Accuracy Of General Practitioners Research Articles

The importance of patient characteristics, operators, and image quality for the accuracy of heart failure diagnosis by general practitioners using handheld ultrasound devices.

To evaluate whether the characteristics of patients, operators, and image quality could explain the accuracy of heart failure (HF) diagnostics by general practitioners (GPs) using handheld ultrasound devices (HUDs) with automatic decision-support software and telemedical support. Patients referred to an outpatient cardiac clinic due to symptoms indicating HF were examined by one of five GPs after dedicated training. In total, 166 patients were included [median (inter-quartile range) age 73 (63-78) years; mean ± standard deviation ejection fraction 53 ± 10%]. The GPs considered whether the patients had HF in four diagnostic steps: (i) clinical examination, (ii) adding focused cardiac HUD examination, (iii) adding automatic decision-support software measuring mitral annular plane systolic excursion (autoMAPSE) and ejection fraction (autoEF), and (iv) adding telemedical support. Overall, the characteristics of patients, operators, and image quality explained little of the diagnostic accuracy. Except for atrial fibrillation [lower accuracy for HUD alone and after adding autoEF (P < 0.05)], no patient characteristics influenced the accuracy. Some differences between operators were found after adding autoMAPSE (P < 0.05). Acquisition errors of the four-chamber view and a poor visualization of the mitral plane were associated with reduced accuracy after telemedical support (P < 0.05). The characteristics of patients, operators, and image quality explained just minor parts of the modest accuracy of GPs' HF diagnostics using HUDs with and without decision-support software. Atrial fibrillation and not well-standardized recordings challenged the diagnostic accuracy. However, the accuracy was only modest in well-recorded images, indicating a need for refinement of the technology.

Clinical judgement by primary care physicians for the diagnosis of all-cause dementia or cognitive impairment in symptomatic people.

Clinical judgement by primary care physicians for the diagnosis of all-cause dementia or cognitive impairment in symptomatic people.

Evaluation of general practitioners' single-lead electrocardiogram interpretation skills: a case-vignette study.

BackgroundHandheld single-lead electrocardiograms (1L-ECG) present a welcome addition to the diagnostic arsenal of general practitioners (GPs). However, little is known about GPs’ 1L-ECG interpretation skills, and thus its reliability in real-world practice.ObjectiveTo determine the diagnostic accuracy of GPs in diagnosing atrial fibrillation or flutter (AF/Afl) based on 1L-ECGs, with and without the aid of automatic algorithm interpretation, as well as other relevant ECG abnormalities.MethodsWe invited 2239 Dutch GPs for an online case-vignette study. GPs were asked to interpret four 1L-ECGs, randomly drawn from a pool of 80 case-vignettes. These vignettes were obtained from a primary care study that used smartphone-operated 1L-ECG recordings using the AliveCor KardiaMobile. Interpretation of all 1L-ECGs by a panel of cardiologists was used as reference standard.ResultsA total of 457 (20.4%) GPs responded and interpreted a total of 1613 1L-ECGs. Sensitivity and specificity for AF/Afl (prevalence 13%) were 92.5% (95% CI: 82.5–97.0%) and 89.8% (95% CI: 85.5–92.9%), respectively. PPV and NPV for AF/Afl were 45.7% (95% CI: 22.4–70.9%) and 98.8% (95% CI: 97.1–99.5%), respectively. GP interpretation skills did not improve in case-vignettes where the outcome of automatic AF-detection algorithm was provided. In detecting any relevant ECG abnormality (prevalence 22%), sensitivity, specificity, PPV and NPV were 96.3% (95% CI: 92.8–98.2%), 68.8% (95% CI: 62.4–74.6%), 43.9% (95% CI: 27.7–61.5%) and 97.9% (95% CI: 94.9–99.1%), respectively.ConclusionsGPs can safely rule out cardiac arrhythmias with 1L-ECGs. However, whenever an abnormality is suspected, confirmation by an expert-reader is warranted.

Competence of general practitioners in requesting and interpreting ECGs - acase vignette study.

