Illness In Primary Care Research Articles

A tool to measure whether business management capacity in general practice impacts on the quality of chronic illness care

Our aim was to develop a tool to identify specific features of the business and financial management of practices that facilitate better quality care for chronic illness in primary care. Domains of management were identified, resulting in the development of a structured interview tool that was administered in 97 primary care practices in Australia. Interview items were screened and subjected to factor analysis, subscales identified and the overall model fit determined. The instrument's validity was assessed against another measure of quality of care. Analysis provided a four-factor solution containing 21 items, which explained 42.5% of the variance in the total scores. The factors related to administrative processes, human resources, marketing analysis and business development. All scores increased significantly with practice size. The business development subscale and total score were higher for rural practices. There was a significant correlation between the business development subscale and quality of care. The indicators of business and financial management in the final tool appear to be useful predictors of the quality of care. The instrument may help inform policy regarding the structure of general practice and implementation of a systems approach to chronic illness care. It can provide information to practices about areas for further development.

Post Partum Psychosis, Infanticide, Case Report, Nigeria.

Introduction: Mental illnesses are very prevalent and highly disabling. Adults with mental illness in primary care are also more likely to be experiencing poorer overall health than those without. They also report more disability days in previous month. The chronic or recurrent nature of mental disorders make relatives fed up with endless care giving and social support rendering a good number of mentally ill homeless. Mental illness and homelessness have been reported to be associated with substance use, chronic medical diseases, self reported poor health and many barriers to service utilization. Method: Descriptive fact finding method of all homeless persons referred for treatment at State hospital, Ring Road, Ibadan between 2004 and 2007. Results: The median age of the respondents was 40 years, 60% were females, the median number of years of education was 3 years, 83.9% were never married, 60% had been on the streets for 5-10 years and 84.3% had never had contact with any formal mental care facility. The most prevalent DSM IV diagnosis was schizophrenia, (34.3%), followed by substance use disorder and co-morbid substance use plus psychosis, 15.7% respectively, 2.8% was commercial sex workers, while one (1.4%) received no diagnosis and was a criminal. All of them had at least a clinical health problem. While the most commonly reported social problem was financial problems leading to begging (95.7%). Conclusion: Homelessness among mentally ill is associated with physical health and social problems, therefore such patients need integrated multidisciplinary approach in designated centers for their care.Key Words: Mental Disorders, Homelessness, Public Health.

Rehabilitation in a primary care setting for persons with chronic illness – a randomized controlled trial

AimThe primary objective of this study was to determine whether adults with a chronic illness within a primary care setting who received a rehabilitation intervention in this setting showed greater improvement in health status and had fewer hospital admissions and emergency room visits compared with adults who do not receive the intervention.BackgroundMore than half of Canadians (16 million people) live with chronic illness. Persons with chronic illness in primary care, especially older persons who are most at risk for functional decline, are currently not receiving effective management.MethodsA randomized controlled trial was used. A rehabilitation multi-component intervention was delivered by a physiotherapist (PT) and occupational therapist in a primary care setting and included collaborative goal setting for rehabilitation needs, a six-week chronic disease self-management (SM) workshop, referral to community programs and a web-based education programme.FindingsThree hundred and three patients participated, n = 152 intervention group and n = 151 in the control group. There was a significant difference between the groups for planned hospital days (F = 6.3, P = 0.00) with an adjusted difference 0.60 day per person, and increased satisfaction with rehabilitation services however no difference on health status or emergency room visits. This rehabilitation intervention which had a strong SM component prevented planned hospitalizations that resulted in a conservative estimated cost saving from reduced hospitalizations of $65 000. Future research needs to examine which patient groups with chronic illness show positive responses to rehabilitation and self-management.

Book Review: Managing Long-term Conditions and Chronic Illness in Primary Care. S Newman, J Carrier

Book Review: Managing Long-term Conditions and Chronic Illness in Primary Care. S Newman, J Carrier

The extraordinary potential of primary care to improve mental health.

