General Practice Network Research Articles

Dementia risk reduction in primary care: what Australian initiatives can teach us

Only limited research has been undertaken to identify factors that impede or facilitate the implementation of evidence-based health promotion, prevention and early intervention (PPEI) activities within primary practice. We examined recent Australian initiatives that encouraged primary care practitioners to implement PPEI activities to reduce the risk of chronic disease, particularly those that have focused on lifestyle risk factors. The aim was to identify barriers and facilitators to the uptake of these activities to inform the Australian National Dementia Prevention Strategy. Barriers that were consistently reported across evaluations and that appear to be of most concern to Australian general practitioners include the issues of financial remuneration and time constraints secondary to heavy work commitments. Factors that were effective in overcoming barriers included the integration of interventions within existing activities, the specification of a clear, funded role for practice nurses and the support of the Australian General Practice Network. It was concluded that these factors should be considered if PPEI activities for dementia are to be successfully incorporated within primary care.

Half of the patients with chest pain that are urgently referred are transported in unsafe conditions

Patients with an acute coronary syndrome should be referred to hospital urgently to start reperfusion therapy as soon as possible. Owing to the risks of ventricular fibrillation and pulseless ventricular tachycardia, urgent transport should be organized under safe conditions, that is, with a defibrillator at hand. To evaluate the type of transport of patients with chest pain referred by their general practitioner (GP). Observational study. A sentinel network of general practices in Belgium, covering almost 1.6% of the total population. One thousand nine hundred and ninety-six patients with chest pain attending their GP in 2003. Descriptive analyses reporting proportions along with their 95% confidence interval (CI). Male patients were referred to hospital more often than female patients: 44.9% (95% CI: 41.6-47.8) versus 36.5% (95% CI: 33.4-39.6). For patients who were referred routinely, 92.7% (95% CI: 89.1-95.2) were transported by family and neighbours, 4.8% (95% CI: 2.8-7.9) by ambulance and 2.5% (95% CI: 1.2-5.1) by GPs. For patients who were referred urgently, ambulances transported 56.9% (95% CI: 51.1-62.7), family and neighbours 36.9% (95% CI: 31.4-42.7) and the GP 6.1% (95% CI: 3.7-9.5). Almost half of the patients with chest pain who require urgent referral are transported in unsafe conditions.

Seasonality and trends in the incidence and prevalence of gout in England and Wales 1994–2007

Objectives:To examine seasonality and long-term trends in the incidence and prevalence of gout.Methods:A retrospective study (1994–2007) using routinely collected surveillance data from the Royal College of General Practitioners Weekly Returns...

Plenty of activity but little outcome data: a review of the “grey literature” on primary care anxiety and depression programs in Australia

To identify reports in the "grey literature" of programs conducted in Australian primary care to improve depression and anxiety outcomes, and to examine these reports for evidence of effectiveness. A systematic search was undertaken for grey literature reports using primary health care research databases, community and professional websites, clearinghouse sources, government reports, and reports from the Australian General Practice Network. Reports were included if they related to programs targeting depression or anxiety, contained qualitative or quantitative effectiveness data, and were published during 1995-2006. In total, 642 reports were identified, of which 43 met inclusion criteria. Of the 43 programs described, 30 were delivered in general practice, five in the community or residential care, three in schools, and five were Internet or computer based. Nine programs were also reported in the formal "black" literature, but most, including the Better Outcomes in Mental Health Care initiative, were not. Limited data on effectiveness or patient outcomes were available in the grey literature. There is currently no single service that identifies, describes and catalogues the range and effectiveness of mental health initiatives in Australia. There may be a role for a mental health information "clearinghouse" to facilitate dissemination and education, and to promote collaboration among researchers, practitioners, consumers and policymakers. Innovative schemes to disseminate evidence-based models and to encourage the collection of data on patient outcomes in such programs are needed.

