Care Family Physicians Research Articles

Chest pain units or chest pain algorithm?

A large number of patients present to the emergency department (ED) for evaluation of acute chest pain. About 10-15% are caused by acute myocardial infarction (MI), and over 50% of cases are due to noncardiac reasons. Further improvement for chest pain evaluation appears necessary. What are current options to improve chest pain evaluation in Germany? A selective literature search was performed using the following terms: "chest pain", "emergency department", "acute coronary syndrome" and "chest pain evaluation". A working group of the German Society of Cardiology published recommendations for infrastructure, equipment and organisation of chest pain units in Germany, which should be separated from the ED of hospitals and be under the leadership of a cardiologist. A symptom-based decision for acute care would be preferable if all differential diagnoses of diseases could be managed by one medical specialty: However, all four main symptoms of patients with acute MI (chest pain, acute dyspnea, abdominal pain, dizziness) are also caused by diseases of different specialties. Evaluation and treatment of acute chest pain by representatives of one specialty would lead to over- or undertreatment of affected patients. Therefore we suggest a multidisciplinary evaluation of patients with acute chest pain including representatives of emergency and critical care physicians, cardiologists, internists, geriatricians, family physicians, premedics and emergency nurses. Definition of key indicators of performance and institutionalized feedback will help to further improve quality of care.

Louisiana family physicians’ contraceptive counseling with adolescents and use of evidence-based criteria for IUD eligibility

Objectives: Louisiana has some of the highest rates of teen pregnancy and birth in the United States. Family physicians care for many Louisiana adolescents and provide contraceptives. Our objective is to describe Louisiana providers’ contraceptive counseling for adolescents; and use of up-to-date eligibility when considering adolescents’ use of IUDs.

SJSN HEALTH REVIEW WITH FAMILY DOCTOR SERVICES

National Social Assurance System (NSAS) has been valid from January 1, 2014 , with PT.ASKES as the Health Social Assurance Agency. The Preparation to welcome the validity of the National Social Assurance System (NSAS) has been doing. Until now the regulation of laws has not come yet to the procedures and technical guidelines. The health services on NSAS primary physician that is comprehensive became a choice by applying the pattern of health care family physician. Based on the regulation of laws, reference books, seminar materials and especially experience as a general practice physician who served patients with pre-paid system for almost 15 years, providing input like problems that can arise and the alternative solutions in order to support NSAS work better, maintained the quality and continuity, seeking the least possible service problems especially on the family physician service

Impact of community based, specialist palliative care teams on hospitalisations and emergency department visits late in life and hospital deaths: a pooled analysis

Objective To determine the pooled effect of exposure to one of 11 specialist palliative care teams providing services in patients’ homes.Design Pooled analysis of a retrospective cohort study.Setting Ontario, Canada.Participants...

Getting a grip on arthritis: web-based continuing health education improves rural/remote primary health care providers’ satisfaction and confidence with managing osteoarthritis

