interventions. Reasons for this can range from confusion about the seriousness of the condition to ineffectiveness in the form of advice and how it is conveyed. However, the social setting can be an important influence on lifestyle change. Objectives.To identify views and experiences of people recovering from myocardial infarction, specifically barriers to, and facilitators of, following advice about lifestyle change and maintenance. Methods. Focus groups and interviews were undertaken with men and women discharged from hospital two/three years previously. A total of 53 people (35 men and 18 women) took part, recruited via a coronary care unit and patients’ GPs. Results. A major finding was participants’ desires for long-term monitoring and support. While reported sources, form and content of coronary heart disease advice varied, most participants agreed that long-term follow up or back-up would be helpful, although what this should include and how it should be undertaken was not the same for all participants. This would fulfil needs such as: help in following lifestyle advice; sharing with people with similar experiences; regular contact with medical/health professionals (for confirmation of good heath and to ask questions); providing reassurance to other members of the patients’ families.
TL;DR: Delays attributable to the women were often compounded by doctor or health service delays, enabling Andersen's five stage model of 'total patient delay' as an analytic framework to expand the fifth stage of Andersen's model.
Abstract: Background: Ovarian cancer symptoms are vague and commonly occur in benign conditions; it often presents late and is diagnosed at an advanced stage when survival rates are poor. Studies of diagnostic delay in conditions with non-specific symptoms are rare. Objectives: To study accounts of diagnostic delays in a sample of British women with ovarian cancer using Andersen's five-stage model of 'total patient delay' as an analytic framework. Methods: Semi-structured interviews were conducted with 43 women. Maximum variation sample was recruited via GPs, clinicians, support organizations and personal contacts. Results: Most women reported pre-diagnostic symptoms and diagnostic delays. Patient delays conformed to Andersen's first four types: 'appraisal, illness, behavioural and scheduling' delays. 'Treatment delays', attributable at least in part to a doctor or the health care system, were common and we have broken them down into five categories: non-investigation of symptoms, treatment for non-cancer causes, lack of follow-up, referral delays and system delays. Conclusions: Our data illuminate the reasons why some British women experience delays in obtaining an ovarian cancer diagnosis. Delays attributable to the women were often compounded by doctor or health service delays, enabling us to expand the fifth stage of Andersen's model. Diagnostic delays in general practice could be minimized by better history taking, explaining the rationale for ruling out non-cancer causes, adopting an 'open-door' policy for patients whose symptoms persist, considering abdominal ultrasound scans and introducing educational sessions for GPs about ovarian cancer symptomatology. © 2007 Oxford University Press.
TL;DR: To determine the incidence of RTI in patients presenting to the GP according to age, gender and common high-risk co-morbidity in primary care, the Second Dutch National Survey of General Practice with 358,008 patients recorded all consecutive patient contact by use of the ICPC coding system in a year.
Abstract: BACKGROUND: Figures on GP-diagnosed respiratory tract infections (RTI) are outdated because of demographic changes and increase in co-morbid conditions, respiratory vaccination programmes and change in illness behaviour. OBJECTIVE: To determine the incidence of RTI in patients presenting to the GP according to age, gender and common high-risk co-morbidity in primary care. METHODS: In the Second Dutch National Survey of General Practice 90 computerized general practices with 358,008 patients recorded all consecutive patient contact by use of the ICPC coding system in a year. Incidences were calculated using the mid-year population in the denominator and RTI episodes as the nominator. RESULTS: In all, 4.2% of the patient population were diagnosed with RTI with an incidence rate of 144 per 1000 person-years. Upper RTI were more common in children of 0-4 years than in other year-cohorts [392 versus 80 per 1000; relative risk 4.9, 95% confidence interval (95% CI) 4.8-5.0]. An U-shape association was observed between age and lower RTI (78 and 70 per 1000 in children and persons aged 75 years or over, respectively, versus 23 per 1000 in other age-categories). Females had slightly higher incidence rates of URTI (relative risk 1.4, 95% CI 1.35-1.45) and similar rates for LRTI. Patients with chronic medical conditions as pulmonary and cardiac disease, and diabetes. DISCUSSION: A small proportion of the patient population present themselves to the GP with a RTI. RTI are more common among children, elderly persons and patients with pulmonary and cardiac disease, and diabetes of the ICPC coding system.
