Primary Care Area Research Articles

Weighing social and economic determinants related to inequalities in mortality.

It is well known that there are social inequalities in health. Following the ecological approach, unemployment has been one of the most used indicators to study social inequalities. The aim of the present study was to investigate the relationships between indicators of extreme poverty and social unrest, along with unemployment, and mortality in Barcelona, during the years 1989 to 1993. A cross-sectional ecological study was carried out using Primary Health Care Areas (PHCAs) as the unit of analysis. The study population consisted of residents in Barcelona City. The indicators studied as dependent variables were the age-standardized mortality rates of the following causes of death: total mortality; lung cancer; bronchitis, emphysema, and asthma; cirrhosis; cerebrovascular disease; ischemic heart disease; breast cancer; traffic accidents; acquired immunodeficiency syndrome (AIDS); and drug overdose. Independent variables were male unemployment rate of the primary health care areas and indicators of extreme poverty and social conflict. A descriptive analysis, a bivariate analysis using Spearman correlation coefficients, and a multivariate analysis fitting Poisson regression models were carried out. For the main results, one group of causes of death was associated only with unemployment: bronchitis, emphysema and asthma, cerebrovascular disease, and ischemic heart disease (both men and women); lung cancer (only among men); total mortality and cirrhosis (only among women). Among men, another group of causes of death was associated with extreme poverty and/or social unrest, as well as unemployment: total mortality, cirrhosis, and drug overdose. AIDS in men was only associated with extreme poverty and social unrest. We concluded that we see different types of relationships between deprivation and mortality. Unemployment has been related to mortality because of pathologies with socially accepted risk factors (tobacco and alcohol). Causes of death with risk factors not socially accepted (illegal drug use) have been related to indicators of marginality as well as unemployment.

Long‐term influences of a biopsychosocial rehabilitation programme for chronic pain patients

Chronic pain leads to high costs in the form of compensation for absence from work due to illness, production loss and health care utilization. Multidisciplinary treatment programmes at pain clinics can result in return to work and a decrease in doctor visits. The aim of this study was to evaluate the long-term influences of a rehabilitation programme in primary health care for chronic pain patients with regard to doctor visits, frequency of sick-leave and level of disability. A longitudinal, intervention study design was used over a three-year period. A biopsychosocial rehabilitation programme based on ego-strengthening psychotherapy was used. An occupational therapist and a physiotherapist led the intervention, which comprised two meetings per week for six weeks. The study was performed in a primary health care area in the southwest of Sweden with 54 chronic pain patients. The results showed a significant decrease in the number of doctor visits as well as sick-leave days. The level of absenteeism due to occupational disability changed significantly from being on sick leave to receiving a disability pension. The rehabilitation programme reduced patient attendance at health care facilities but did not increase the numbers of patients returning to work.

The 21st century: the age of family medicine research?

Family medicine has matured as an academic and scientific discipline with its own core concepts, knowledge, skills, and research domains. It has acquired much expertise in studying common illnesses; the integration of medical, psychological, social, and behavioral sciences; patient-centered care; and health services delivery. Many health care challenges in the 21st century will place a great demand on primary care, which can serve its purpose only if it is of high quality and evidence based. Family medicine research can contribute to many areas of primary care, ranging from the early diagnosis to equitable health care. Stakeholders, such as the World Health Organization, governments, and funding agencies, are becoming more supportive to family medicine research because they recognize its key importance in improving the quality of primary care and bridging the gap between biomedical research and clinical practice. Family medicine can play a leading role in shifting the paradigm of medical research from the laboratory to the person. The 21st century should be a golden age of family medicine research because the time is right for the discipline, the health care environment is most suitable, and stakeholders are supportive. Family medicine must prepare for it by building up its research track record and capacity.

Evaluation of a health promotion programme to prevent the misuse of androgenic anabolic steroids among Swedish adolescents.

