Diagnoses In Primary Health Care Research Articles

DIFFICULTIES FOR DENTAL SURGEONS REGARDING THE EARLY DIAGNOSIS OF MOUTH CANCER IN PRIMARY HEALTH CARE

Introduction: In Brazil, oral cancer disease is considered a malignant neoplasm of the lip, tongue, gums, floor of the mouth, hard palate and other parts of the mouth. It represents a serious public health problem due to the high rates of late diagnoses and, consequently, the significant rates of morbidity and mortality. General objective: This is a research developed through an opinion article focusing on the dental surgeon’s approach to diagnosis in Primary Health Care (PHC). Methods: This is an opinion article survey, developed from February to June 2024, through the reflection of the texts published in the area as well as through the guidelines of the dental surgeon in PHC. Results: In the end, it can be seen that associated factors evidence this difficulty, such as the lack of materials for biopsy performance. Another important point is the non-implementation of family health strategies as an approach to the prevention of oral cancer. Final considerations: It can be stated that the training of professionals is an important factor for early diagnosis, as well as the expansion of resources.

Comparing the effectiveness of competition as a method of reminding primary oral health care dentists to record diagnoses with two alternative methods used to enhance the recording of diagnoses in primary health care

ABSTRACT The purpose of this study was to investigate whether competition is an effective method to remind primary oral health care dentists to record diagnoses (RRD). The effectiveness of competition was examined in comparison with financial group bonuses (FGBs) and electronic reminders (ERs) of the electronic health record, together with superior-subordinate or development discussions. Putative differences in the diagnosis recording cultures of Finnish public health care physicians and dentists were studied. This was a retrospective quasi-experimental observational study in which the effects of the interventions on the rate of recording diagnoses were identified using a general linear regression model and proportions of visits with recorded diagnoses. The rate of increase in the recording of diagnoses in dentists was 0.995 ± 0.273%/month (mean ± SEM) after the implementation of RRDs and this did not differ from that obtained after starting FGBs (0.919 ± 0.130%/month) or ERs with superior-subordinate or development discussions (1.562 ± 0.277%/month) in physicians. As the rates of increase did not differ none of the applied methods seemed to be more effective than the others when trying to influence the behaviour of primary health care clinicians. Altogether, public primary health care physicians were more active than respective primary oral health care dentists to record diagnoses.

Artificial intelligence in the GPs office: a retrospective study on diagnostic accuracy

Objective Machine learning (ML) is expected to play an increasing role within primary health care (PHC) in coming years. No peer-reviewed studies exist that evaluate the diagnostic accuracy of ML models compared to general practitioners (GPs). The aim of this study was to evaluate the diagnostic accuracy of an ML classifier on primary headache diagnoses in PHC, compare its performance to GPs, and examine the most impactful signs and symptoms when making a prediction. Design A retrospective study on diagnostic accuracy, using electronic health records from the database of the Primary Health Care Service of the Capital Area (PHCCA) in Iceland. Setting Fifteen primary health care centers of the PHCCA. Subjects All patients that consulted a physician, from 1 January 2006 to 30 April 2020, and received one of the selected diagnoses. Main outcome measures Sensitivity, Specificity, Positive Predictive Value, Matthews Correlation Coefficient, Receiver Operating Characteristic (ROC) curve, and Area under the ROC curve (AUROC) score for primary headache diagnoses, as well as Shapley Additive Explanations (SHAP) values of the ML classifier. Results The classifier outperformed the GPs on all metrics except specificity. The SHAP values indicate that the classifier uses the same signs and symptoms (features) as a physician would, when distinguishing between headache diagnoses. Conclusion In a retrospective comparison, the diagnostic accuracy of the ML classifier for primary headache diagnoses is superior to GPs. According to SHAP values, the ML classifier relies on the same signs and symptoms as a physician when making a diagnostic prediction. Keypoints Little is known about the diagnostic accuracy of machine learning (ML) in the context of primary health care, despite its considerable potential to aid in clinical work. This novel research sheds light on the diagnostic accuracy of ML in a clinical context, as well as the interpretation of its predictions. If the vast potential of ML is to be utilized in primary health care, its performance, safety, and inner workings need to be understood by clinicians.