TL;DR: Patients with colorectal cancer travel several different pathways to diagnosis, and the pathway with the most resources-the 2-week clinic-is used by a minority of patients.
Abstract: Methods. We designed an observational audit in Exeter, Oxford and Sheffield, UK. Colorectal cancers diagnosed in 2002 from participating practices were identified and the presence and timing of seven important clinical features noted: diarrhoea, constipation, rectal bleeding, abdominal pain, the finding of an abdominal or rectal mass on examination, anaemia and positive faecal occult blood tests. The referral pathways to secondary care were identified. Results. Of the 151 patients studied, 112 (74%) were referred with at least one clinical feature of colorectal cancer to a specialist. Only 43 of these (28% of the total) were referred to a 2-week clinic; 39 patients (26% of the total) had an emergency admission, of whom 10 (7%) had their emergency admission after referral to a specialist for investigation but before a diagnosis had been established. The time intervals between the first consultation with a symptom of cancer and referral were mostly short. Conclusion. Patients with colorectal cancer travel several different pathways to diagnosis. The pathway with the most resources—the 2-week clinic—is used by a minority of patients.
TL;DR: Roles for primary and secondary care professionals are inappropriately distributed and require clearer definition, and developers of shared care protocols must dissect layered obstacles, addressing the issues of therapeutic nihilism, risk management and clinical competence.
Abstract: Background. All Primary Care Trusts in England were meant to have shared care protocols for antidementia medication use in place by 1 April 2004. Shared care of medical treatment in dementia depends upon early diagnosis, but under-recognition of and under-response to dementia appear widespread in general practice.Aim. To investigate the perceptions of specialists and generalists about the potential for shared care of people with dementia.Design of study. Qualitative study with semistructured interviews.Setting. Three inner-city and two rural areas.Methods. Semistructured interviews were arranged at the participants' convenience and were tape-recorded and transcribed. Thematic analysis of the anonymized transcripts was undertaken and a case and cross-case analysis was performed.Results. Thirty-nine GPs and 30 specialists were interviewed. Broad themes were reduced to following four key categories which appear to be layered over each other: therapeutic nihilism; risk reduction or avoidance; concerns about competency; and resources for shared care.Conclusion. Roles for primary and secondary care professionals are inappropriately distributed and require clearer definition. Resistance to shared care mostly comes from within general practice and reflects concerns about staffing, time constraints, lack of experience and confidence in making and disclosing a diagnosis. Developers of shared care protocols must dissect layered obstacles, addressing the issues of therapeutic nihilism, risk management and clinical competence.
TL;DR: It is found that family physicians classify as depressed those patients who do not have the formal signs of depression but who do have antecedents of this disorder or a psychological distress that may be prodromal of future depressive episodes.
Abstract: depression scale (SDS). In the second phase, all the 209 patients with a positive screening and 97 patients with a negative screening (1 out of 7 randomly) were given the Structured Clinical Interview for DSM-IV Disorders, a series of questionnaires, and the family physician judged whether depression was present. In the 186 patients for whom there were no criteria of major depression or dysthymia, the association of various variables with the physicians’ overdiagnosis of depression was analysed. Results. The rate of diagnosis of depression in non-depressed patients was 26.5% (95% CI: 19.0–33.9). The factors associated independently with overdiagnosis were the SDS score (OR: 1.05; 95% CI: 1.01–1.10), the Global Assessment of Functioning score (OR: 0.95; 95% CI: 0.90–0.99), previous history of depression (OR: 2.66; 95% CI: 1.12–6.30) and presence of generalized anxiety (OR: 0.42; 95% CI: 0.18–0.97).
TL;DR: It is found that an Internet-based Ask the Doctor service run by family physicians on the whole was evaluated positively by the participants both in terms of the answers and the service.
Abstract: BACKGROUND: Internet consultation without a previous relationship between the doctor and the enquirer seems to be increasing in popularity. However, little is known about the advantages, disadvanta ...