Mixed Dyslipidemia Among Patients Using Lipid-Lowering Therapy in French General Practice: An Observational Study

Background: Low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglycerides (TGs) are associated with an increased incidence of coronary heart disease (CHD). However, limited data are available about the prevalence of dyslipidemias related to LDL-C, HDL-C, and TGs among French patients treated with lipid-lowering agents. Objective: This paper describes the prevalence of various types of dyslipidemias among patients treated with lipid-lowering agents in French general practice. Methods: This was a cross-sectional, observational study conducted using retrospective data collection at the time of enrollment. Eligible patients were those treated pharmacologically for dyslipidemia in the Cegedim Strategic Data general practice network. Fasting lipid values and cardiovascular (CV) risk factors were gathered by investigators using an ad hoc questionnaire. European guidelines were used to define various types of dyslipidemias. Polytomous logistic regression was used to assess the associations between different dyslipidemias and diabetes mellitus, a history of CHD, and the number of CV risk factors. Results: A total of 946 patients had a complete lipid profile and valid data for determining CV risk status. The mean (SD) age of these patients was 64.0 (9.9) years, and 55.7% of the patients were men. At least 1 abnormality in LDL-C, HDL-C, or TGs was present in 791 (83.6 %) of the 946 patients. The rates of elevated LDL-C, low HDL-C, and elevated TGs were 73.2%, 16.9%, and 30.3%, respectively (these groups are not mutually exclusive). Among those who did not reach the LDL-C goal, 38.7% had dyslipidemias with low HDL-C, elevated TGs, or both. Compared with having a normal lipid profile, each additional CV risk factor increased the likelihood of the following types of dyslipidemias: low HDL-C and/or elevated TGs, but normal LDL-C (odds ratio [OR], 1.36; 95% CI, 1.03–1.79); elevated LDL-C and TGs, but normal HDL-C (OR, 1.58; 95% CI, 1.24–2.02); and all 3 lipid abnormalities (OR, 1.54; 95% CI, 1.10–2.14). Patients with diabetes had a similarly increased risk of mixed dyslipidemias, whereas patients with a history of CHD did not. Conclusions: Among these patients treated with lipid-lowering agents, 38.7% had mixed dyslipidemias, including low HDL-C, elevated TGs, both low HDL-C and elevated TGs, or all 3 lipid abnormalities. Patients with a greater number of nonlipid CV risk factors or with diabetes had a significantly increased risk of mixed dyslipidemias involving elevated TGs and/or low HDL-C in addition to elevated LDL-C.

To what extent does IQ 'explain' socio-economic variations in function?

BackgroundThe aims of this study were to examine the extent to which higher intellectual abilities protect higher socio-economic groups from functional decline and to examine whether the contribution of intellectual abilities is independent of childhood deprivation and low birth weight and other socio-economic and developmental factors in early life.MethodsThe Maastricht Aging Study (MAAS) is a prospective cohort study based upon participants in a registration network of general practices in The Netherlands. Information was available on 1211 men and women, 24 – 81 years old, who were without cognitive impairment at baseline (1993 – 1995), who ever had a paid job, and who participated in the six-year follow-up. Main outcomes were longitudinal decline in important components of quality of life and successful aging, i.e., self-reported physical, affective, and cognitive functioning.ResultsPersons with a low occupational level at baseline showed more functional decline than persons with a high occupational level. Socio-economic and developmental factors from early life hardly contributed to the adult socio-economic differences in functional decline. Intellectual abilities, however, took into account more than one third of the association between adult socio-economic status and functional decline. The contribution of the intellectual abilities was independent of the early life factors.ConclusionRather than developmental and socio-economic characteristics of early life, the findings substantiate the importance of intellectual abilities for functional decline and their contribution – as potential, but neglected confounders – to socio-economic differences in functioning, successful aging, and quality of life. The higher intellectual abilities in the higher socio-economic status groups may also underlie the higher prevalences of mastery, self-efficacy and efficient coping styles in these groups.

Psychosocial well‐being of patients with skin diseases in general practice

Skin diseases are a substantial part of the problems dealt with by general practitioners. Although the psychosocial consequences of skin diseases in secondary care has been extensively studied, little is known about the psychosocial well-being of patients with skin diseases in primary care. To investigate the psychosocial well-being of patients with skin diseases in primary care. Questionnaires about the psychosocial consequences of skin diseases were sent to patients with a skin disease who were registered within a research network (continuous morbidity registration) of general practices that continuously have recorded morbidity data since 1971. Questionnaires completed by 532 patients were eventually suitable for analyses. Compared with the general population, patients with skin diseases reported significantly lower scores for psychosocial well-being. Furthermore, a lower psychosocial wellbeing was significantly related with higher levels of disease-severity, lower disease-related quality of life, longer disease duration, more comorbidity and more physical symptoms of itch, pain and fatigue. After demographic variables and comorbidity were controlled for, sequential regression analyses showed that disease duration, disease severity and physical symptoms (itch, pain and fatigue) were significant predictors of psychosocial well-being. The psychosocial well-being of patients with skin diseases in primary care is lower than that of the general population. Special attention has to be directed to those patients with lowered psychosocial well-being who might be at risk of developing severe psychosocial impairments such as clinical depression.