The status of integrated care on the chronic abuse of alcohol response - A cross-sectional study

Abstract Background In 2017, the risk-weighted prevalence of alcohol consumption was the health indicator with a more negative impact on the Institute for Health Metrics and Evaluation Sustainable Development Goals Health Index Value in Portugal. According to data from 2012-14, the Alto Tâmega and Barroso (ATB) had the highest value of Years of potential life lost (YPLL) in North Portugal - 4570,1/10.000 people. Liver chronic disease was the specific cause of death that contributed to the value of YPLL - 465,4/10.000 people. Methods A cross-sectional study was conducted with data from the Northern Health Administration and the General Directorate for Intervention on Addictive Behaviours and Dependencies. We compared the number of patients with chronic alcohol consumption (CAC) in 2018, the leading causes of death between 2012-14, the main morbidity causes according to data from primary healthcare (PHC) physicians in 2018 and the number of patients in specialized treatment team (STT) for alcohol abuse treatment in 2018 in ATB. Results In 2018, 2643 patients of ATB had a diagnosis of CAC; only 178 were followed by an STT. Although CAC had a massive influence on YPLL, this was only the 11º cause of morbidity in ATB according to the data from PHC. The number of women with CAC was stable between 2012 (n = 284) and 2018 (n = 291). In the same period, there was an increase of 52,86% of CAC on men (n = 1523 to n = 2348). Even though 18,4% of YPLL due to chronic liver disease happen in women, only 11,2%of the patients with CAC in the PHC are women. Conclusions There is a need for the improvement of CAC diagnosis in PHC, and the improvement of referral of patients to STT and hospital care. Besides, to reach the SDG3, there is the need to work intensely on SDG 17 (partnership for the goals). The Public Health Unit of ATB is organizing Operation PROMETEU to improve communication, institutional collaboration, and monitoring of the existing health activities that are tackling CAC. Key messages The need to integrate data from different healthcare sources for a better analysis on health problems. The urgent need to tackle the alcohol abuse problem in ATB.

Establishing Technical Values for Nursing Diagnoses in Primary Healthcare.

To establish technical values for nursing diagnoses in primary healthcare with which to weight the delivery of care based on criteria of complexity and relevance. A three-phase cross-sectional descriptive study: (1) establishing and weighting of the assessment criteria of technical values, (2) scoring of the assessment criteria per diagnosis, and (3) assigning technical values. Diagnoses were ordered on the scoring scale obtained and a technical value of 1 to 4 was assigned according to their quartile. Having a technical value for each nursing diagnosis helps to measure the diversity and complexity of care. Technical values may contribute to improving nursing management indicators, as they incorporate a quantitative view into the assessment process.

The quality of the sickness certificate. A case control study of patients with symptom and disease specific diagnoses in primary health care in Sweden

Objective: To compare information in sickness certificates and rehabilitation activities for patients with symptom diagnoses vs patients with disease specific diagnoses.Design: Retrospective case control study 2013–2014.Setting: Primary health care, Sweden.Subjects. Patients with new onset sickness certificates with symptom diagnoses n = 222, and disease specific diagnoses (controls), n = 222.Main outcome measures: Main parameters assessed were: information about body function and activity limitation in certificates, duration of sick leave, certificate renewals by telephone, diagnostic investigations, health care utilisation, contacts between patients, rehabilitation coordinators, social insurance officers, employers and occurrence of rehabilitation plans.Results: Information about body function and activity limitation was sufficient according to guidelines in half of all certificates, less in patients with symptom diagnoses compared to controls (44% vs. 56%, p = 0.008). Patients with symptom diagnoses had shorter sick leave than controls (116 vs. 151 days p = 0.018) and more certificates issued by telephone (23% vs. 15% p = 0.038). Furthermore, they underwent more diagnostic investigations (32% vs. 18%, p < 0.001) and the year preceding sick leave they had more visits to health care (82% vs. 68%, p < 0.001), but less follow-up (16% vs. 26%, p < 0.008). In both groups contacts related to rehabilitation and with employers were scarce.Conclusion: Certificates with symptom diagnoses compared to disease specific diagnoses could be used as markers for insufficient certificate quality and for patients with higher health care utilisation. Overall, the information in half of the certificates was insufficient and early contacts with employers and rehabilitation activities were in practice missing.KEY POINTSSymptom diagnoses are proposed as markers of sickness certification quality. We investigated this by comparing certificates with and without symptom diagnoses.Certificates with symptom diagnoses lacked information to a higher degree compared to certificates with disease specific diagnoses.Regardless of diagnoses, early contacts between patients, rehabilitation coordinators and social insurance officers were rare and contacts with employers were absent.

