http://www.biomedcentral.com/bmcfampract/ The latest research articles published by BMC Family Practice 2009-11-30T00:00:00Z This is an RSS newsfeed from BioMed Central It is intended to be used with an RSS reader. For more information about RSS newsfeeds from BioMed Central, visit http://www.biomedcentral.com/info/about/rss/ Background: Metabolic syndrome (MetS) is a major public health challenge. General practitioners (GPs) could play a key role in its recognition. However, it often remains undiagnosed in primary care. This study assesses how well GPs and patients recognise MetS among patients with coronary heart disease or at least one of its risk factors. Methods: Twenty-six health centres around Finland were randomly selected for the purpose of identifying, over a two-week period in April 2005, patients meeting the inclusion criteria of coronary heart disease or one of its risk factors. GPs and identified patients (n = 1880) were asked to complete surveys that included a question about the patient's MetS status. A trained nurse conducted health checks (n = 1180) of the identified patients, utilising criteria of MetS modified from the National Cholesterol Program. Data from the GPs' survey were compared with those from the health check to establish the extent of congruence of identification of MetS. Results: Almost half (49.4%) of the patients met the criteria of MetS as established by objective measures. However, in the GPs' survey responses, only 28.5% of the patients were identified as having MetS. Additionally, these groups of MetS patients were not congruent. The sensitivity of the GPs' diagnosis of MetS was 0.31 with a specificity of 0.73. Only 7.1% of the study patients stated that they were suffering from MetS. Conclusions: Detection of MetS is inaccurate among GPs in Finland. Most patients were not aware of having MetS. The practical relevance of MetS in primary care should be reconsidered. http://www.biomedcentral.com/1471-2296/10/76 Eeva-Eerika Helminen Pekka Mantyselka Irma Nykanen Esko Kumpusalo BMC Family Practice 2009, 10:76 2009-11-30T00:00:00Z doi:10.1186/1471-2296-10-76 BMC Family Practice 1471-2296 10 76 2009-11-30T00:00:00Z PDF Background: Lack of time and competing demands limit the ability of patients and providers to engage in informed decision-making discussions about prostate cancer screening during primary care visits. We evaluated a patient recall invervention to mitigate these challenges. Methods: Using mail and telephone outreach we invited men age 50-74 years without a PSA test in the prior 12 months to make appointments with their primary care providers in order to discuss the pros and cons of PSA-based prostate cancer screening. We assessed patient responsiveness to the program, provider documentation of screening discussions, orders for PSA laboratories, and provider attitudes. Results: Out of 80 eligible patients, 37 (46%) scheduled and 28 (35%) completed a recall appointment. A large majority (91%) of patients eligible for PSA screening received an order for this test. Providers documented PSA discussions more often for these patients than for a recent sample of their other patients who received traditional care (47.8% vs. 12.5%, p = 0.009). Twelve of 14 participating providers felt the program improved their ability to impart information about the risks and benefits of screening, but were uncertain whether it influenced their patients' preexisting preferences for screening. Some expressed doubts about the advisability of PSA-specific appointments. Conclusion: To a limited extent, this pilot recall intervention enhanced opportunities for discussions of prostate cancer screening between patients and their primary care providers. As currently configured, however, this program was not found to be feasible for this purpose. A future version should promote screening discussions in the context of a broader range of health maintenance concerns and include more detailed, low-literacy information to educate patients in advance of clinic visits. http://www.biomedcentral.com/1471-2296/10/75 Thomas Denberg Manisha Bhide Alyssa Soenksen Trina Mizrahi Laura Shields Chen-Tan Lin BMC Family Practice 2009, 10:75 2009-11-30T00:00:00Z doi:10.1186/1471-2296-10-75 BMC Family Practice 1471-2296 10 75 2009-11-30T00:00:00Z XML Background: Physicians' heavy workload is often thought to jeopardise the quality of care and to be a barrier to improving quality. The relationship between these has, however, rarely been investigated. In this study quality of care is defined as care 'in accordance with professional guidelines'. In this study we investigated whether GPs with a higher workload adhere less to guidelines than those with a lower workload and whether guideline recommendations that require a greater time investment are less adhered to than those that can save time. Methods: Data were used from the Second Dutch National survey of General Practice (DNSGP-2). This nationwide study was carried out between April 2000 and January 2002.A multilevel logistic-regression analysis was conducted of 170,677 decisions made by GPs, referring to 41 Guideline Adherence Indicators (GAIs), which were derived from 32 different guidelines. Data were used from 130 GPs, working in 83 practices with 98,577 patients. GP-characteristics as well as guideline characteristics were used as independent variables. Measures include workload (number of contacts), hours spent on continuing medical education, satisfaction with available time, practice