Mental health service in primary care has traditionally been viewed as the Cinderella of the health system. Mental illness contributes 12% to the global burden of disease, yet European countries spend on average about 5% of their health budget on mental health care.1 The new European Community member states spend an even smaller proportion of their health budgets on mental health services, perhaps around 2%.1 In the last few years, however, mental health services in primary care attracted considerable interest and the importance of mental illness in primary care became apparent. Nine out of ten depressed patients are treated only in primary care.2 Over three quarters of patients consulting their general practitioner admit to at least one psychosocial problem, over one third report that psychosocial problems impact on their present health,3 and up to two thirds of suicide victims contact a general practitioner in the four weeks before their death.4 In addition, the general public, surveyed more than a decade ago, preferred to see general practitioners rather than psychiatrists for depression and to receive psychological treatments and counselling rather than drug treatment.5 This perhaps indicates that seeing a psychiatrist is still associated with considerable stigma, but also provides primary care professionals with an opportunity to engage patients effectively. The realisation of the importance of mental health led to numerous recent developments and initiatives both in the UK and internationally. Three of those appear to be especially pertinent for primary care.

Medical students’ attitudes to psychiatric illness in primary care

Previous research has shown that general practitioners (GPs) hold negative attitudes towards patients with schizophrenia, which do not simply reflect the nature or chronic aspects of the illness. This study aimed to describe the attitudes and predicted behaviour of medical students towards patients with mental illness in a primary care setting and to investigate whether these were affected by the students' level of training. A sample of 1239 students from the University of Birmingham Medical School were each given one of four case vignettes, all of which were identical except that the patient involved was described as having a previous diagnosis of, respectively, schizophrenia, depression, diabetes or no illness. Students rated their level of agreement with 12 attitudinal statements relating to the vignette. A total of 1081 (88%) students responded to the questionnaire. Students were generally less favourable in their responses to patients with either schizophrenia or depression. They would not be as happy to have them on their list, believed they would consume more time and considered they would be less likely to comply with advice and treatment. They expressed more concern about the risk of violence, the potential welfare of children and the possibility of illegal drug and excessive alcohol use. General clinical and psychiatric training had little effect on these reactions. Patients with mental illness provoke less favourable responses in medical students, which are not altered by furthering education. Undergraduate primary care-based mental health education should be re-evaluated to ensure that students develop an empathetic and positive approach to mental health patients and their treatment.

Functional illness in primary care: dysfunction versus disease.

BackgroundThe Biopsychosocial Model aims to integrate the biological, psychological and social components of illness, but integration is difficult in practice, particularly when patients consult with medically unexplained physical symptoms or functional illness.DiscussionThis Biopsychosocial Model was developed from General Systems Theory, which describes nature as a dynamic order of interacting parts and processes, from molecular to societal. Despite such conceptual progress, the biological, psychological, social and spiritual components of illness are seldom managed as an integrated whole in conventional medical practice. This is because the biomedical model can be easier to use, clinicians often have difficulty relinquishing a disease-centred approach to diagnosis, and either dismiss illness when pathology has been excluded, or explain all undifferentiated illness in terms of psychosocial factors. By contrast, traditional and complementary treatment systems describe reversible functional disturbances, and appear better at integrating the different components of illness. Conventional medicine retains the advantage of scientific method and an expanding evidence base, but needs to more effectively integrate psychosocial factors into assessment and management, notably of 'functional' illness. As an aid to integration, pathology characterised by structural change in tissues and organs is contrasted with dysfunction arising from disordered physiology or psychology that may occur independent of pathological change.SummaryWe propose a classification of illness that includes orthogonal dimensions of pathology and dysfunction to support a broadly based clinical approach to patients; adoption of which may lead to fewer inappropriate investigations and secondary care referrals and greater use of cognitive behavioural techniques, particularly when managing functional illness.

Quality of care for chronic illnesses

The purpose of this paper is to discover the extent to which evidence-based practices and computer systems for managing chronic illness are used within Swedish primary health care. The methodology was a replication of a similar national USA survey study and an interview study. The findings show large variations and an under-use of a number of evidence-based care management practices and of IT for managing depression, heart disease, asthma, and diabetes in Sweden. Follow-up interview studies with heads of primary care centres gathered their views about the factors which helped and hindered improving care and prevention for these patient groups. The study data identify actions which would significantly improve the quality of care for people suffering from chronic illnesses. Effective prevention and management of chronic illness in primary care can reduce unnecessary patient suffering and lower costs of care. Evidence of effective methods for managing these illnesses has been reported, but it is not known how widely these methods or information technology are used in primary care outside the USA. The paper gives the first comprehensive nation-wide data on the use of evidence-based practices and computer systems for managing chronic illness in primary care in a European public health care system. It provides information allowing targeted actions which would improve quality of care which are low cost and high cost saving in the long term.