Validity of polymyalgia rheumatica diagnoses and classification criteria in primary health care

ObjectivesPMR is an inflammatory disease with prominent morning stiffness and muscular tenderness, usually diagnosed in primary health care (PHC). The objectives were to examine the validity of PMR diagnoses in PHC and to validate the use of classification criteria for PMR. MethodsMedical records for patients with a registered PMR diagnosis at two PHC facilities were reviewed. Patients were classified according to several sets of criteria. An independent review, with assessment of the PMR diagnosis, was performed by an experienced rheumatologist.ResultsOf 188 patients, the PMR diagnosis was in agreement with the independent review in 60% overall, in 84% of those fulfilling a modified version of the ACR/EULAR classification criteria and in 52% of those who did not. The corresponding proportions for the Bird criteria were 66 and 31%, and for the Healey criteria 74 and 42%. In 74% of the medical records, documentation on morning stiffness was missing. Rheumatoid factor was tested in 22% and anti-CCP antibodies in 15%.ConclusionIn this study of patients with PMR diagnosed in PHC, the diagnosis was supported by the independent review in 60% of the patients. Documentation on morning stiffness and testing for autoantibodies were limited. A modified version of the ACR/EULAR criteria can be used to identify patients with a valid PMR diagnosis in retrospective surveys but does not capture all PMR patients. The modified ACR/EULAR criteria may be more stringent than some of the older criteria sets.

Primary health care: an opportunity for early identification of people living with undiagnosed HIV infection.

We aimed to determine the fraction of HIV-diagnosed individuals who had primary health care (PHC) contacts 3years prior to HIV diagnosis and whether the risk of HIV diagnosis and degree of immunodeficiency were associated with the frequency of visits or procedures performed. We used data from national registries to conduct a population-based nested case-control study. Cases were individuals diagnosed with HIV infection in Denmark from 1998 to 2016. Population controls were extracted from the general population matched 13:1 on gender and age. We used conditional logistic regression. As there was a statistically significant interaction, analyses were further stratified by gender and Danish/non-Danish origin. We identified 2784 cases and 36192 controls. Ninety-three per cent of cases and 88% of controls attended PHC at least once in the 3years prior to diagnosis, with a higher median number of visits to PHC (NVPC) for cases. We found a statistically significant positive association between NVPC and risk of subsequent HIV diagnosis in men and non-Danish women. A U-shaped association between NVPC and risk of HIV diagnosis among Danish women. No substantial association between NVPC and degree of immunodeficiency was found. Risk of HIV diagnosis and degree of immunodeficiency were weakly associated with type of procedures performed. For most HIV-infected individuals, there seem to be many opportunities for earlier diagnosis in PHC. In men and non-Danish women, the risk of HIV diagnosis but not the degree of immunodeficiency was related to NVPC. The results suggest that the type of medical procedure performed cannot not be used as a guide by the primary physician to indicate which patients to test.

Evidence Based Medical Prevention: International Experience

The objective: was to study the international experience of evidence based preventive medicine development as well as to estimate its perspectives in Ukraine.&#x0D; Patients and methods. Main principles and methods of scientific knowledge and research have been used including universal ones, methods of systemic approach, quantitative and qualitative information analysis, classification and systematization of theoretical and empirical data, hystorical and logical methods, health statistics as well). In total 529 scientific information sources have been studied, particularly a number of evidence based medicine (EBM) computer databases, special task forces recommendations and Cochrane reviews on prevention, Register of medical and technological documents for health care standards in Ukraine et al.&#x0D; Results. The contribution of foreign scientific schools in the development of EBM has been determined, as well as the crucial role of scientific works carried out in the US and Great Britain in 1930–80s as to the development of evidence based preventive medicine. The international experience of the development and functioning of evidence based practice centers’ and special task forces on prevention has been summarized, as the experience of the development and implementation of recommendations on prevention in primary health care (PHC) in high income countries acceptable for Ukraine. The concept of evidence based prevention has been first proposed. It is revealed, that EBM implementation in Europe has been prioritized in both the field of infectious diseases prevention and PHC, while there are both the development of differentiated evidence based prevention and early evidence based diagnosis in PHC in the US.&#x0D; Conclusion. The results proved importance of taking into consideration of international experience while evidence based PHC is being developed as a priority in Ukraine.