s / Osteoarthritis and Cartilage 22 (2014) S57–S489 S202 physical therapists reported that they would use other interventions in addition to advice and exercise (manual therapy 27%, acupuncture 5%, electrotherapy 2%) and there was an increased focus on aerobic training (37%). More physical therapists reported that they would supervise exercise (95%) and provide written advice about home exercise (75%) during follow-up appointments, and more would use an exercise diary to monitor exercise adherence (43%). Changes appeared most pronounced in those physical therapists attending the training days supporting ‘targeted exercise adherence’ and ‘individually tailored exercise’ interventions. Some of the reported changes were maintained at the post-intervention evaluation, including lower reported rates of other treatments, greater supervision of exercise during follow-up (89%) and use of exercise diaries (49%). However, use of specific aerobic training had reverted to pre-training levels (15%), as had use of written exercise advice during follow-up appointments (69%). Conclusion: Overall, participating in a dedicated training programme as part of a randomised trial changed some aspects of how physical therapists manage patients with knee OA. This suggests that attending training programmes, particularly those that are highly focused, are useful in terms of changing clinical practice, but multi-faceted approaches are likely to be needed to successfully maintain changes in clinical behaviour over time. 351 GETTING A GRIP ON ARTHRITIS: WEB-BASED CONTINUING HEALTH EDUCATION IMPROVES RURAL/REMOTE PRIMARY HEALTH CARE PROVIDERS’ SATISFACTION AND CONFIDENCE WITH MANAGING OSTEOARTHRITIS E. Badley yz, L. Fleet x, M. Bell y, S. Lineker k{, V. Curran x, M. Del Pino#, F. Kirby x, A. Lyddiatt yy, L. Moore k, K. Simmons x, R. Sweezie k, P. Tugwell zz, E. Ziesmann k. yUniv. of Toronto, Toronto, ON, Canada; zArthritis Community Res. and Evaluation Unit, Toronto, ON, Canada; xMem. Univ., St. John’s, NL, Canada; k The Arthritis Society, Toronto, ON, Canada; {McMaster Univ., Hamilton, ON, Canada; Hlth.Canada, Winnipeg, MB, Canada; yy Patient Partners in Arthritis, Toronto, ON, Canada; zzUniv. of Ottawa, Ottawa, ON, Canada Purpose: Osteoarthritis (OA) is highly prevalent in Canada’s rural/ remote communities. Primary health care providers serving these communities are often challenged with delivering optimal OA care and accessing relevant up-to-date information. Getting a Grip on Arthritis, a web-based continuing health education module with case-based content developed around best practice guidelines, was recently developed to address these issues. An evaluation of the program’s effectiveness in improving primary health care providers’ confidence and satisfaction with their ability to manage OA was performed. Methods: An online learning module was developed for OA based on a needs assessment with primary health care providers, and input from an interdisciplinary expert panel. The module was piloted in two predominantly rural/remote areas of Canada with documented arthritis prevalence and health human resource shortages. These areas encompassed the NorthWest Local Health Integration Network in Ontario and the Central Health Region in Newfoundland. A mixed methods evaluation was performed. This included 1) paired samples analyses of pre/ post measurements of confidence and satisfaction with ability to manage arthritis and 2) an evaluation of module content and design. Confidence and satisfaction were measured on 10 point numerical rating scales (0 1⁄4 not satisfied/not at all confident; 10 1⁄4 extremely satisfied/confident). Results: Thirty-four providers participated in the pilot, which exceeded our target of 30. Participants represented various primary health care professions, including physiotherapists, occupational therapists, nurses, and family physicians. After taking the module, satisfaction with ability to manage OA improved significantly (p 1⁄4 0.02). Significant increases in confidence with different aspects of OA care were also observed. Participants’ confidence also improved for the comprehensive musculoskeletal examination (p 1⁄4 0.02), prescribing/recommending corticosteroids (p 1⁄4 0.02), ordering/recommending serological tests (p 0.01), and managing common musculoskeletal conditions (p 1⁄4 0.03). The majority of respondents agreed that the module was consistent with stated objectives (97.5%), addressed their learning needs (87.2%) and was relevant to practice (80.0%). The planned use of relevant resources in practice and with patients highlighted the participants’ commitment to change. Participant feedback highlighted the need for additional information relevant to professions other than physicians to better capture the importance of inter-professional care. Conclusions: With knowledge gained from the online module, participants reported an increase in both satisfaction and confidence with managing OA. The module was also relevant to practice and the content addressed the participants’ learning needs. The case-based format simulated interaction with ‘real’ patients and enabled participants to practice their diagnostic and management skills. Feedback is being incorporated into the final version of the module with plans for a national launch in 2014. Epidemiology and Health Services Research 352 THE RELATIVE CONTRIBUTION OF MECHANICAL STRESS AND SYSTEMIC PROCESSES IN DIFFERENT TYPES OF OSTEOARTHRITIS: THE NEO STUDY A.W. Visser, R. de Mutsert, S. le Cessie, M. den Heijer, F.R. Rosendaal, M. Kloppenburg, NEO Study Group. Leiden Univ. Med. Ctr., Leiden,

Del lado de allá y del lado de acá: ¿qué pueden aprender mutuamente los países emergentes latinoamericanos y España para mejorar sus perfiles del médico de familia?