characteristics and patient characteristics. Outcome measure is an indicator score, which is 1 when a decision is in accordance with professional guidelines or 0 when the decision deviates from guidelines. Results: On average, 66% of the decisions GPs made were in accordance with guidelines. No relationship was found between the objective workload of GPs and their adherence to guidelines. Subjective workload (measured on a five point scale) was negatively related to guideline adherence (OR=0.95). After controlling for all other variables, the variation between GPs in adherence to guideline recommendations showed a range of less than 10%.84% of the variation in guideline adherence was located at the GAI-level. Which means that the differences in adherence levels between guidelines are much larger than differences between GPs. Guideline recommendations that require an extra time investment during the same consultation are significantly less adhered to: (OR=0.46), while those that can save time have much higher adherence levels: OR=3.13). Recommendations that reduce the likelihood of a follow-up consultation for the same problem are also more often adhered to compared to those that have no influence on this (OR=3.13). Conclusions: No significant relationship was found between the objective workload of GPs and adherence to guidelines. However, guideline recommendations that require an extra time investment are significantly less well adhered to while those that can save time are significantly more often adhered to. http://www.biomedcentral.com/1471-2296/10/74 Michael van den Berg Dinny de Bakker Peter Spreeuwenberg Gert Westert Joze Braspenning Jouke van der Zee Peter Groenewegen BMC Family Practice 2009, 10:74 2009-11-28T00:00:00Z doi:10.1186/1471-2296-10-74 BMC Family Practice 1471-2296 10 74 2009-11-28T00:00:00Z PDF Background: A new intervention aimed at managing patients with medically unexplained symptoms (MUS) based on a specific set of communication techniques was developed, and tested in a cluster randomized clinical trial. Due to the modest results obtained and in order to improve our intervention we need to know the GPs' attitudes towards patients with MUS, their experience, expectations and the utility of the communication techniques we proposed and the feasibility of implementing them. Physicians who took part in 2 different training programs and in a randomized controlled trial (RCT) for patients with MUS were questioned to ascertain the reasons for the doctors' participation in the trial and the attitudes, experiences and expectations of GPs about the intervention. Methods: A qualitative study based on four focus groups with GPs who took part in a RCT. A content analysis was carried out. Results: Following the RCT patients are perceived as true suffering persons, and the relationship with them has improved in GPs of both groups. GPs mostly valued the fact that it is highly structured, that it made possible a more comfortable relationship and that it could be applied to a broad spectrum of patients with psychosocial problems. Nevertheless, all participants consider that change in patients is necessary; GPs in the intervention group remarked that that is extremely difficult to achieve. Conclusions: GPs positively evaluate the communication techniques and the interventions that help in understanding patient suffering, and express the enormous difficulties in handling change in patients. These findings provide information on the direction in which efforts for improving intervention should be directed.Trial registration: US ClinicalTrials.gov NCT00130988 http://www.biomedcentral.com/1471-2296/10/73 Jose Aiarzaguena Idoia Gaminde Gonzalo Grandes Agustin Salazar Itziar Alonso Alvaro Sanchez BMC Family Practice 2009, 10:73 2009-11-25T00:00:00Z doi:10.1186/1471-2296-10-73 BMC Family Practice 1471-2296 10 73 2009-11-25T00:00:00Z PDF Background: Information technology (IT) is increasingly being used in general practice to manage health care including type 2 diabetes. However, there is conflicting evidence about whether IT improves diabetes outcomes. This review of the literature about IT-based diabetes management interventions explores whether methodological issues such as sample characteristics, outcome measures, and mechanisms causing change in the outcome measures could explain some of the inconsistent findings evident in IT-based diabetes management studies. Methods: Databases were searched using terms related to IT and diabetes management. Articles eligible for review evaluated an IT-based diabetes management intervention in general practice and were published between 1999 and 2009 inclusive in English. Studies that did not include outcome measures were excluded. Results: Four hundred and twenty-five articles were identified, sixteen met the inclusion criteria: eleven GP focussed and five patient focused interventions were evaluated. Nine were RCTs, five non-randomised control trials, and two single-sample before and after designs. Important sample characteristics such as diabetes type, familiarity with IT, and baseline diabetes knowledge were not addressed in any of the studies reviewed. All studies used HbA1c as a primary outcome measure, and nine reported a significant improvement in mean HbA1c over the study period; only two studies reported the HbA1c assay method. Five studies measured diabetes medications and two measured psychological outcomes. Patient lifestyle variables were not included in any of the studies