Intertester reliability of shoulder complaints diagnoses in primary health care

Objective: Shoulder complaints are frequently encountered in general practice, but precise diagnosing is challenging. This study investigated agreement of shoulder complaints diagnoses between clinicians in a primary health care setting.Design: Cross-sectional study.Setting: Four primary health care clinicians used patients’ history and functional examination of the shoulder by selective tissue tension techniques (STTs), to diagnose shoulder complaints.Subjects: 62 patients, aged 18–75 years.Main outcome measure: Reliability of diagnoses was assessed by observed intertester agreement and Cohen’s kappa. A total of 372 diagnostic pairs were available for intertester comparisons.Results: Six diagnoses were assigned by all clinicians; supraspinatus-, infraspinatus-, subscapularis-tendinopathies; chronic subacromial bursitis; glenohumeral capsulitis, and acromioclavicular joint lesion. The observed agreement on these diagnoses ranged from 0.84 for glenohumeral capsulitis to 0.97 for acromioclavicular joint lesion. Kappa scores were 0.46 (95% CI 0.33, 0.58) for chronic subacromial bursitis; 0.53 (95% CI 0.34, 0.68), 0.59 (95% CI 0.47, 0.70), and 0.68 (95% CI 0.53, 0.82) for infraspinatus -, supraspinatus -, and subscapularis-tendinopathy, respectively. For glenohumeral capsulitis and acromioclavicular lesion kappa scores were 0.66 (95% CI 0.57, 0.73) and 0.78 (95% CI 0.61, 0.90). Kappa scores were higher for individual diagnoses than for individual tests, except for limitation in passive abduction (0.70, 95% CI 0.62, 0.78) and passive lateral rotation (0.66, 95% CI 0.57, 0.73).Conclusions: Although experienced clinicians showed substantial intertester agreement, precise diagnoses of shoulder complaints in primary health care remain a challenge. The present results call for further research on refined diagnoses of shoulder complaints.Key points Based on medical history and a systematic functional examination by selective tissue tension techniques (STTs), we investigated the agreement of shoulder complaints diagnoses across four primary health care clinicians and 62 patients.• Agreements on diagnoses were generally better than the agreement on individual tests.• Good kappa scores were obtained for the diagnoses glenohumeral capsulitis, rotator cuff tendinopathy, and acromioclavicular lesion.• Further research is necessary to investigate the diagnostic validity of functional shoulder examination by the STTs method.

How should prevalence of alcohol use disorders be assessed globally?

Alcohol is a major risk factor for global burden of disease, and alcohol use disorders make up a considerable portion of this burden. Up to now, prevalence of alcohol use disorders has been estimated based on general population surveys with the Composite International Diagnostic Interview (CIDI) as the gold standard for assessment. However, three major problems have been identified with the current conceptualization of alcohol use disorders and its measurement via CIDI: cultural specificity of key criteria measured such as loss of control; lack of convergence of diagnoses identified by CIDI with clinically relevant diagnoses in primary health care; and impact of stigma on measurement. As a solution, it is proposed to measure alcohol use disorders via heavy drinking over time, with thresholds taken from the European Medicines Agency (60 and more grams on average per day of pure alcohol for men, and 40+ grams for women). Current data on level of drinking (per capita consumption) assessed via taxation and other means allow for a measure of less bias. If these thresholds are considered too low and there is more emphasis on need for specialized treatment, then thresholds for very heavy drinking can be taken as alternatively (100+, and 60+ grams per day pure alcohol for men and women, respectively). Copyright © 2016 John Wiley & Sons, Ltd.