From one side of the ocean to the other. What can emerging latinamerican countries and Spain learn from each other to improve their family physician profile? Objective: A qualitative study was carried out with the aim to find strategic factors involving learning opportunities that northern developed countries could use from emerging countries in the South and vice versa. Design, setting and participants: A non-random intentional sampling, followed by a snowball sampling until data saturation were carried out by a group of primary health care family physicians in Toledo and Tenerife in Spain and Paraguay, Mexico and Peru. Field diaries of a normal day and its health and social care context were kept and analyzed, and a SWOT study (strengths weaknesses, opportunities and threats) was performed. Main measures and results: Twenty-four diaries of a normal day were obtained (9 physicians in Spain, 7 in Mexico, 4 in Paraguay and 4 in Peru). Some strengths were found in the South in the coexistence of ambulatory care and hospital work, in the wide range of care tasks, in the greater weight of health promotion and educational activities targeted to the population, in the presence of community field activities, in the integration of traditional medicine, in the better patient-doctor relationship and a more positive perception of the workload. And the strengths in northern countries were: more prevention, health promotion and educational actions integrated in visits to the family physician in primary care settings and more material resources available. Conclusions: There are some areas in which the Spanish family physician could learn from the latinamerican physician and vice versa.

Como dormimos? – Avaliação da qualidade do sono em cuidados de saúde primários

Aim: Assessment of sleep quality in adult primary care patients Type of study: Cross-sectional study Place: Gil Eanes Family Health Unit – Unidade Local de Saude do Alto Minho, EPE Population: Adult primary care patients Methods: We used the Pittsburgh Sleep Quality Index (PSQI). Good sleep quality was defined as a PSQI less or equal to 5 and poor sleep quality as a PSQI greater than 5. We also collected data on age, sex, marital status, schooling, profession, and professional status, a personal history of psychiatric problems and the use of sleep medication. The questionnaire was administered to a convenience sample of adult patients on the practice lists of the researchers. Patients with chronic illnesses, cognitive dysfunction, pregnant women, women up to 6 weeks postpartum, and illiterate patients were excluded from the study. Results: The study included 103 patients, of which 36,9% were men. Sleep problems were found in over half of the study sample (PSQI < 5 in 52,4% versus PSQI <= 5 in 47,6%). There were significant associations found between sleeping quality and sex, age, education and professional status. Conclusions: Sleep disorders are common in primary care patients and family physicians are well placed to diagnose and treat them. The PSQI is a good instrument for assessing sleep quality.

The role of primary care in the organisation of home care services

Purpose: To understand the use of primary care and the preference of the patients and the families in order to be registered/included in home care services. Theory: Health care delivery is a complex system that combines many different parties around a shared topic. The “chronic diseases” is a subject topic in medicine that has a great economic and emotional burden with the high hospitalisation rates and palliative care need. All the family members, care givers, health professionals, social security system, pharmacology industry besides the patients are the members of the chronic disease management procedure. Home care is a new area for Turkey that may help this procedure to flow in a more humanistic and cost efficient way. It is beneficial to administer the home care health services from the primary care level but neither the roles and the responsibilities of the health professionals nor the organisational patterns are defined in Turkey. Method: A questionnaire is applied to 46 new respondents of home care about how they learnt about the home care services, their registration way, possible reasons of the problems that they were confronted and their solution suggestions. Findings: Most of the care givers were over 45 years of age (70%), female (61%), with a monthly income of 1500-2500TL (900-1500USD). Most commonly the patients' children or the children inlaw were the caregivers (78%, n=36). Primary health care units and family physicians were the first source of information for the 48% of the participants. Main problems were defined as the lack of coordination and communication of the hospital units with the family physicians (20%) and also with the families (15%) so to be late and inefficiency was the main outcome of dissatisfaction. Discussion: Use of home care services is a new health behaviour for Turkey and “changes” need to convince and motivate the all partners to adopt the new way. So a collaborative study period is needed to be established.