Primhe: Primary Care Mental Health & Education

AbstractThe role of the primary care liaison nurseHere, Tony White provides an overview of the key responsibilities of primary care liaison nurses (PCLNs), the impact they can have on the management of mental illness in primary care and the potential difficulties they currently face. Copyright © 2008 Wiley Interface Ltd

HEALTH RELATED QUALITY OF LIFE AFTER AN ACUTE ILLNESS IN EMERGENCY DEPARTMENT (ED) AND PRIMARY CARE (PC) SETTINGS

s: American Academy of Pediatrics, Section on Emergency Medicine, Scientific Abstract Presentations, AAP National Conference & Exhibition, October 26, 2007 - San Francisco, CA: ORAL ABSTRACTS

Treatment of minor illness in primary care: a national survey of patient satisfaction, attitudes and preferences regarding a wider nursing role

This study investigated patient opinion about the provision of nurse-led vs. doctor-led primary health care in the treatment of minor illness. A postal questionnaire survey including discrete choice experiment (DCE) of a national sample followed by telephone interviews with respondent volunteers. A large random sample of the population of Scotland from a range of general practices including traditional and extended practice nursing roles was invited to participate. Patient satisfaction with, opinion of and preference for practice nurse (PN) vs. doctor consultation in primary care in relation to gender, age, education and income. Questionnaire response rate was 49% (1343 of 2740). Women, younger people, the less well-educated and those with higher income had a more positive attitude towards the PN. Older people had a more positive attitude to the doctor. Results from the DCE indicated that whilst most respondents would prefer a doctor consultation, many would be happy to consult with a nurse if other aspects of the consultation were improved. Forty-eight people were interviewed. The main perceived differences between doctors and nurses were academic ability and qualifications. Most respondents thought nurses could deal with relatively minor problems and should be able to prescribe some drugs. Patients would always want their choice of health professional to be available at first contact. However, this study suggests that, in primary health-care practices, if nurses take on more roles previously the preserve of doctors, patients would accept them, particularly if patients receive information on nurses' capabilities.

Interventions to improve adherence to medication in people with type 2 diabetes mellitus: a review of the literature on the role of pharmacists

Pharmacists are now adopting a crucial role in the management of chronic illness in primary care, providing diabetes care and advice. This review aims to show whether a range of diabetes care interventions delivered by pharmacists is successful in improving adherence to medication. The studies reviewed formed a subgroup of a Cochrane review on interventions to improve adherence to medication in people with type 2 diabetes. Search terms were 'type 2 diabetes mellitus' and 'compliance' or 'adherence'. Studies were included if they assessed adherence to medical treatment specifically, rather than other aspects of self-management. Out of the 21 studies selected for review, five described an intervention delivered by a pharmacist. Two studies reported on attempts to improve adherence focused on the taking of medication. A system of reminders and packaging improved medication adherence, but measuring medicine taking through pill counts or Medication Event Monitoring System was not effective. Three studies evaluated pharmacist-led integrated management and education programmes designed to improve glycaemic control for under-served patient populations. They all succeeded in lowering glycated haemoglobin, but it remains unclear whether this resulted from improved patient adherence. This review indicates a potential benefit of pharmacist interventions to improve medication adherence in diabetes, especially in providing patient education.

Associations between psychological trauma and physical illness in primary care

Psychological trauma is associated with poor physical health. We examined whether specific trauma types (assaultive, sexual, any) are associated with specific medical illnesses and whether posttraumatic stress disorder (PTSD) mediated these relationships in 680 primary care patients. For men, trauma history was associated with arthritis and diabetes; PTSD mediated the association between trauma and arthritis but not diabetes. Among women, trauma was associated with digestive diseases and cancer; PTSD did not mediate these relationships. Awareness of the presence of the physical illnesses examined here may help with the identification and treatment of primary care patients with trauma histories.

