Preventive Care In General Practice Research Articles

Childhood obesity prevention in general practice: supporting implementation through co-ideation.

Childhood obesity is associated with physical and psychological complications thus the prevention of excess weight gain in childhood is an important health goal. Relevant to the prevention of childhood obesity, Australian general practice-specific, preventive care guidelines recommend General Practitioners (GPs) conduct growth monitoring and promote a number of healthy behaviours. However, challenges to providing preventive care in general practice may impact implementation. In October and November, 2022, a series of three workshops focusing on the prevention of childhood obesity were held with a group of Australian GPs and academics. The objective of the workshops was to determine practical ways that GPs can be supported to address barriers to the incorporation of obesity-related prevention activities into their clinical practice, for children with a healthy weight. This paper describes workshop proceedings, specifically the outcomes of co-ideation activities that included idea generation, expansion of the ideas to possible interventions, and the preliminary assessment of these concepts. The ecological levels of the individual, interpersonal, and organisation were considered. Possible opportunities to support childhood obesity prevention were identified at multiple ecological levels within the clinic. The preliminary list of proposed interventions to facilitate action included GP education and training, clinical audit facilitation, readily accessible clinical guidelines with linked resources, a repository of resources, and provision of adequate growth monitoring tools in general practice. Co-ideation with GPs resulted in a number of proposed interventions, informed by day-to-day practicalities, to support both guideline implementation and childhood obesity prevention in general practice.

Patient-directed reminders to improve preventive care in general practice for patients with type 2 diabetes: A proof of concept.

Preventive care in general practice is fundamental to managing the Australian diabetes epidemic. Recommended preventive care is nonetheless underperformed. The aim of this pilot study was to demonstrate proof of concept that pre-consultation patient-directed reminders could improve preventive care in general practice. Over two weeks, four general practices used a special software tool to generate reminder sheets listing recommended checks for a subset of patients with type 2 diabetes mellitus (T2DM). The sheets were given to patients before their consultations. The number of checks performed was compared for patients who did and did not receive reminders. General practitioners (GPs) were interviewed about the reminders and chronic disease management. Patients who received reminders had more recommended checks performed than those who did not receive reminders. GPs found the reminders useful but suggested that broader system changes are required. Pre-consultation patient-directed reminders could potentially be an effective tool to increase preventive care for patients with T2DM in generalpractice.

Preventive care in general practice among healthy older New South Wales residents

BackgroundDespite being at high risk, disadvantaged patients may be less likely to receive preventive care in general practice. This study aimed to explore self-reported preventive care received from general practitioners and the factors associated with this by healthy New South Wales (NSW) residents aged 45–74 years.MethodsA self-completed questionnaire was sent to 100,000 NSW residents in the 45 and Up cohort study. There was a 60% response rate. After exclusions there were 39,964 participants aged 45–74 years who did not report cardiovascular disease or diabetes. Dichotomised outcome variables were participant report of having had a clinical assessment of their blood pressure (BP), blood cholesterol (BC) or blood glucose (BG), or received advice to eat less high fat food, eat more fruit and vegetables or be more physically active from their GP in the last 12 months. Independent variables included socio-demographic, lifestyle risk factors, health status, access to health care and confidence in self-management.ResultsMost respondents reported having had their BP (90.6%), BC (73.9%) or BG (69.4%) assessed. Fewer reported being given health advice to (a)eat less high fat food (26.6%), (b) eat more fruit and vegetables (15.5%) or (c) do more physical activity (19.9%). The patterns of association were consistent with recognised need: participants who were older, less well educated or overweight were more likely to report clinical assessments; participants who were overseas born, of lower educational attainment, less confident in their own self-management, reported insufficient physical activity or were overweight were more likely to report receiving advice. However current smokers were less likely to report clinical assessments; and rural and older participants were less likely to receive diet or physical activity advice.ConclusionsThis study demonstrated a gap between reported clinical assessments and preventive advice. There was evidence for inverse care for rural participants and smokers, who despite being at higher risk of health problems, were less likely to report receiving preventive care. This suggests the need for greater effort to promote preventive care for these groups in Australian general practice.