There are considerable drawbacks to oral anticoagulant for monitoring patients at home which should lead family physicians to discuss alternative or enhanced solutions: a cross-sectional study

BackgroundINR (International Normalized Ratio) is the biological reference test for the monitoring of vitamin K antagonist (VKA) therapy. Overdosage of VKAs causes about 17,000 hospitalizations and 5,000 deaths each year in France. To avoid these complications, monitoring and blood sampling conditions must be rigorous. In France, more than half of INRs are carried out at home. The aim was to determine blood-sampling conditions at home, transit time and the quality of the laboratory reagents used.MethodQuestionnaire-based, descriptive epidemiological cross-sectional prevalence study involving home care nurses, family physicians (FPs) and clinical laboratories. Setting: Brittany, France, 2008. Study of the pre-analytical phase of INRs sampled at home and its influence on INR results.ResultsThe study included 291 FPs, 249 home care nurses, and 49 laboratories. 32.5% of reported INRs were outside the therapeutic range. Samples were drawn into unsuitable tubes in 5.5% of cases and delivered in a chilled condition in 9% of cases. In urban areas 50% of the tubes took more than 2 hours to reach the laboratory compared with 71% from rural areas. The average International Sensitivity Index (ISI) of the thromboplastin was 1.62. The INRs provided by the laboratories were not analyzable in 64.7% of cases where blood samples had been taken at home.ConclusionBlood sample quality, transit time and the reagents used are currently inadequate. The majority of INRs taken at home are not reliable. FPs should consider these drawbacks in comparison with alternative solutions to increase patient safety.

Care From Family Physicians Reported by Pregnant Women in the United States

We describe the proportion of family physicians providing care of any sort to pregnant women in the United States from 2000 to 2009. We used a repeat, cross-sectional design with data from the nationally representative Integrated Health Interview Series (2000-2009) for respondents who reported being pregnant at the time of the survey (N = 3,204). Using multivariate logistic regression, we modeled changes over time in pregnant women's reports of care from family physicians. We used interaction terms to test for regional differences in trends. Approximately one-third of pregnant women reported having seen or talked to a family physician for medical care during the prior year, a percentage that remained stable for the period of 2000 to 2009 (adjusted odds ratio for annual change = 1.006). Most pregnant women reported care from multiple types of clinicians, including family physicians, obstetrician-gynecologists, midwives, nurse practitioners, and physician assistants. There were regional differences in trends in family physician care; pregnant women in the North Central United States increasingly reported care from family physicians, whereas women in the South reported a decline (6.7% annual increase vs 4.7% annual decrease, P ≥.001). Trends in family medicine care for pregnant women have remained steady for the nation as a whole, but they differ by region of the United States. Most pregnant women reported care from multiple clinicians, highlighting the importance of care coordination for this patient population.

Patient Satisfaction with Services Provided by Multidisciplinary Anticoagulation Clinics

To assess patients' perception of care delivery by anticoagulation clinics (ACs) throughout Alberta, Canada. Prospective postal survey. Therapy provision by an AC to ambulatory-based patients for a minimum of 3 months across the province. A total of 1687 patients (67.9%) receiving warfarin therapy from 6 ACs for a minimum of 3 months responded. The 25-item survey had responses grouped into domains of patient preference, knowledge, and service delivery. A 5-point Likert scale enabled each response to be assigned a numerical value from 1 (strongly disagree) to 5 (strongly agree). Overall, the mean response for patient satisfaction was 4.54, indicating most patients were satisfied with the AC care they received. Among those who had received care outside of an AC, 70.4% preferred AC care compared with 18.4% for family physician care. Mean responses for knowledge and service delivery exceeded 4.0, demonstrating positive responses in favor of AC care. This study demonstrates that most patients were greatly satisfied with AC care and preferred the care received from an AC to that provided by their family physician. Service delivery across Alberta is well perceived by patients.