Reinventing Depression

Remember the mid-1980s? Many psychiatric researchers were very surprised to find a large burden of depression in primary care patients. Of course, with the advent of the SSRIs (selective serotonin reuptake inhibitors) and other safe and effective antidepressants, we in primary care were reassured that we could, indeed, adequately treat these patients, reducing morbidity (and mortality!) with expedition and ease. Twenty years on, and the plot has thickened. In our offices and for our patients, the high prevalence of treatment-resistant depression, the confusion involving differential diagnoses (including bipolar depression and substance abuse disorder), and the interplay of Axis II disorders with Axis I pathology have laid bare some of the halcyon assumptions regarding easy efficacy that marked primary care affective medicine 2 decades ago. If the past informs the present, and is truly prologue to the future, then we could use a history lesson. Callahan and Berrios provide the very best kind—well-written, informative, clearly referenced, and lucidly conceptualized—to tell a story of how we came to approach mental illness in primary care as we do. Their central thesis states that the current model of depression is deterministic and too narrowly defined, overemphasizing the biomedical and failing to take fully into account the contributions of psychosocio-spiritual factors to the patient's experience of emotional suffering. They contend that this narrow model, developed by specialty psychiatry and later endorsed by primary care physicians, prevents many patients from receiving adequate diagnoses and treatment. In addition, it neglects many of the multidisciplinary strengths of the generalist physician and thus lowers the quality of care. To begin, the authors explode 2 favorite myths of modern medicine: that of the old-time doctor (who saw fewer patients, had more time, and was happier with the practice) and that of the old-time patient (who complained less, appreciated the doctor more, and was reluctant to accept medical treatment for emotional suffering). Next, they portray the realities of midcentury primary care and subsequent changes in generalist practices. They then trace the emergence of specialty psychiatry, the development of effective medications for psychiatric disorders, and the rise of criteria-based psychiatric diagnoses. Following the development of fluoxetine as penicillin for the blues, the authors describe the consequences of marketing in a vacuum—the interaction of pharmaceutical companies with physicians or patients in the absence of robust regulatory and academic relationships. The book closes by arguing that only a broader model of mental health and illness will bring to bear the particular strengths of primary care in reducing the overall burden of morbidity and mortality (in a manner similar to the mass strategy associated with such multifactorial illnesses as coronary artery disease and diabetes mellitus). In other words, we don't necessarily need to become better psycho-pharmacologists; we might better serve our patients as better listeners, or counselors, or in some other capacity. As an intriguing aside, the authors propose that the confusion that reigns with regard to the treatment of affective illness in primary care is symptomatic of a more fundamental problem—the failure of generalists to posit and practice a comprehensive vision of their relationship to patients and to society as a whole. Having yielded to the allure of becoming Everydoctor for Everypatient, will generalists suffer a dilution of skills and focus that will ultimately devalue the enterprise entirely? The authors believe this may be the case and argue that the emotionally suffering patient is the canary in the coal mine that signals this unraveling of a coherent role for the generalist in modern medicine. Now and again, a book or paper appears that seems to part the fog, not only showing things as they are but explaining how they arrived to be that way. Reinventing Depression is that kind of book. In a manner reminiscent of Starr's classic The Social Transformation of American Medicine,1 it points the ways to a workable postmodern model of primary care affective medicine by thoroughly illuminating past and present conditions, with all their inconsistencies and serendipities. Serious students of the sociology of medicine, the evolution of primary care as a practice and as a discipline, and the treatment of mental illness will find it time well spent.