General practice and preventive health care: a view through the eyes of community members

To identify barriers to, and enablers of, the uptake of preventive care in general practice from the perspective of community members, and to explore their sense of the effectiveness of that care. Qualitative study involving 18 focus groups comprising 85 community members aged over 25 years, from two areas of metropolitan Melbourne that were identified as being of high and low socioeconomic status (SES). The study was performed between 25 May and 9 December 2010. Groups were stratified by age, sex and location (high or low SES). Factors related to practitioners, patients and structure and organisation that may act as barriers to and/or enablers of preventive care in general practice. Participants saw preventive care as legitimate in general practice when it was associated with concrete action or a test, but rated their general practitioners as poor at delivering prevention. Trust, rapport and continuity of care were viewed as enablers for participants to engage in prevention with their GP. Barriers to participants seeking preventive care through their GPs included lack of knowledge about what preventive care was relevant to them, consultations focused exclusively on acute-care concerns, time pressures and the cost of consultations. A disconnect exists between patient perceptions of prevention in general practice and government expectations of this sector at a time when general practice is being asked to increase its focus and effectiveness in this field.

Verschillen in preventieve zorg door huisartsen verklaren sociaal-economische verschillen in de incidentie van CVA niet

Objective: To assess socioeconomic disparities in stroke incidence and in the quality of preventive care in general practice for stroke in the Netherlands. Study design and setting A total of 190,664 patients who registered in 96 general practices were followed up for 12 months. Data were collected on diagnoses, referrals, prescriptions, and diagnostic procedures. Hazard ratios (HR) were calculated to assess the association between educational level and stroke incidence. We developed quality indicators based on evidence based guidelines for stroke prevention at general practice, and assessed deviations from these guidelines. Multilevel logistic regression was used to assess socioeconomic disparities in the quality of preventive care for stroke precursors. Results: Lower educational level was associated with higher incidence of stroke in men (HR 1.36, 95% CI 1.06-1.74) but not in women. Among both men and women, there were socioeconomic disparities in the prevalence of hypertension, hypercholesterolemia, diabetes, angina pectoris, heart failure, and peripheral artery disease. Lower educated hypercholesterolemia patients under medication were less likely to be prescribed statins (odds ratio 0.62, 95% CI 0.42-0.91). However, for other precursors of stroke, there were no major disparities in the quality of preventive care. Conclusion: There are socioeconomic disparities in stroke incidence among men but not among women. Socioeconomic differences in factors such as hypertension and diabetes are likely to contribute to stroke disparities. Universal access to general practice and the implementation of general practice guidelines in the Netherlands are likely to have promoted the provision of equal and standardised care for stroke precursors across socioeconomic groups.

Disparities in stroke preventive care in general practice did not explain socioeconomic disparities in stroke

Objective To assess socioeconomic disparities in stroke incidence and in the quality of preventive care for stroke in the Netherlands. Study Design and Settings A total of 190,664 patients who registered in 96 general practices were followed up for 12 months. Data were collected on diagnoses, referrals, prescriptions, and diagnostic procedures. Hazard ratios (HR) were calculated to assess the association between educational level and stroke incidence. Multilevel logistic regression was used to assess socioeconomic disparities in the quality of preventive care for stroke precursors. Results Lower educational level was associated with higher incidence of stroke in men (HR = 1.36, 95% CI = 1.06–1.74) but not in women. Among both men and women, there were socioeconomic disparities in the prevalence of hypertension, hypercholesterolemia, diabetes, angina pectoris, heart failure, and peripheral artery disease. Lower educated hypercholesterolemia patients under medication were less likely to be prescribed statins (odds ratio = 0.62, 95% CI = 0.42–0.91). However, for other precursors of stroke, there were no major disparities in the quality of preventive care. Conclusion There are socioeconomic disparities in stroke incidence among men but not among women. Socioeconomic differences in factors such as hypertension and diabetes are likely to contribute to stroke disparities. However, general practitioners(GPs) provide care of a similar quality to patients from different socioeconomic groups.

Patients’ ideas, fears and expectations of their coronary risk: barriers for primary prevention

The application of cardiovascular guidelines and risk tables may be impeded by many barriers. In the present paper, we explored the role of patients in the feasibility of cardiovascular preventive care in general practice. Patient-related barriers were examined by means of a qualitative study. Fifteen GPs audio-taped one or two consultations on primary cardiovascular preventive care. The tapes were used to guide the subsequent semi-structured in-depth interviews with patients. Twenty-two patients were interviewed. Patients’ understanding of prevention of cardiovascular disease (CVD) was often insufficient. The risk table and the multi-factorial approach were difficult to understand. Risk perception was often unrealistic and dichotomous, and mainly based on personal experiences. There was a demand for more information and cholesterol tests. At the patient level, many barriers impede effective prevention of cardiovascular diseases. In particular, the highly individualized high-risk approach needs to be explained to patients. Educational patient materials, intended to support both the GP and the patient, should take into account the ideas, fears and expectations of patients.