reviewed. IT was the intervention method considered to effect changes in the outcome measures. Only two studies mentioned alternative possible causal mechanisms. Conclusion: Several limitations could affect the outcomes of IT-based diabetes management interventions to an unknown degree. These limitations make it difficult to attribute changes solely to such interventions. http://www.biomedcentral.com/1471-2296/10/72 Beth Costa Kristine Fitzgerald Kay Jones Trisha Dunning BMC Family Practice 2009, 10:72 2009-11-17T00:00:00Z doi:10.1186/1471-2296-10-72 BMC Family Practice 1471-2296 10 72 2009-11-17T00:00:00Z XML Background: Efficacy research has shown that intensive individual lifestyle intervention lowers the risk for developing type 2 diabetes mellitus and the metabolic syndrome. Translational research is needed to test real-world models of lifestyle interventions in primary care settings.DesignE-LITE is a three-arm randomized controlled clinical trial aimed at testing the feasibility and potential effectiveness of two lifestyle interventions: information technology-assisted self-management, either alone or in combination with care management by a dietitian and exercise counselor, in comparison to usual care. Overweight or obese adults with pre-diabetes and/or metabolic syndrome (n = 240) recruited from a community-based primary care clinic are randomly assigned to one of three treatment conditions. Treatment will last 15 months and involves a three-month intensive treatment phase followed by a 12-month maintenance phase. Follow-up assessment occurs at three, six, and 15 months. The primary outcome is change in body mass index. The target sample size will provide 80% power for detecting a net difference of half a standard deviation in body mass index at 15 months between either of the self-management or care management interventions and usual care at a two-sided α level of 0.05, assuming up to a 20% rate of loss to 15-month follow-up.Secondary outcomes include glycemic control, additional cardiovascular risk factors, and health-related quality of life. Potential mediators (e.g., treatment adherence, caloric intake, physical activity level) and moderators (e.g., age, gender, race/ethnicity, baseline mental status) of the intervention's effect on weight change also will be examined.DiscussionThis study will provide objective evidence on the extent of reductions in body mass index and related cardiometabolic risk factors from two lifestyle intervention programs of varying intensity that could be implemented as part of routine health care.Trial registrationNCT00842426 http://www.biomedcentral.com/1471-2296/10/71 Jun Ma Abby King Sandra Wilson Lan Xiao Randall Stafford BMC Family Practice 2009, 10:71 2009-11-12T00:00:00Z doi:10.1186/1471-2296-10-71 BMC Family Practice 1471-2296 10 71 2009-11-12T00:00:00Z XML Background: Previous studies indicate that clinical guidelines using combined risk evaluation for cardiovascular diseases (CVD) may overestimate risk. The aim of this study was to model and discuss implementation of the current (2007) hypertension guidelines in a general Norwegian population. Methods: Implementation of the current European Guidelines for the Management of Arterial Hypertension was modelled on data from a cross-sectional, representative Norwegian population study (The Nord-Trøndelag Health Study 1995-97), comprising 65,028 adults, aged 20-89, of whom 51,066 (79%) were eligible for modelling. Results: Among individuals with blood pressure ≥120/80 mmHg, 93% (74% of the total, adult population) would need regular clinical attention and/or drug treatment, based on their total CVD risk profile. This translates into 296,624 follow-up visits/100,000 adults/year. In the Norwegian healthcare environment, 99 general practitioner (GP) positions would be required in the study region for this task alone. The number of GPs currently serving the adult population in the study area is 87 per 100,000 adults. Conclusion: The potential workload associated with the European hypertension guidelines could destabilise the healthcare system in Norway, one of the world's most long- and healthy-living nations, by international comparison. Large-scale, preventive medical enterprises can hardly be regarded as scientifically sound and ethically justifiable, unless issues of practical feasibility, sustainability and social determinants of health are considered. http://www.biomedcentral.com/1471-2296/10/70 Halfdan Petursson Linn Getz Johann Sigurdsson Irene Hetlevik BMC Family Practice 2009, 10:70 2009-10-30T00:00:00Z doi:10.1186/1471-2296-10-70 BMC Family Practice 1471-2296 10 70 2009-10-30T00:00:00Z XML Background: Drug formularies have been created by third party payers to control prescription drug usage and manage costs. Physicians try to provide the best care for their patients. This research examines family physicians' attitudes regarding prescription reimbursement criteria, prescribing and advocacy for patients experiencing reimbursement barriers. Methods: Focus groups were used to collect qualitative data on family physicians' prescribing decisions related to drug reimbursement guidelines. Forty-eight family physicians from four Ontario cities participated. Ethics approval for this study was received from the Hamilton Health Sciences/Faculty of Health Sciences Research Ethics Board at McMaster University. Four clinical scenarios were used to situate and initiate focus group discussions about prescribing decisions. Open-ended questions