Morbidity profiles of patients consulting during influenza and respiratory syncytial virus active periods

We compared the burden of illness due to a spectrum of respiratory diagnostic categories among persons presenting in a sentinel general practice network in England and Wales during periods of influenza and of respiratory syncytial virus (RSV) activity. During all periods of viral activity, incidence rates of influenza-like illness, bronchitis and common cold were elevated compared to those in baseline periods. Excess rates per 100,000 of acute bronchitis were greater in children aged <1 year (median difference 2702, 95% CI 929-4867) and in children aged 1-4 years (994, 95% CI 338-1747) during RSV active periods rather than influenza; estimates for the two viruses were similar in other age groups. Excess rates of influenza-like illness in all age groups were clearly associated with influenza virus activity. For common cold the estimates of median excess rates were significantly higher in RSV active periods for the age groups <1 year (3728, 95% CI 632-5867) and 5-14 years (339, 95% CI 59-768); estimates were similar in other age groups for the two viruses. The clinical burden of disease associated with RSV is as great if not greater than influenza in patients of all ages presenting to general practitioners.

General Practice Based Multidisciplinary Care Teams in Australia: Still some unanswered questions. A discussion paper from the Australian General Practice Network

Evidence indicates that general practice-based multidisciplinary teams can offer a means of addressing some of the key issues currently facing Western health systems, especially workforce and chronic disease management. Elements of team-working have been addressed in research and policy initiatives both overseas and in Australia, yet some important aspects of primary health care multidisciplinary team-working still remain unclear in the Australian context. This discussion paper has been developed by the Australian General Practice Network (AGPN) to raise awareness of and promote thought on four questions relating to multidisciplinary team-working that AGPN considers important but that, as yet, have not been fully addressed. (Except where indicated, it is not a position statement about AGPN's views on this matter.) Questions considered are: Who is in the team? What makes a successful team? How should teams be funded in Australia? Who coordinates the team? Each question broadly considers what is already known about the area through purposeful literature reviews of the published and grey literature, current policy impacting on the area, and suggested areas for policy development in the context of Australian general practice and primary care.

A hair of the dog that bit you

Shang A, Hulwiler-Muntener K, Nartey L, Juni P, Dorig S, Sterne JAC, Pewsner D, Egger M (Department of Social and Preventive Medicine, University of Berne, Berne, Switzerland; Medical Research Council Health Services Research Collaboration, Department of Social Medicine, University of Bristol, Bristol, UK; Department of Pharmacology, University of Zurich, Zurich, Switzerland; and Practice Bruckfeld, MediX General Practice Network, Berne, Switzerland). Are the clinical effects of homoeopathy placebo effects? Comparative study of placebo-controlled trials of homeopathy and allopathy.

The association between impetigo, insect bites and air temperature: a retrospective 5-year study (1999-2003) using morbidity data collected from a sentinel general practice network database

Impetigo is one of the commonest childhood skin infections. Insect bites are commonly implicated in the development of impetigo. There are, however, very few data available to describe the seasonal incidences and association between the two conditions. To describe the seasonal incidence of impetigo in England and Wales and to investigate the reported association with insect bites. Clinical diagnoses of impetigo and insect bites were recorded from a sentinel GP network over the years 1999-2003. The highest mean weekly rates of impetigo were in children aged 0-4 years (84 per 100 000) and in those aged 5-14 years (54 per 100 000). In contrast, the incidence of insect bite only varied between 3 and 5 per 100 000 for males and between 5 and 9 per 100 000 for females. The relative risk (RR) for females consulting over males with impetigo was similar in children [RR 0.99 (95% CI 0.96-1.02)] and adults [RR 1.20 (1.16-1.25)]; the RR of insect bite was similar in children [RR 1.21 (1.09-1.34)] but almost twice as likely in adults [RR 2.13 (2.02-2.25)]. Insect bite peaked almost coincidentally with temperature whereas there was a lag of one-to-two 4-week periods between impetigo and temperature. There is suggestion of some degree of association between impetigo and insect bites. The improved management of patients consulting with insect bites and better use of antiseptic treatments might provide the basis for reducing the incidence of impetigo in the community.