The aim of this study was to design an appearance programme in order to prevent the misuse of androgenic anabolic steroids among adolescents and to evaluate the adolescents' perception of this programme. The study was performed in all schools in a primary health care area on the south west coast of Sweden. The intervention targeted all 16- and 17-year-old males and females (n = 921). The intervention and evaluation were completed by 451 boys. The strategy of the appearance programme was to create awareness of and to discuss attitudes towards steroid hormones among these adolescents. Youth leaders and health workers, who discussed these subjects with adolescents over a period of 2 years, carried out the intervention programme. The perception of the programme was analysed anonymously using questionnaires. Effects on the total population of youths were assessed by two cross-sectional surveys. The intervention programme was well received by the adolescents. The misuse of androgenic anabolic steroids had a tendency to decrease after the appearance programme. We demonstrated a method for involving the community in an appearance programme to reduce misuse of anabolic steroids and showed that youth were sensitive to our discussions about appearance and attitudes. This study indicates that drug abuse among adolescents can be decreased by health promotion activities, such as group discussions. Controlled studies are needed before the results of this appearance programme can be generalized.

Características métricas del Cuestionario de Calidad de Vida Profesional (CVP-35)

ObjectiveTo assess the internal consistency, discriminative capacity and factorial composition of the Professional Quality of Life Questionnaire (QPL-35) in a population of primary care professionals. MethodsWe performed a cross-sectional analytical study in a primary care area in Madrid from 2001 to 2003. Random sampling of 450 healthcare professionals was performed on 2 occasions. The sample was stratified into 3 groups: group I (clinicians, pharmacologists, psychologists), group II (nurses, midwives, physiotherapists, social workers) and group III (administrative staff, porters, auxiliary nurses). The self-administered questionnaire QPL-35 was sent in January 2001 and January 2003 and on each occasion the questionnaire was sent again 1 month later. The percentages of total responses and responses per item were studied. We also studied the distribution of each answer by examining the «floor effect» and «ceiling effect», as well as the factorial composition based on a previous validation study. ResultsFive hundred sixty-three questionnaires (62.6%) were returned. All the questions had a response rate of more than 96%. At least one unanswered question was found in 22.0% of the questionnaires, and at least 2 were unanswered in 7.1%. The distribution of the answers did not fit normal distribution in any of the cases. The floor effect was present in questions related to management support and the ceiling effect was found in those related to motivation. The factorial analysis found 3 factors that explained 39.6% of the variance in the total number of questions. These factors were very similar to those of the previous validation study: «management support», «perception of workload» and «intrinsic motivation» explained 17.0%, 13.2% and 9.4% of the variance, respectively. Internal consistency was high for each factor (Cronbach’s α > 0.7) and for the total score (Cronbach’s α = 0.81). ConclusionsThe metric properties of the QPL-35 are maintained in different environments. This questionnaire can be recommended as a tool to measure and compare quality of professional life in primary care.

Integración del Modelo EFQM y el despliegue Hoshin Kanri en un área de atención primaria

IntroductionThe experience of Area 11 (Primary Care, Madrid public health service) has been directed toward the integration of selfevaluation with the EFQM Excellence Model and policy deployment (Hoshin Kanri model) by systematically applying a strategic plan. MethodologyAt the heart of the process of designing a strategic plan was the integration of benchmarking tools (EFQM Excellence Model and GIB Model for the internal and external environment, respectively), as well as techniques relating strategic and operational features (Hoshin Kanri Model) for policy deployment. In each phase, methodological rigor was guaranteed by using classical and advanced quality techniques (brainstorming, affinity diagrams, tree diagrams, DAFO), as well as prioritization techniques (Saaty’s prioritization matrix or Analytical Hierarchy Process, Hanlon’s matrix). ConclusionsStrategically, the opportunity to integrate institutional policies with the normal operational planning of the primary care area was strengthened by directing it toward integrated quality improvement.The application of a policy management system (Hoshin Kanri) and policy deployment after self-evaluation with the EFQM Excellence Model allowed greater participation among management and health professionals, thus directing the health area toward integrated quality improvement.