Women’s impressions of their inpatient birth care as provided by family physicians in the Shizuoka Family Medicine Training Program in Japan

BackgroundEven though Japan faces serious challenges in women’s health care such as a rapidly aging population, attrition of obstetrical providers, and a harsh legal climate, few family medicine residency training programs in Japan include training in obstetrics, and the literature lacks research on women’s views of intra-partum pregnancy care by family physicians.FindingsIn this exploratory study, we conducted semi-structured qualitative interviews with five women who received their admission, intrapartum, delivery and discharge care from family medicine residents in the obstetrics ward of a community training hospital. Four women had vaginal births, and one had a Cesarean section. Three were primiparous, and two multiparous. Their ages ranged from 22–33. They found value in family physician medical knowledge and easy communication style, though despite explanation, some had trouble understanding the family physician’s scope of work. These women identified negative aspects of the hospital environment, and wanted more anticipatory guidance about what to expect physically after birth, but were enthusiastic about seeing a family doctor after discharge.ConclusionsThese results demonstrate the feasibility of family medicine residents providing inpatient birth care in a community hospital, and that patients are receptive to family physicians providing that care as well after discharge. Women’s primary concerns relate mostly to hospital environment issues, and better understanding the care family physicians provide. This illustrates-areas for family physicians to work for improvements.

Medical School Rural Programs

Comprehensive medical school rural programs (RPs) have made demonstrable contributions to the rural physician workforce, but their relative impact is uncertain. This study compares rural primary care practice outcomes for RP graduates within relevant states with those of international medical graduates (IMGs), also seen as ameliorating rural physician shortages. Using data from the 2010 American Medical Association Physician Masterfile, the authors identified all 1,757 graduates from three RPs (Jefferson Medical College's Physician Shortage Area Program; University of Minnesota Medical School Duluth; University of Illinois College of Medicine at Rockford's Rural Medical Education Program) practicing in their respective states, and all 6,474 IMGs practicing in the same states and graduating the same years. The relative likelihoods of RP graduates versus IMGs practicing rural family medicine and rural primary care were compared. RP graduates were 10 times more likely to practice rural family medicine than IMGs (relative risk [RR] = 10.0, confidence interval [CI] 8.7-11.6, P < .001) and almost 4 times as likely to practice any rural primary care specialty (RR 3.8, CI 3.5-4.2, P < .001). Overall, RPs produced more rural family physicians than the IMG cohort (376 versus 254). Despite their relatively small size, RPs had a significant impact on rural family physician and primary care supply compared with the much larger cohort of IMGs. Wider adoption of the RP model would substantially increase access to care in rural areas compared with increasing reliance on IMGs or unfocused expansion of traditional medical schools.

Unruptured Left Coronary Sinus of Valsalva Aneurysm Causing Mitral Valve Obstruction

A 77-year-old man was admitted for congestive heart failure. He had started to have palpitations after eating supper 2 days before the admission and had experienced dyspnea on exertion since then. He visited his family physician, who referred him to the cardiology clinic of our hospital. The patient was under the family physician's care for diabetes mellitus, hypertension, and paroxysmal atrial fibrillation. He had never been diagnosed as having any organic heart disease. He was an ex-smoker and drank alcohol on social occasions. The patient was on β-blockers and Coumadin. His cardiovascular physical examination was significant for a 3/6 systolic murmur and a rapid, irregular heart beat. His ECG showed atrial fibrillation with a ventricular rate of 150 bpm. His portable chest x-ray (Figure 1A) showed bilateral pleural effusion and pulmonary edema. An emergency transthoracic echocardiogram showed normal left and right ventricular function. A large mass in the left atrium was seen that was causing functional mitral stenosis. The patient was admitted to the hospital, given digoxin, and started on intravenous diuresis. His ECG on normal sinus rhythm (Figure 1B), which was …

Neonatal Resuscitation Skills Among Pediatricians and Family Physicians: Is Residency Training Preparing for Postresidency Practice?