BackgroundPerforming electrocardiography is common in general practice, but the quality of indication setting and diagnostic accuracy have been disputed.ObjectivesTo assess the competence of general practitioners (GPs) in their decision-making process with regard to recording and interpreting an electrocardiogram (ECG) and evaluating the relevance of the result for management.MethodsAn online case vignette survey was performed among GPs and cardiologists (in 2015). Nine cases describing situations for which Dutch clinical guidelines recommend or advise against recording an ECG were presented. In each case, the participant had to make choices on recording an ECG, interpreting it, and using the result in a management decision. The reference standard for each ECG diagnosis was set by the expert author team.ResultsFifty GPs who interpret ECGs themselves, eight GPs who do not and 12 cardiologists completed the survey. Adherence to guidelines recommending an ECG was high for suspected atrial fibrillation, suspected arrhythmia present during consultation, including bradycardia, but much lower for progressive heart failure and stable angina. Diagnostic accuracy of GPs was best in atrial fibrillation (96%), sick sinus syndrome (85%) and old myocardial infarction (82%), but poor in left anterior fascicular block (16%) and incomplete right bundle branch block (10%). GPs often acknowledged the low relevance of the results of a non-indicated ECG.ConclusionGPs do not fully adhere to Dutch cardiovascular guidelines on indications for recording ECGs. Diagnostic accuracy was high for atrial fibrillation, sick sinus syndrome and old myocardial infarction and poor for left anterior fascicular block and incomplete right bundle branch block.Electronic supplementary materialThe online version of this article (10.1007/s12471-018-1124-2) contains supplementary material, which is available to authorized users.

Post-mortem external examination: competence, education and accuracy of general practitioners in a metropolitan area.

In several countries, general practitioners conduct post-mortem external examination (PMEE) and certify death in out-of-hospital cases. A possible lack of accuracy has been repeatedly criticised, although data on everyday practice of PMEE on outpatients are scarce. To evaluate medical practitioner's competence, education and accuracy regarding PMEE, we conducted a fax-survey among 1343 medical doctors in the metropolitan area of Hamburg, Germany. The results indicate considerable shortcomings in up to 63% regarding the inspection of body orifices and hidden areas, palpation of osseous structures, ectropionisation of the eyelids and use of aids. More than 5% of respondents reported to fill in a death certificate without performing a complete PMEE in the majority of cases. While theoretical teaching on PMEE was reported quite frequently (up to 78%), a considerably smaller group received practical training (32% during undergraduate and 13% during postgraduate education). To estimate the effects of training on PMEE, an individual "accuracy score" was calculated (range 1-5). Mean score was 3.63 (SD 0.81), and results differed significantly (p<0.001) among groups of medical practitioners with or without education on PMEE and was highest among doctors who received practical training (p<0.005). The results indicate that there are major shortcomings in a relevant portion of PMEE performed on out-of-hospital deaths that might lead to misdiagnosis of non-natural causes of deaths and homicides. Practical pre- and postgraduate education appears to positively impact accuracy and therefore quality of the procedure. Consequently, corresponding practical training should be mandatory during academic studies and ongoing education programs.

DETECTION OF ANXIETY DISORDERS IN PRIMARY CARE: A META-ANALYSIS OF ASSISTED AND UNASSISTED DIAGNOSES.

Evidence suggests that general practitioners (GPs) fail to diagnose up to half of common mental disorder cases. Yet no previous research has systematically summarized the evidence in the case of anxiety disorders. The aim of this review was to systematically assess and meta-analyze the diagnostic accuracy of GPs' assisted (i.e., using severity scales/diagnostic instruments) and unassisted (without such tools) diagnoses of anxiety disorders. Systematic review (PROSPERO registry CRD42013006736) was conducted. Embase, Ovid Journals--Ovid SP Medline, Pubmed, PsycINFO, Scopus, Web of Science, and Science Direct were searched from January 1980 through June 2014. Seven investigators, working in pairs, evaluated studies for eligibility. The quality of included studies was assessed with the Quality Assessment of Diagnostic Accuracy Studies tool version 2 (QUADAS-2). The main outcome measures were sensitivity and specificity of clinical diagnoses of any anxiety disorder. We pooled sensitivity and specificity levels from included studies using bivariate meta-analyses. Twenty-four studies were included in the meta-analysis with a total sample of 34,902 patients. Pooled sensitivity and specificity were estimated at 44.5% (95% CI 33.7-55.9%) and 90.8% (95% CI 87-93.5%). GPs' sensitivity was higher when diagnoses were assisted (63.6%, 95% CI 50.3-75.1%) than when unassisted (30.5%, 95% CI 20.7-42.5%) to the expense of some specificity loss (87.9%, 95% CI 81.3-92.4% vs. 91.4%, 95% CI 86.6-94.6%, respectively). Identification rates remained constant over time (P-value = .998). The use of diagnostic tools might improve detection of anxiety disorders in "primary care."