were used to probe physicians' experiences and attitudes and responses were audio recorded. NVivo software was used to assist in data analysis. Results: Most physicians reported that drug reimbursement guidelines complicated their prescribing process and can require lengthy interpretation and advocacy for patients who require medication that is subject to reimbursement restrictions. Conclusion: Physicians do not generally see their role as being cost-containment monitors and observed that cumbersome reimbursement guidelines influence medication choice beyond the clinical needs of the patient, and produce unequal access to medication. They observed that frustration, discouragement, fatigue, and lack of appreciation can often contribute to family physicians' failure to advocate more for patients. Physicians argue cumbersome reimbursement regulations contribute to lower quality care and misuse of physicians' time increasing overall health care costs by adding unnecessary visits to family physicians, specialists, and emergency rooms. http://www.biomedcentral.com/1471-2296/10/69 L. Suzanne Suggs Parminder Raina Amiram Gafni Susan Grant Kevin Skilton Aimei Fan Karen Szala-Meneok BMC Family Practice 2009, 10:69 2009-10-16T00:00:00Z doi:10.1186/1471-2296-10-69 BMC Family Practice 1471-2296 10 69 2009-10-16T00:00:00Z XML Background: Persistent presentation of medically unexplained symptoms (MUS) is troublesome for general practitioners (GPs) and causes pressure on the doctor-patient relationship. As a consequence, GPs face the problem of establishing an ongoing, preferably effective relationship with these patients. This study aims at exploring GPs' perceptions about explaining MUS to patients and about how relationships with these patients evolve over time in daily practice. Methods: A qualitative approach, interviewing a purposive sample of twenty-two Dutch GPs within five focus groups. Data were analyzed according to the principles of constant comparative analysis. Results: GPs recognise the importance of an adequate explanation of the diagnosis of MUS but often feel incapable of being able to explain it clearly to their patients. GPs therefore indicate that they try to reassure patients in non-specific ways, for example by telling patients that there is no disease, by using metaphors and by normalizing the symptoms. When patients keep returning with MUS, GPs report the importance of maintaining the doctor-patient relationship. GPs describe three different models to do this; mutual alliance characterized by ritual care (e.g. regular physical examination, regular doctor visits) with approval of the patient and the doctor, ambivalent alliance characterized by ritual care without approval of the doctor and non-alliance characterized by cutting off all reasons for encounter in which symptoms are not of somatic origin. Conclusion: GPs feel difficulties in explaining the symptoms. GPs report that, when patients keep presenting with MUS, they focus on maintaining the doctor-patient relationship by using ritual care. In this care they meticulously balance between maintaining a good doctor-patient relationship and the prevention of unintended consequences of unnecessary interventions. http://www.biomedcentral.com/1471-2296/10/68 Tim olde Hartman Lieke Hassink-Franke Peter Lucassen Karel van Spaendonck Chris van Weel BMC Family Practice 2009, 10:68 2009-09-24T00:00:00Z doi:10.1186/1471-2296-10-68 BMC Family Practice 1471-2296 10 68 2009-09-24T00:00:00Z XML Background: High utilising primary care patients with medically unexplained symptoms (MUS) often frustrate their primary care providers. Studies that elucidate the attitudes of these patients may help to increase understanding and improve confidence of clinicians who care for them. The objective of this study was to describe and analyze perceptions and lived experiences of high utilising primary care patients with MUS. Methods: A purposive sample of 19 high utilising primary care patients for whom at least 50% (69.6% in this sample) of visits for two years could not be explained medically, were encouraged to talk spontaneously about themselves and answer semi-structured questions. Verbatim transcripts of interviews were analyzed using an iterative consensus building process. Results: Patients with MUS almost universally described current and/or past family dysfunction and were subjected to excessive testing and ineffective empirical treatments. Three distinct groups emerged from the data. 1) Some patients, who had achieved a significant degree of psychological insight and had success in life, primarily sought explanations for their symptoms. 2) Patients who had less psychological insight were more disabled by their symptoms and felt strongly entitled to be excused from normal social obligations. Typically, these patients primarily sought symptom relief, legitimization, and support. 3) Patients who expressed worry about missed diagnoses demanded excessive care and complained when their demands were resisted. Conclusion: High utilising primary care patients are a heterogeneous group with similar experiences and different perceptions, behaviours and needs. Recognizing these differences may be critical to effective treatment and reduction in utilisation. http://www.biomedcentral.com/1471-2296/10/67 Francesca Dwamena Judith Lyles Richard Frankel Robert Smith BMC Family Practice 2009, 10:67 2009-09-21T00:00:00Z doi:10.1186/1471-2296-10-67 BMC Family Practice 1471-2296 10 67 2009-09-21T00:00:00Z XML