Improving Quality of Organizing Cardiovascular Preventive Care in General Practice by Outreach Visitors: A Randomized Controlled Trial

Background. Adequate care for patients with cardiovascular risks requires an adequate practice organization. Educational outreach visits are a promising approach to modifying professional behavior. We aimed to assess whether the quality of cardiovascular preventive care in general practice can be improved through a comprehensive intervention implemented by an educational outreach visitor. Methods. After baseline measurements, general practices ( n = 124) in the southern half of The Netherlands were randomly allocated to either intervention or control group. The intervention, based on the educational outreach model, comprised 15 practice visits over a period of 21 months and addressed a large number of issues around task delegation, availability of instruments and patient leaflets, record-keeping, and follow-up routines. Twenty-one months after the start of the intervention, postintervention measurements were performed. The difference between ideal and actual practice in each aspect of organizing preventive care was defined as a deficiency score. Primary outcome measure was the difference in deficiency scores before and after the intervention. Results. All practices completed both baseline and postintervention measurements. The difference in change between intervention and control group adjusted for baseline was statistically significant ( P < 0.001) for each aspect of organizing preventive care. The largest absolute improvement was found for the number of preventive tasks performed by the practice assistant. Conclusions. This study showed that a comprehensive intervention implemented by outreach visitors was effective in improving organization of cardiovascular preventive care in general practice.

Organizing Cardiovascular Preventive Care in General Practice: Determinants of a Successful Intervention

Background. Although outreach visitor interventions have proven to be effective, more detailed studies are needed to understand what elements of interventions work and why. In this study we investigate the determinants of success of an intervention for optimizing cardiovascular preventive care in general practice. Methods. After baseline measurements and randomization, 62 general practices received a comprehensive intervention program, by means of outreach visitors, lasting 21 months. Data on practice management and preventive activities were gathered at baseline and at postintervention measurements. Key characteristics of the intervention considered possible determinants of success were gathered by questionnaire. The difference between ideal and actual practice in each aspect of organizing cardiovascular preventive care was calculated as a deficiency score. The difference between deficiency scores before and after the intervention were the main outcome measures. Results. The key characteristic, duration of exposure to an aspect (in months), was positively related to the change in availability of separate clinics and in the amount of teamwork. The improvement in instruments and materials was positively related to the general practitioner's opinion about the given feedback. No relations were found between the key characteristics and changes in record-keeping or follow-up routines. Conclusion. Although implementation of a comprehensive prevention program is effective, we could not fully disentangle the “black box” of the intervention. The duration of exposure to an aspect of organizing cardiovascular care was the key determinant to success.

Continuation and initiation of preventive care in general practice following myocardial infarction

This study assesses the extent to which general practitioners maintain hospital-initiated preventive treatment for patients one year after a myocardial infarction and initiate preventive care for patients discharged from hospital without such care. A cross-sectional study was conducted following up 565 myocardial infarction one-year survivors aged less than 80 years from two district general hospitals and 97 general practices in Oxfordshire and bordering areas. Hospital discharge records and general practice casenotes were reviewed for prescriptions of aspirin, β-blockers, ACE inhibitors, and lipid-lowering drugs. The number of patients continuing to receive hospital-initiated prescriptions one year after the acute event was: for aspirin 437/466 (94%); β-blockers 217/276 (79%); ACE-inhibitors 189/218 (87%) and lipid lowering drugs 57/66 (86%). The number of patients discharged without appropriate preventive care but receiving prescriptions initiated in general practice was: for aspirin 30/40 (75%); β-blockers 49/169 (27%); ACE-inhibitors 11/20 (55%) and lipid-lowering drugs 81/261 (31%). In conclusion, improving the implementation of evidence-based preventive care for patients with coronary heart disease is now a national priority. Most post-infarction patients were managed to a high standard, but the highest rates were attained when prescribing was initiated in hospital. Achieving optimal preventive care at hospital discharge is a crucial step in achieving appropriate long-term care in general practice.

Primary health care. Screening in primary care: health for all? A study in Dutch general practice

Background: in recent years there has been an increasing emphasis on the delivery of preventive care in general practice. At the same time, available evidence suggests people from lower social classes receive less preventive care compared with people from higher social class. The objective of this study was to assess the uptake of screening by blood pressure measurement, cervical cytology and manual breast examination in risk populations by patients attending their general practioners and relate the findings to levels of educational attainment and type of health insurance. Methods: the study was based on data gathered in the Dutch National Survey of General Practice in which 161 GPs recorded sociodemographic data, reasons for encounter, diagnoses and interventions during a 3 month period. Persons receiving the above procedures as screening measures were counted and expressed as rates per 1,000 persons registered and per 1,000 persons consulting. These rates were examined at three levels of educational attainment and according to the health insurance of the patient using logistic regression methods. Results: when analysed by educational attainment, high levels of blood pressure measurement were found in persons of lower educational attainment in both males and feamles (30-59 years) while for cervical cytology (35-54 years) higher levels were found amongst the better educated and for breast examination (40-69 years) the rates were similar regardless of educational attainment. When analysed by insurance status parallel trends were observed, with higher rates for blood pressure measurement among the publicly insured and higher rates for cervical cytology among the privately insured. Conclusions: the results, whether based on persons registered or persons consulting, suggest no important social bias in the extent to which persons are screened by blood pressure measurement or breast examination. There were strong social gradients for cervical cytology favouring the better educated and privately insured. More effective targeting of women with low educational attainment and publicly insured is called for. (aut.ref.)