Altering a computerized laboratory test order form rationalizes ordering of laboratory tests in primary care physicians

BackgroundTo reduce physicians’ inappropriate laboratory requests for their patients, administrators have used methods such as modifying a laboratory request order form with an agreed requesting protocol for the most common diagnoses in primary health care. ObjectiveTo study the effects of removing the erythrocyte sedimentation rate (ESR) and aspartate transaminase (AST) which are considered of limited clinical value for primary care clinical decision-making from a computerized laboratory test order form. These tests were removed to another new view from the electronic laboratory menu where the physicians, instead of just ticking the desired test from the list, had to do 4–8s extra work by writing down the abbreviation to order the test. MethodsAn observational controlled prospective study based on a before-after design was performed by removing AST and ES from the laboratory test order form of the computerized laboratory system for all primary care in the city of Helsinki, Finland. The numbers of annual and monthly use of AST and ESR and their controls, alanine transaminase (ALT) and C-reactive protein (CRP) ordered by General practitioners (GPs) was recorded over an eight-year period: four years before and a four years after the removal of AST and ES. ResultsRemoving AST and ESR from the computerized laboratory test order form decreased their use by up to 90%, whereas the use of the control tests increased throughout the follow-up period. The variation in use of these removed tests also decreased. ConclusionRemoving a laboratory test from a computerized laboratory test order form may significantly reduce GPs’ use of the laboratory test. Further studies are needed, however, to ensure the safety of this type of intervention.

Most common diseases diagnosed in primary care in Stockholm, Sweden, in 2011

The most commonly reported diagnoses in primary care are useful to identify and meet health care needs in society. We estimated the rates of the most common diagnoses in primary health care in total and also by gender. This was a cross-sectional study including all 2.0 million inhabitants living in Stockholm County, Sweden, on 1 January 2009. Data on all health care appointments made in primary care in 2011 and during 2009-11 were extracted from the Stockholm County Council data warehouse VAL (Vårdanalysdatabasen; Stockholm regional health care data warehouse). Primary care data were analysed by underlying population and age. Appropriate specialist open care and inpatient data were used for comparison. The five most common diagnoses in primary care (in 2011) were acute upper respiratory tract infections (6.0% of the population), essential hypertension (5.6%), coughing (2.6%), dorsalgia (2.6%) and acute tonsillitis (2.4%). Female-to-male ratios were higher for 27 of the 30 most common diagnoses, the exceptions being type 2 diabetes, unspecified types of diabetes and multiple wounds. The 30 most common diagnoses in primary care reflect the complexity of disorders cared for in the first line of health care. Knowledge of these patterns is important when aiming at using primary health care resources in a proper way.

Medical Yoga for Patients with Stress-Related Symptoms and Diagnoses in Primary Health Care: A Randomized Controlled Trial

An increasing number of patients are suffering from stress-related symptoms and diagnoses. The purpose of this study was to evaluate the medical yoga treatment in patients with stress-related symptoms and diagnoses in primary health care. A randomized controlled study was performed at a primary health care centre in Sweden from March to June, 2011. Patients were randomly allocated to a control group receiving standard care or a yoga group treated with medical yoga for 1 hour, once a week, over a 12-week period in addition to the standard care. A total of 37 men and women, mean age of 53 ± 12 years were included. General stress level (measured using Perceived Stress Scale (PSS)), burnout (Shirom-Melamed Burnout Questionnaire (SMBQ)), anxiety and depression (Hospital Anxiety and Depression Scale (HADS)), insomnia severity (Insomnia Severity Index (ISI)), pain (visual analogue scale (VAS)), and overall health status (Euro Quality of Life VAS (EQ-VAS)) were measured before and after 12 weeks. Patients assigned to the Yoga group showed significantly greater improvements on measures of general stress level (P < 0.000), anxiety (P < 0.019), and overall health status (P < 0.018) compared to controls. Treatment with medical yoga is effective in reducing levels of stress and anxiety in patients with stress-related symptoms in primary health care.

National education and implementation initiatives in the field of alcohol and their effect on perceived competence and clinical practice in Swedish primary care