Are Anxiety and Depression Addressed in Primary Care Patients With Chronic Obstructive Pulmonary Disease? A Chart Review

Screening for mental illness in primary care is widely recommended, but little is known about the evaluation, treatment, and long-term management processes that follow screening. The aim of this study was to examine and describe the quality of mental health care for persons with chronic obstructive pulmonary disease (COPD) and anxiety/depressive disorders, as measured by adherence to practice guidelines. This retrospective chart review examined data for 102 primary care and mental health care patients with COPD who were diagnosed, using Structured Clinical Interview for DSM-IV criteria, with major depressive disorder, dysthymia, depression not otherwise specified, generalized anxiety disorder, or anxiety not otherwise specified. Data were gathered from primary care progress notes from the year prior to enrollment in a randomized controlled trial (enrollment was from July 2002 to April 2004). We compared the care received by these patients over 1 year with that recommended by practice guidelines. Charts were abstracted using a checklist of recommended practice guidelines for diagnostic evaluation, acute treatment, and long-term management of anxiety and depressive disorders. Fifty (49%) of the 102 patients were recognized during the review year as having an anxiety or depressive disorder. Eighteen patients were newly assessed for depressive or anxiety disorders during the chart review year. Patients followed in primary care alone, compared with those who were comanaged by mental health care providers, were less likely to have guideline-adherent care. Depressive and anxiety disorders are recognized in about half of patients; however, guideline-supported diagnostic evaluation, acute treatment (except for medications), and long-term management rarely occur in the primary care setting. To improve the treatment of depressive and anxiety disorders in primary care, the process of care delivery must be understood and changed.

In This Issue: Bursting the Bubble on Chronic Disease Management, the Meaning of Healing, PBRN Methods Supplement, and the Annals' 2-Year Anniversary

This issue features a provocative collection of articles that address different aspects of the integration of care of multiple comorbid illnesses in primary care.[1][1]–[5][2] Other articles reflect the patient perspective and the clinician perspective on health, illness, and healing. An online

A randomised controlled trial to compare the cost-effectiveness of tricyclic antidepressants, selective serotonin reuptake inhibitors and lofepramine

To determine the relative cost-effectiveness of three classes of antidepressants: tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and the modified TCA lofepramine, as first choice treatments for depression in primary care. Open, pragmatic, controlled trial with three randomised arms and one preference arm. Patients were followed up for 12 months. UK primary care: 73 practices in urban and rural areas in England. Patients with a new episode of depressive illness according to GP diagnosis. Patients were randomised to receive a TCA (amitriptyline, dothiepin or imipramine), an SSRI (fluoxetine, sertraline or paroxetine) or lofepramine. Patients or GPs were able to choose an alternative treatment if preferred. At baseline the Clinical Interview Schedule, Revised (CIS-R PROQSY computerised version) was administered to establish symptom profiles. Outcome measures over the 12-month follow-up included the Hospital Anxiety and Depression Scale self-rating of depression (HAD-D), CIS-R, EuroQol (EQ-5D) for quality of life, Short Form (SF-36) for generic health status, and patient and practice records of use of health and social services. The primary effectiveness outcome was the number of depression-free weeks (HAD-D less than 8, with interpolation of intervening values) and the primary cost outcome total direct NHS costs. Quality-adjusted life-years (QALYs) were used as the outcome measure in a secondary analysis. Incremental cost-effectiveness ratios and cost-effectiveness acceptability curves were computed. Estimates were bootstrapped with 5000 replications. In total, 327 patients were randomised. Follow-up rates were 68% at 3 months and 52% at 1 year. Linear regression analysis revealed no significant differences between groups in number of depression-free weeks when adjusted for baseline HAD-D. A higher proportion of patients randomised to TCAs entered the preference arm than those allocated to the other choices. Switching to another class of antidepressant in the first few weeks of treatment occurred significantly more often in the lofepramine arm and less in the preference arm. There were no significant differences between arms in mean cost per depression-free week. For values placed on an additional QALY of over 5000 pounds, treatment with SSRIs was likely to be the most cost-effective strategy. TCAs were the least likely to be cost-effective as first choice of antidepressant for most values of a depression-free week or QALY respectively, but these differences were relatively modest. When comparing the different treatment options, no significant differences were found in outcomes or costs within the sample, but when outcomes and costs were analysed together, the resulting cost-effectiveness acceptability curves suggested that SSRIs were likely to be the most cost-effective option, although the probability of this did not rise above 0.6. Choosing lofepramine is likely to lead to a greater proportion of patients switching treatment in the first few weeks. Further research is still needed on the management of depressive illness in primary care. This should address areas such as the optimum severity threshold at which medication should be used; the feasibility and effectiveness of adopting structured depression management programmes in the UK context; the importance of factors such as physical co-morbidity and recent life events in GPs' prescribing decisions; alternative ways of collecting data; and the factors that give rise to many patients being reluctant to accept medication and discontinue treatment early.