WHO diagnostic criteria as a validation tool for the diagnosis of diabetes mellitus: A study in five European countries

Objective: In 1999, the World Health Organization (WHO) published new diagnostic criteria for diabetes mellitus (DM). The cut-off value of the fasting plasma glucose concentration was lowered from 7.8 to 7.0 mmol/l. The WHO criteria were used to validate the diagnosis made by the general practitioner, and to compare the diagnostic validity of diabetes mellitus in different countries. Methods: We retrospectively analysed 2556 newly diagnosed diabetics. Incidence was calculated according to the 1999 WHO criteria. Data were collected in general practice networks in five European countries or regions (Belgium, England, the Netherlands, Portugal, Spain). Results: According to the WHO criteria, 82% of the cases were valid diagnoses. Compared to the total group, in Spain, significantly more diagnoses were in agreement with the WHO criteria, whereas this number was significantly lower in England and Portugal. From the patients whose diagnosis was not in agreement with the WHO criteria, significantly more were women than men.Conclusion: By using the WHO diagnostic criteria, the international standard, as a validation tool, we show that the diagnoses of diabetes mellitus made in primary care are valid. Furthermore, we show that these diagnoses are comparable between countries. Therefore, information from general practice registration networks is a valuable and valid source for international comparisons.

Bisphosphonate use and subsequent prescription of acid suppressants

To determine the extent of prescribing of acid suppression agents associated with initiation of bisphosphonate therapy. This was a case control study, performed within the General Practice Network, Australia. The main outcome measure was re-attendance within six weeks from index bisphosphonate prescription for acid supression agents. Of the bisphosphonate cases, 2.9%[95% confidence interval (CI) 1.8, 3.9] returned within 6 weeks for a prescription for proton pump inhibitor, histamine 2 receptor antagonist or antacid, compared with 0.9% of control patients (95% CI 0.5, 1.2). However, the bisphosphonate cases had significantly higher rates of previous use of nonsteroidal anti-inflammatory agents. After controlling for previous nonsteroidal anti-inflammatory drug use, the increased use of acid suppression agents was statistically significant, the odds ratio = 3.21 (95% CI 2.02, 5.11). Bisphosphonate use appears to be associated with increased use of acid suppressant agents within 6 weeks of first supply.

Diagnosis and treatment of type 2 diabetes in three Belgian regions. Registration via a network of sentinel general practices.

The objective of this descriptive study is to investigate the incidence of type 2 diabetes in sentinel general practices in three regions in Belgium and to describe the patient characteristics and the start of the medical management after diagnosis. For two successive years all patients who were newly diagnosed with type 2 diabetes were registered. Two weeks after inclusion, the registering physician completed an extensive questionnaire. This questionnaire dealt with risk factors, biochemical parameters, existing complications and treatment. According to this study, the yearly incidence of type 2 diabetes in Belgium is 231 per 100,000 inhabitants. Though the biochemical parameters (BMI, HbA1c, serum cholesterol and triglycerides) do not differ in the three regions of the country being investigated, there are considerable differences in the treatment prescribed for diabetes and its co-morbidity. In Flanders, treatment is usually started with sulphonylurea, in the Walloon provinces with biguanides. Hypolipaemic treatment is also started more frequently in the latter region. In Flanders, hypertension is registered in 51.4% of the newly diagnosed patients with diabetes, which is higher than in the other regions. However, no difference is noted between the different regions in the number of patients with diabetes who are treated for hypertension. A network of sentinel physicians, taking part in voluntary registration, can be helpful in calculating the incidence of a health problem, in particular type 2 diabetes in general practice. The sentinel net can also serve as an instrument for describing patient characteristics and showing how physicians deal with health problems. The regional differences in medical approach that are described require further investigation, mainly with respect to their impact on the patients' outcome.