To encourage health professionals to raise the issue of alcohol among patients and to provide better advice to reduce hazardous drinking, Swedish health authorities implemented the Risk Drinking Project (RDP) between 2004-2009. The main activities were training seminars focusing on teaching motivational interviewing and screening for risky drinking. To evaluate the impact of RDP, baseline and follow-up surveys (in 2006 and 2009) were conducted. Participants were general practitioners (GPs) and district nurses (DNs). They were asked how often they discussed alcohol with their patients, and how they estimated their skill at providing advice about drinking and their effectiveness in helping patients reduce risky drinking. We triangulated the results with two population surveys where patients reported whether they had been asked about alcohol when visiting their primary health care (PHC) provider. We also studied changes in the number of alcohol-related diagnoses in PHC in western Sweden between 2005- 2009. Fifty-five percent of PHC providers in the 2009 follow-up survey reported participating in alcohol-related education in the past three years. For all three parameters analyzed (frequency, skill, and effectiveness), there were significant increases during the three years, particularly among DNs. However, the population surveys showed no change in patients being asked about their alcohol consumption. Further, there was only a small increase in alcohol-related diagnoses over this time-period (9%). The RDP is a likely cause of enhanced self-perceived competence among nurses and GPs. Using a combination of data sources to evaluate the impact of RDP raises uncertainty as to whether the educational effort alone was sufficient to increase screening and brief intervention.

Evaluation of Use Biochemical Diagnostics in Primary Health Care: Example of Quality Assesment

Problem: Laboratory medicine, medical-biochemical diagnosis in primary health care is much represented. By organization of family medicine medical-biochemical diagnosis is defined as a branch of diagnostic services in primary health care. For these actions is necessary in the morning prior to admission of users and their demands that all jobs are properly prepared. On previous day should be provided and prepared: accessories, reagents and machines. Morning daily routine work of preceding control and calibration equipment, methods and process quality control of work in the laboratory. Only after the fulfillment of the procedures followed overview of search control of samples. After validating the results of daily quality control and after they met the criteria can be analytically examined samples from users. These procedures are not sufficiently familiar to users and doctors, for that are very often necessary the direct telephone communication between them. To make the results of laboratory tests needed are huge material resources. This is evident in the economic analysis where laboratory tests are valued with a score of: search by type and material resources expended for analytical examination. These technical and financial performances of laboratory medicine are not appropriately classified as blatant as that in other industries, technology and other primary health care (PHC) and family medicine (FM). Goal: The overall objective of the research is to define a model of efficiency (or effectiveness) of medical-biochemical diagnosis for users with the requirements of units of family medicine (FM), in a representative sample of patients in the unit for the laboratory diagnosis of the Primary Health Care Center Gracanica. Confirm what is the usefulness of the application of laboratory diagnosis in family medicine. Determine the frequency of the need for laboratory tests in the therapeutic treatment of major diseases. Evaluate the need for using laboratory diagnostics to try to prevent major diseases. Material and methods: The study included a total of 1000 respondents. All subjects were users of primary health care in Primary Health Care Center Gracanica (Tuzla Canton) in primary health care units have received requests for laboratory diagnosis. This paper is an analysis of the representation requirements for the laboratory diagnosis by doctors in primary health care and the most frequent diseases in primary care. An analysis is made of laboratory test results, based on requests for laboratory diagnosis by doctors and illnesses in primary care. Made is analysis of the presence of normal and pathological laboratory test results from the request for the laboratory diagnosis by doctors in primary health care. Made is an analysis of the most common laboratory tests requests, and based on requests for laboratory diagnosis by doctors in primary health care and the most frequent diseases in primary health care. Incorporated is the economic analysis of labor

Patient based patterns of morbidity, a 17 year follow-up on patient records in primary care in Sweden

Results It was feasible to elucidate the longitudinal pattern of morbidity during all 17 years. The categories of patients according to the case-mix system showed great stability over time. On the diagnosis level some distinct shifts over timewere found. Conclusion Diagnoses fromelectronic patient records in primary health care during seventeen years could be used to elucidate the morbidity pattern among people in a defined geographic area. From a patient perspective thecase-mix system used showed great stability over time in terms of categories of patients with similar morbidity pattern. From the diagnosis perspective a slow shift in some types of diagnoses could be seen. The need for rules of coding and registering diagnoses in primary health care has to be emphasized. from 23rd Patient Classifications Systems International (PCSI) Working Conference Venice, Italy. 7–10 November 2007

African Caribbean hypertensive patients' perceptions and utilization of primary health care services