Inequalities of primary care microbiology testing between hospital catchment areas

Aims: To compare differences in microbiology testing activity between general practices within and between five hospitals in two National Health Service (NHS) regions in England. Methods: Retrospective capture of standardised...

El discurso de los profesionales de atención primaria de la Comunidad de Madrid acerca del trabajo con grupos: sobre técnicas y técnicos

Group-focused education for health is becoming a progressively more important activity in primary care. With the metaobjective of contributing to the further development thereof, this research set outs as specific objectives: knowing what is meant by "group-focused work" and ascertaining who is doing this work and how the group practices are carried out.From a qualitative-structural standpoint, four discussion groups and four open interviews were held. The discussion groups held were: two with physicians, specialists in pediatrics, in family medicine and in community medicine, one with nursing professionals and another with professional social workers. The open interviews: two with general practitioners and two with social workers in the Primary Care Areas in the Autonomous Community of Madrid.The groups are understood, by most of the professionals, as groupings of homogeneous individuals as regards age and the disease involved to which information is conveyed by means of informal "talks" which are given mainly by nurses. A minority called for another way of construing and doing work with groups based more on a sharing of experiences and on fostering the group dynamics, an approach spearheaded particularly by women social workers. The physicians play a minority, sporadic role which is always in conjunction with the other professions.Groups-focused work in education for health in primary care involves mostly "talks" given by nurses and social workers, it therefore being found necessary to promote team activities in this group-focused work, by boosting the motivation and the training of the professional and bettering the evaluation of group experiences.

Joint Working: The Health Service Agenda

The purpose of this article is to examine the policy and practice of collaboration between health and local government from a health servicesperspective. Within this remit, the authors primarily focus on the area of primary care. Four key elements of the post-1997 policy context are discussed: the move from GP fund-holding to Primary Care Groups and Trusts (PCG/Ts); a shift from treating to preventing illness; a drive for implementation by central government; and an emphasis on collaboration. Within this broad context, there are a number of factors which may support enhanced collaboration: the size, scope, responsibilities and budgets of PCG/Ts may well provide an organisational framework which is supportive of joint working. However, the ‘Berlin Wall’ between health and social care has proved to be enduring, and there are aspects of the post-1997 policy context which will continue to inhibit effective joint working, in particular centrally designed performance management systems and the dominance by GPs of PCG/Ts.

Comparación de dos modelos de indicadores de la calidad de la prescripción farmacéutica en atención primaria

ObjectivesTo assess the quality of prescriptions in primary care area through indicators established by a team of physicians and to analyze the relationship between these indicators and those used by the Spanish public health system (INSALUD) in the same area. MethodsAn observational, cross sectional study was performed in a primary care area in Asturias with 156,614 inhabitants and 9 health centers. An overall quality score was obtained for each of the physicians in the primary care area by using quality indicators and standards agreed on by the prescribers themselves. The relationship between the score obtained and the indicators normally used in the area by INSALUD and pharmaceutical cost was also analyzed. ResultsMean compliance with the optimal standard was 29%. The mean overall quality score was 3.24. None of the physicians achieved the maximum score of 11. No significant association was found between the score and the indicators for drugs of limited clinical value. Adherence to the pharmaceutical guide for the area was positively correlated with quality (r = 0.44, p < 0.001). A negative linear association (p < 0.001) was found between the overall quality score and incurred cost. The adjusted coefficient of determination was 0.29. ConclusionsPoor prescribing quality was widespread. Indicators for drugs of limited clinical value, frequently used as a measure of quality, showed no relationship with quality. Adherence to the area's pharmaceutical guide remains a valid indicator of prescribing quality. Overall, there was a correlation between higher quality and lower prescribing cost, although this correlation was not found for individual physicians.