HRT, A GENERAL PRACTICE APPROACH: HOW TO REACH THE MOST VULNERABLE

SUMMARY Hormone replacement therapy has been shown to be effective in the preservation of bone density and its use should lead to a substantial reduction in the fracture rate of older women. Observational studies have also suggested that it may lead to a reduction in the incidence of coronary heart disease. Both effects are relevant to preventive care in general practice and have been applied within the framework of health promotion clinics. However, the tendencies for patients who are already healthy to select themselves for attendance at these clinics, and for long‐term hormone therapy, mean that efforts to improve the health of the population do not reach those most in need. Groups most at risk should be defined by individual practices and identification of high‐risk patients be followed by appropriate investigation and treatment. It is possible to identify the following high‐risk groups: long‐term users of corticosteroid therapy or thyroxine; women who have had an early hysterectomy or oophorectomy; women with known coronary artery disease, diabetes or familial hyperlipidaemia. Methods of ascertainment and investigation are described, as are the various modes of therapy and lifestyle modifications considered appropriate. Health promotion clinics are not currently reaching those most in need, and preventive therapy should be extended to target the most vulnerable.

Preventive care in general practice in Australia: a public health perspective

There is considerable potential in Australia for implementing effective preventive care strategies in the general practice setting, especially in the context of Australia's new health goals and targets towards the year 2000. There is a clear need for the clinical paradigm, which focuses on developing efficacious, intensive, practitioner-delivered lifestyle change interventions, to be integrated within a broader public health approach. However, while there has been considerable growth in the breadth and variety of health promotion research and activity being carried out in general practice in Australia, the evidence supportive of the efficacy and effectiveness of physician-based interventions (except in the case of smoking cessation) has been less than compelling, and a number of problems still remain. These include: health promotion still remains a minor component of the great majority of consultations; there are many potential interventions which are possible, but little evidence that they will be used appropriately; there is little evidence that patients who are most in need are receiving appropriate services; there is generally a poor linkage between research and practice; and there are real doubts about the ability of the system to sustain preventive care in general practice.

Preventive care in general practice.

Preventive care is an integral component of general practice teaching in all Australian medical schools. While curriculum time and teaching methods vary, the overriding emphasis remains on integrating both epidemiological and behavioural science approaches into the primary care setting. Preventive aspects are stressed during attachments with general practitioners. Use of appropriate theoretical frameworks and models allows the role of the general practitioner in disease prevention to be formalized. Undergraduate teaching is further reinforced by programs within the Family Medicine Programme at a vocational training level, and the Royal Australian College of General Practitioners at a continuing medical education level.

Strategies to increase preventive care in general practice

Strategies to increase preventive care in general practice

Strategies to increase preventive care in general practice

To develop strategies to overcome barriers to preventive care in general practice. Participants invited to attend a one-day workshop ranked barriers to preventive care in a pre-workshop survey. During the workshop, small groups generated strategies to overcome the most influential barriers. After the workshop, participants nominated strategies for implementation in the ideal world and in the realities of resource constraints. Twenty-six participants representing general practice, medical academe, funding authorities, health policy planners, researchers, medicopolitical organisations and consumers. The surveys yielded preferred strategies for implementation in the ideal world and 10 preferred strategies for implementation given likely resource constraints. Authoritative guidelines are needed to guide clinical practice and to evaluate research. Other comprehensive strategies to overcome barriers to preventive care must be implemented and evaluated for effectiveness and acceptability in field experiments before wider implementation. The controlled implementation and evaluation of these strategies requires genuine collaboration amongst clinicians, health policy planners, researchers, funding authorities and general practice academe.

A self-contained method of evaluating the provision of preventive care in general practice.

In an earlier paper a method was described by which general practitioners are able to obtain dissatisfaction data from their patients by means of questionnaires. A similar approach has been used to study preventive care activities of general practitioners. We have found it to be practicable and acceptable to patients and surgery personnel. It also yields results which are consistent and which have apparently stimulated some practitioners to alter their practice behaviour by increasing their preventive care activities.