The aim of this article is to illuminate participants' access, utilization and perceptions of primary health care (PHC) services in two cities in England, including factors that militate against or enhance utilization of PHC services for African Caribbean people residing in England. Hypertension remains a major health issue amongst immigrant and UK born African Caribbean people. Current policy agendas are concerned with a reduction in cardiovascular disease and with addressing social exclusion, ameliorating health inequalities, and ensuring that individuals from black and minority ethnic groups receive fair and equitable access, care and treatment. The research conducted in two English cities investigates the meaning and consequences of hypertension and perceptions of PHC services. The research explored the decision making processes that lead to the presentation of individuals in PHC in England for early diagnosis and treatment. This qualitative study draws heavily on the focused ethnography methodological approach. Multiple methods were employed including two focus groups interviews, 21 semi-structured interviews and five vignette-based interviews. Participants numbered 36 in total. Data were analysed with the aid of Atlas/ti. using established principles for analysing ethnographic data. The findings map out the factors influencing early presentation for diagnosis in PHC and perspectives are gained on the quality of the participant/general practitioner (GP) relationship, as perceived by the participants. Participants' satisfaction and dissatisfaction with PHC services are also evidenced. It is relatively common in English communities of African Caribbean origin to use private PHC services. Motivations for this are evidenced, including historical antecedents. Participants used non-concordance (ie, non-compliance with prescribed medications) and traditional Caribbean herbal remedies as strategies of empowerment.

Heart failure diagnosis in primary health care: clinical characteristics of problematic patients. A clinical judgement analysis study.

BackgroundEarly detection of chronic heart failure has become increasingly important since the introduction of effective treatment. However, clinical diagnosis of heart failure is known to be difficult, especially in mild cases or early in the course of the disease. The purpose of this study is to analyse how patient characteristics contribute to difficulties in diagnosing systolic heart failure.MethodsDesign: A Clinical Judgement Analysis study of 40 case vignettes based on authentic patients, including relevant clinical data except echocardiography. Setting: Primary health care and two cardiology outpatient clinics in Stockholm. Subjects: 70 participants with different types of clinical experience; 27 specialists in general practice, 22 cardiologists, and 21 medical students. Main outcome measures: The assessed probability of heart failure for each case vignette, and the disagreement between the participants. The number of clinical variables (cues) indicative of heart failure in the case vignettes.ResultsThe ten case vignettes with the least diverging assessments more often had increased relative cardiac volume and atrial fibrillation. No further specific clinical patterns could be found in subgroups of the case vignettes. The ten case vignettes with the most diverging assessments were those with an intermediate number of clinical variables. The case vignettes with the least diverging assessments more often represented patients with cardiac enlargement and atrial fibrillation.ConclusionDiagnosing mild heart failure is difficult, as these patients are not easy to characterise. In our study, a larger number of positive cues resulted in more diagnostic conformity among the participants, and the most important information was cardiac enlargement. The importance of more objective diagnostic methods in diagnosing suspected cases of heart failure should be emphasised.

Musculoskeletal chronic pain in general practice: Studies of health care utilisation in comparison with pain prevalence

Objective - To study the relations between population prevalence of chronic pain and pain-related diagnoses (musculoskeletal and headaches) in primary health care (PHC) and to examine longitudinal variations in these diagnoses. Design - A population-based mailed survey to catch prevalence data and continuous computerised diagnosis registration in PHC. Setting - General population in a well-defined Swedish PHC district. Subjects - A random sample of 15% of the population aged 25-74, n=1101. Annual visitors to district physicians at the health centre. Main outcome measures - Rates of pain-related diagnoses in PHC in relation to population prevalence of chronic pain. Comparisons of the number of individuals (annual visiting rates) with pain-related diagnoses 1987-1996. Results - Population pain prevalence and pain-related diagnoses in PHC corresponded as regards the magnitude and distribution of chronic pain by age and partly by pain location. Compared to low-back and widespread pain, neck-shoulder pain and headaches were less frequent in PHC in relation to reported prevalence. From 1987 to 1996 we found an increasing number of individuals seeking primary care with pain-related diagnoses. The increase was mainly assigned to the groups of fibrositis/myalgia and headache. Conclusion - Pain-related diagnoses in PHC reflect partly the occurrence of self-reported chronic pain symptoms in the population. The observed increase in visits with pain-related diagnoses in the last 10 years is due to an increased number of individuals with soft-tissue rheumatism and headaches. Future studies will have to elucidate whether these findings are due to an increase in morbidity or changes in care-seeking and social conditions.