Estudio de la marca en la prescripción de genéricos en 6 centros de salud durante el año 2001

To examine, through the analysis of the prescriptions billed during 2001, the brands of generic medicine prescribed by family doctors at 6 health centres in a primary care area. Descriptive study of medical prescription. SETTING. Primary care health area.Participants/context. 6 health centres: 3 urban and 3 metropolitan. Pharmaceutical prescription was analysed through the billing procedures for medical prescriptions, with the help of the administrator for GAIA pharmaceutical provision. 50% of the total generics billed in 2001, involving 7 active principles, were studied. Statistically significant differences in the prescription at the 6 centres were only found in two (omeprazole and ranitidine) of the 7 active principles. There was wide variety in the prescription of the various brands for all active principles. By assessing the involvement of the pharmaceutical industry in health centres, it was found that the smallest and the most metropolitan centres had different patterns of brand prescription. Determined brands of generic drugs were prescribed more than others. Active information on brands of generic medicines, coming from professional purveyors of information for family doctors, influenced prescription more than passive information. Doctors' lack of information on a brand of generic medicine from a particular laboratory was no obstacle to their being represented just the same on pharmaceutical billing.

Use of hypnotic and tranquillising drugs in general practice

In the Netherlands, as in other countries, the prevalence of long-term use of benzodiazepines is high. There was a high correlation between long-term use of benzodiazepines on the one hand and age and psychic condition on the other. The use was much higher in women than in men. Health problems were mentioned most (patient's view) as causing the use. Objective r - r To know more about the characteristics of long-term users of hypnotic and tranquillising drugs in a primary health care area in The Netherlands. Design r - r A questionnaire was applied to users of benzodiazepines and the computerised medical records were analysed. Setting r - r Nine general practices affiliated to the Registration Network Family Practices (RNH) of the University of Maastricht (UM). Subjects r - r A sample of 506 users, aged U 30 years, was divided into four categories: short-term (<3 months) users (once-only and episodic) and long-term users (episodic and continuous). Results r - r In 1992/93, 81% were long-term users and 42% of these took their drug continuously. All groups investigated had a preponderance of women. Health problems more so than social problems led to use of the drug. Long-term use was associated with older age, depressive behaviour in handling problems, a higher score on the medicine addiction index, problems with children or housing, and satisfaction with the effects of the drug. Conclusion r - r Most people taking benzodiazepines are long-term users. Age, depressive behaviour, addiction, satisfaction and problems with children or housing are risk factors for long-term use. Gender is not risk factor.

Cámara de retina no midriática: estudio de coste-efectividad en la detección temprana de la retinopatía diabética

Cost-effectiveness analysis (ACE) for application of fundoscopic photograph with non mydriatic retinal camera (Ffo-CNM) in early diagnostic of diabetic retinopathy (RD) compared with ophthalmoscopic view by pupillary dilation. diabetic patients, older than 14 years, attended on three Health Primary Care Areas (n=1495). Effectiveness measurement: predictive value of a positive test (VPD) and correctly diagnosed cases. Cost measurement: total cost by patient. ACE: defined as expected cost by VPD case and as expected cost by correctly diagnosed case. The results were submitted to an analysis of sensitivity for the study main variables. Ffo-CNM presented 90.91% of sensitivity [95% CI, 69.4-98.4%], 78.21% of specificity [95% CI, 67.1-86.4%], 54.05% positive predictive value [95% CI, 37.1-70.2%] and 96.83% of negative predictive value [95% CI, 88-99.4%]. Effectiveness, defined as VPD case, was 15.4% for ophthalmoscopic view and 19.5% for Ffo-CNM, and defined as correctly diagnosed case, was 70% and 79.8%, respectively. Cost-effectiveness ratio: a) for health care system, the cost by VPD case was 52.62 euros for ophthalmoscopic view and 28.44 euros for Ffo-CNM and cost by correctly diagnosed case was 11.58 euros and 6.95 euros, respectively, and b) for the society, cost by VPD case was 100.13 euros for ophtalmoscopic view and 34.54 for Ffo-CNM and the cost by correctly diagnosed case was 22.03 euros and 8.44 euros respectively. If an introduction of a early detection of RD program for the entire diabetic population was decided the option to make it using Ffo-CNM would be the most efficient.