Pediatricians and family physicians are responsible for providing newborn resuscitation, yet Accreditation Council for Graduate Medical Education requirements for training in this area during residency differ markedly for the two specialties. Our objectives were to determine (1) the extent to which neonatal resuscitation training differs for pediatric and family medicine residents; (2) the extent to which general pediatricians and family physicians engage in newborn resuscitation in their practice; and (3) whether use of resuscitation skills differs between urban/suburban and rural providers. We surveyed a national cohort of pediatricians and family physicians who obtained board certification between 2001 and 2005. Data were analyzed based on type of physician and setting of current practice. Survey response rate was 22% (382 of 1736). Compared with family medicine physicians, pediatricians received more neonatal resuscitation training during residency. Most members of both groups had attended no deliveries in the year prior to the survey (75% [111 of 148] versus 74% [114 of 154]). In their current practice, the groups were equally likely to have provided a newborn bag and mask ventilation, chest compressions, and resuscitation medications. Pediatricians were more likely than family physicians to have attempted to either intubate a newborn (20% [28 of 148] versus 10% [16 of 153]; P = .0495) or insert umbilical catheters (15% [22 of 148] versus 5% [8 of 153]; P = .005). Regardless of specialty, rural physicians were much more likely to report that they attended deliveries (61% [41 of 67] versus 15% [36 of 234]; P < .001). Among rural pediatricians attending deliveries, 44% (7 of 16) reported feeling inadequately prepared for at least one delivery in the past year. Few primary care pediatricians and family physicians provide newborn resuscitation after residency. For those who do attend deliveries, current training 5 provide insufficient preparation. Flexible, individualized residency curricula could target intensive resuscitation training to individuals who plan to practice in rural areas and/or attend deliveries after graduation.

Analysing spatial accessibility to health care: a case study of access by different immigrant groups to primary care physicians in Toronto

This article analyses the spatial accessibility of a number of immigrant groups to linguistically diverse primary care (family) physicians in the Toronto Census Metropolitan Area (CMA). The two-step floating catchment area (2SFCA) method, a special type of gravity model, is employed to measure spatial accessibility using Network Analyst in ArcGIS 9.3. The context of this study is the predominantly publicly funded Canadian health-care system and a multicultural urban setting where both the population and the physicians are culturally and linguistically diverse. This article focuses on a total of eight ethnicities: six groups of recent immigrants – from Hong Kong, Iran, Mainland China, Pakistan, Russia and Sri Lanka; and two groups of long-standing immigrants – from Italy and Portugal. It examines the spatial (mis)match between the residential distribution of immigrant populations and the distribution of linguistically appropriate family physicians. The quantitative data analysed in this article include the physician data set from the College of Physicians and Surgeons of Ontario and geo-referenced 2006 Canadian Census data. This article highlights areas of poor accessibility and provides a comparison of the different ethnic groups. It demonstrates the use of the geographical information system (GIS) in public health research and yields important policy implications for public health planning.

Family physician attitudes in managing obesity: a cross-sectional survey study

BackgroundObesity is epidemic in primary care. While family physicians care for the consequences of obesity, they do not generally feel confident managing obesity itself. We examined the barriers to obesity management in a sample of family physicians in a primary care practice-based research network (PBRN).Findings204 family physicians were invited to respond to a survey on physician beliefs about obese patients and causes of obesity. A total of 75 physicians responded to the survey. Responses were factor analyzed using standard techniques. Comments were sorted into ranked themes by the investigators. The results show systemic barriers to obesity management. Seven general factors were identified, with some discrepancy seen in the role of "psychobehavioral causation" between rural and non-rural physicians. Themes derived from the comments reflected frustration with the resources and structure of current primary care systems to be able to deal with obesity.ConclusionsOur pilot survey suggests that differences in beliefs regarding the causes of obesity may exist between rural and non-rural physicians. Further research in larger, more diverse samples is necessary to further illuminate practice differences. More comprehensive approaches to obesity management, like the Chronic Care Model, are suggested by these results.

316 Patient satisfaction with anticoagulation clinics across Alberta

316 Patient satisfaction with anticoagulation clinics across Alberta

The Complexity of Family Medicine Care

In this issue, Katerndahl et al[1][1] quantify the complexity of family physician care compared with cardiology and psychiatry. When accounting for the length of the encounter, the complexity in family medicine is one-third higher than cardiology and 5 times higher than psychiatry. The measured

Family Practice is a Highly Complex Business

Starting with the Katerndahl et al[1][1] article—family physician care is more complex per hour than that of cardiologists or psychiatrists. Whew! What an important statement, and what a difficult fact for our health system to believe and adequately support. This is discussed more fully in the