Mental disorders in primary care: prevalence and co-morbidity among disorders. Results from the Functional Illness in Primary care (FIP) study

Prevalence and co-occurrence of mental disorders is high among patients consulting their family general practitioner (GP) for a new health problem, but data on diagnostics and socio-demographics are sketchy. A cross-sectional two-phase epidemiological study. A total of 1785 consecutive patients with new complaints, aged 18-65 years, consulting 28 family practices during March-April 2000 in Aarhus County, Denmark were screened, in the waiting room, for mental and somatic symptoms with SCL-8 and SCL-Somatization questionnaires, for illness worry with Whitely-7 and for alcohol dependency with CAGE. In a stratified random sample of 701 patients, physician interviewers established ICD-10 diagnoses using the SCAN interview. Prevalence was calculated using weighted logistic regression, thus correcting for sample skewness. Half of the patients fulfilled criteria for an ICD-10 mental disorders and a third of these for more than one group of disorders. Women had higher prevalence of somatization disorder and overall mental disorders than men. Men had higher prevalence of alcohol abuse and hypochondriasis than women. Psychiatric morbidity tended to increase with age. Prevalence of somatoform disorders was 35.9% (95% CI 30.4-41.9), anxiety disorders 164% (95% CI 12.7-20.9), mood disorders 13.5% (95% CI 11.1-16.3), organic mental disorders 3.1% (95% CI 1.6-5.7) and alcohol abuse 2.2% (95% CI 1.5-3.1). Co-morbidities between these groups were highest for anxiety disorders, where 89% also had another mental diagnosis, and lowest for somatoform disorders with 39%. ICD-10 mental disorders are very prevalent in primary care and there is a high co-occurrence between most disorders. Somatoform disorders, however, more often than not exist without other mental disorders.

Screening for Mental Illness in Primary Care Clinics

To assess the prevalence of mental disorders in inner city outpatient clinics and to improve the diagnosis of mental illness in primary care. The Problem Oriented Patient Report (POPR), a patient self-report checklist, was administered to 362 outpatients at two inner-city Buffalo primary care clinics. Patients' completed POPR checklists were evaluated to identify those with potential mental illness diagnoses and were available for the physicians' review during the patients' visits. After the visit, clinical charts were reviewed to determine the frequency of new mental illness diagnoses among continuing and new patients. The screening checklist (POPR) revealed potential mental illnesses in 148/362 outpatients, of which 98% had not been identified by the physicians who had reviewed the patients' completed POPR forms. Only five new diagnoses of mental illnesses were independently made by clinics' physicians-all in follow-up (continuing) patients. The physicians in the two clinics did not diagnose mental illnesses in their patients, even when written checklists of self-reports were available to them. Differences in staff attitudes may influence the data collection process, and patients' as well as physicians' responses. A weakness of this study is that the POPR might generate false positive results. Even if this were the case, the rate of previous diagnoses was still extremely low.

Developing a local shared care protocol for managing people with psychotic illness in primary care

Aims and Method The National Service Framework sets standards to improve the treatment of mental health on a national level, and requires the development of localised shared care protocols. We aimed to develop a shared care protocol for use in local National Health Service (NHS) services, based on best practice guidelines and local consensus. A systematic literature search used three databases and the advice of a clinical expert. Articles satisfying the search inclusion criteria were retrieved and appraised. Clinical recommendations from well-designed regional and national documents relevant to all aspects of the management of psychotic illness in primary care were compared and contrasted by a facilitated group involving primary and secondary care clinicians who drafted the final recommendations. A multi-agency steering group guided the work. Results Twenty-two articles were retrieved, of which nine reached the criteria for inclusion. The protocol provided a comprehensive range of recommendations regarding detection, assessment, management, referral and shared working with local mental health services. Clinical Implications Using local clinical consensus to resolve uncertainty about conflicting clinical recommendations from a series of well-designed guidelines was an effective method for adapting clinical guidelines to local circumstances.