Accuracy of general practitioners’ readings of ECG in primary care

Abstract

Accuracy of general practitioners' assessment of chest pain patients for coronary heart disease in primary care: cross-sectional study with follow-up.

To estimate how accurately general practitioners' (GP) assessed the probability of coronary heart disease in patients presenting with chest pain and analyze the patient management decisions taken as a result. During 2005 and 2006, the cross-sectional diagnostic study with a delayed-type reference standard included 74 GPs in the German state of Hesse, who enrolled 1249 consecutive patients presenting with chest pain. GPs recorded symptoms and findings for each patient on a report form. Patients and GPs were contacted 6 weeks and 6 months after the patients' visit to the GP. Data on chest complaints, investigations, hospitalization, and medication were reviewed by an independent panel, with coronary heart disease being the reference condition. Diagnostic properties (sensitivity, specificity, and predictive values) of the GPs' diagnoses were calculated. GPs diagnosed coronary heart disease with the sensitivity of 69% (95% confidence interval [CI], 62-75) and specificity of 89% (95% CI, 87-91), and acute coronary syndrome with the sensitivity of 50% (95% CI, 36-64) and specificity of 98% (95% CI, 97-99). They assumed coronary heart disease in 245 patients, 41 (17%) of whom were referred to the hospital, 77 (31%) to a cardiologist, and 162 (66%) to electrocardiogram testing. GPs' evaluation of chest pain patients, based on symptoms and signs alone, was not sufficiently accurate for diagnosing or excluding coronary heart disease or acute coronary syndrome.

The accuracy of general practitioners’ clinical assessment of chest pain patients

Objective: To study general practitioners’ (GP) assessment of the probability of ischaemic heart disease (IHD) and GP action in daily practice regarding chest pain patients. Methods: All chest pain patients aged 20–79 years, attending three primary health-care centres in south-east Sweden and assessed by the GP to have high, low or very low probability of IHD, were included consecutively over a two year period. The “GP action in daily practice” was classed as “active decisions” (investigation or treatment) or “wait and see”. “IHD” or “not IHD” was settled according to the results of acute hospital investigation or exercise testing/myocardial perfusion scintigraphy. Results: 516 patients were included, 93 high, 145 low and 278 very low probability cases. The outcome was “IHD” in 47%, 9% and 1% respectively. The sensitivity and specificity of the “GP assessment of the probability of IHD” were 72% and 89%. The sensitivity and specificity of the “GP action in daily practice” were 88% and 72%, respectively. The negative predictive value was 98%. Conclusion: GP assessment, after clinical evaluation, that the probability of IHD was low did not safely rule out IHD. GP action in daily practice however, indicates that general practice is an appropriate level of care for chest pain patients.

Prevalence and Detection of HIV Risk Behavior in Primary Care: Implications for Clinical Preventive Services

Despite their potential to reduce the incidence of HIV infection through primary prevention, family physicians report low levels of routine identification of patients at risk and counseling. This may reflect perceptions that few of their patients are at risk, that patients at risk will self-disclose during consultations, or that a physician-initiated approach is unacceptable to patients presenting for non-HIV-related problems. Our aim was to determine the prevalence of risk factors for HIV infection and HIV testing among patients in general practice, the acceptability to patients of opportunistic identification of risk during routine consultations and the accuracy of general practitioners' assessment of HIV risk. Our setting included randomly selected general practitioners' surgeries in metropolitan Sydney, Australia. We conducted a self-administered survey about risk factors in a consecutive sample of patients 18-50 years of age and compared it to a checklist about patient's risk factors completed by general practitioners unaware of the patients' answers. Of 1,030 patients, 43 (4%) were at risk of HIV infection having received blood transfusions between 1980 and 1985 and seven (1%) had injected intravenous drugs in the previous 12 months. In the previous 12 months, 133 (21%) female and 110 (28%) male patients had been in nonmutually monogamous heterosexual relationships. Only 26% always used condoms. While the majority of patients indicated they were heterosexual, 42 (4%) were homosexual and 23 (2%) bisexual. Of those men who had had sex with other men, 39% always used condoms.(ABSTRACT TRUNCATED AT 250 WORDS)