Population estimates of persons presenting to general practitioners with influenza-like illness, 1987-96: a study of the demography of influenza-like illness in sentinel practice networks in England and Wales, and in The Netherlands.

Incidence data by age of new episodes of influenza-like illness reported by sentinel general practice networks in England and Wales and in The Netherlands over a 10-year period were examined to provide estimates of the consulting population during influenza epidemic periods. Baseline levels of recording in each age group were calculated from weeks in which influenza viruses were not circulating and the excess over baseline calculated to provide the population estimates during influenza epidemics. Influenza A/H3N2 epidemics were associated with higher population estimates for consultations than influenza B, especially in the age groups 0-4 and 65 years and over. In the intervening age groups, population estimates were more consistent regardless of the virus type. Both networks reported simultaneous peaking of incidence rates in all of the age groups. There were substantial increases in the number of persons reporting other respiratory illnesses during influenza epidemics. Population estimates of the consulting population provide the only secure basis for which health services resource utilization during influenza epidemics can be estimated.

Metabolic control and morbidity of type 2 diabetic patients in a general practice network.

Glycaemic control and the prevalence of modifiable cardiovascular risk factors, and micro- and macrovascular morbidity was examined in 637 Type 2 diabetic patients in general practice, of whom 405 consented to undergo a more extensive examination. In these 405 patients, HbA1c was > or = 7% in 56.6%, and hypertension and dyslipidaemia were found in 59.8% and 46.5% of the patients, respectively. The level of cardiovascular risk factors was acceptable, according to the European guidelines, in the following proportions of patients: BMI 45.0%; total cholesterol 69.1%; HDL-cholesterol 68.1%; triglycerides 67.8%; current blood pressure 89.8%; and smoking 21.0%. Retinopathy was present in 12.5% and microalbuminuria in 27.0% of the patients. In all 637 patients, the prevalence of angina pectoris was 17.7%, of myocardial infarction 11.4% and of congestive heart failure 10.7%. The care for Type 2 diabetic patients needs improvement and should focus on cardiovascular risk factors as much as on glycaemic control.

Effect of UK national guidelines on services to treat patients with acute low back pain: follow up questionnaire survey

In 1994 the UK Clinical Standards Advisory Group recommended eight treatment standards for back pain.1 In 1995 availability of these services to general practitioners was generally poor.2 We conducted another...

EURACT The European Academy of Teachers in General Practice Network organisation within WONCA Region EUROPE - ESGP/FM

(1999). EURACT The European Academy of Teachers in General Practice Network organisation within WONCA Region EUROPE - ESGP/FM. European Journal of General Practice: Vol. 5, No. 2, pp. 82-83.

Communication Section: EURACT The European Academy of Teachers in General Practice Network organisation within WONCA Region EUROPE - ESGP/FM

Communication Section: EURACT The European Academy of Teachers in General Practice Network organisation within WONCA Region EUROPE - ESGP/FM

Rotterdam general practitioners report (ROHAPRO): a computerised network of general practices in Rotterdam, The Netherlands. Rotterdam's HuisArtsen Project.

Dutch public health services are charged with collective preventive care for the population--care that should, by law, be based on epidemiological data. General practices potentially offer important data for this purpose, particularly since more and more use a computer. This study aimed to assess whether it is possible to obtain useful epidemiological data from this source. In 1990, the Rotterdam Municipal Health Service, in collaboration with the Erasmus University Rotterdam, started a computerised sentinel practice network. The main features of this and a specific small investigation are described. The following institutions cooperate in the network: Municipal Health Service Rotterdam Area; Departments of General Practice and of Medical Informatics, Erasmus University Rotterdam; Rotterdam District Association of General Practitioners. Data are currently collected from 20 general practitioners and > 40,000 patients. In a specific project, the distribution of cardiovascular risk factors in different ethnic groups was compared. It was possible to build up a regional epidemiological registration system in this manner. In the cardiovascular project we found striking differences between ethnic groups. The risk profile for Turkish men, in particular, was less favourable. The health service also uses the system to improve cooperation between public health and primary health care (for example, in cervical screening, influenza vaccination). Computerised general practices offer great possibilities for research and for preventive activities in which public health care and general practitioners can cooperate.