Antibiotic prescribing and urinary tract infection

The aim of this study was to evaluate the diagnostic and therapeutic approach to urinary tract infections (UTIs) by primary care physicians, in Samsun, Turkey. Data were obtained from the records of 2083 visits at eight primary care areas. Trained research students were stationed on site at each of the eight primary care centres between 1 June, 1999 and 1 July, 1999. Patients who had acute cystitis, recurrent UTIs, acute pyelonephritis and acute urethritis were included in the study. A total of 2083 office visits were recorded and 419 (20.1%) of the patients had UTIs and acute urethritis. Antibiotics were prescribed for 94.7% of the patients with UTIs and urethritis. Some 74% of prescriptions were consistent with current recommendation, but only 41% of the antibiotic prescriptions were rational according to dosage, dosage interval and duration of therapy. Urinary antiseptic agents were prescribed to 75% of patients with UTIs. These data indicate that polypharmacy is widespread in our region; primary care physicians need to review their knowledge about the diagnosis and treatment of UTIs and acute urethritis.

El discurso de los profesionales de atención primaria de la Comunidad de Madrid sobre el trabajo con grupos: sentido, finalidades y ámbitos de intervención

Health Education with groups is an increasingly important activity in primary care. For the purpose of contributing to the furthering thereof, this research is aimed at ascertaining the opinions of the health care professionals with regard to the group practices and particularly with regard to their reason for being, purposes and fields of intervention. From a qualitative-structural perspective, four discussion groups and four open interviews were held with general practitioners, specialists in Pediatrics, in Family and Community Medicine, Nursing and Social Work in the Primary Care Areas in the Autonomous Community of Madrid. The opinions of the primary care professionals regarding the groups are confined to the activities of Health Education, this being an activity subject to individual inquiry. To form groups, the professionals include arguments on the order of hierarchy, efficiency, effectiveness and personal satisfaction. The main groups regarding which the group work was done are chronic patients (hypertension and diabetes), women (pre-menopause, general malaise), school-age children and teachers, community associations and caregivers of the chronically ill. The majority of the primary care professionals consider the work with groups to be something on the side, the end purpose of which would be savings and, on a secondary scale, Health Education. These groups mainly regard chronic patients and women, community work being approached on a second plane.

Accidentes atendidos en un área básica de salud de girona, españa

Accidents have been largely unstudied in the area of Primary Care. They are one of the most frequent motives for consultation in the Emergency Services and the first assistance that accident victims receive is usually in primary care centres. Establishment of the incidence and clinicoepidemiological characteristics of the accidents attended in a Basic Health Area can provide important information about which of these could be susceptible to preventive actions. descriptive study. primary care: all the patients attended for accidents (389) in the Primary Care Centre between October 1998 and May 1999. age, sex, place of the accident, type of lesion, location of lesions, agents involved, intentionality, complementary tests, treatment and referral. estimation of means, standard deviation, proportions and 95% confidence intervals. Incidence: 4.1% (CI95%: 3.7-4.5%). Sex: males 59% (CI95%: 54.2-64%) and females 40.9% (CI95%: 36-45.8%). Age: younger than 20 years, 50.4% (CI95%: 45.4-55.4%). Most common activity associated with accidents: leisure 24.4% (CI95%: 20.2-28.7%). home 36.2% (C95%: 31.5-41%). Most frequent lesion: contusion 39.6% (CI95%: 34.7-44.4%). Most frequent site of lesion: arms 37.5% (CI95%: 32.7-42.3%). Most common agent involved: tools and machinery 15.9% (CI95%: 12.3-19.6%). Of these, 92.2% (CI95%: 89.3-94.7%) were accidental. Type of visit: 83.3% (CI95%: 79.6-87%) were attended as emergencies; 79.5% (CI95%: 75.4-83.5%) received treatment with dressings and/or medication. Of these, 9.8% (CI95%: 6.8-12.7%) required referral to a hospital, 13.3% (CI95%: 10-16.7%) required complementary tests. Most accidents occur in young people and educational campaigns to prevent accidents and directed towards this population group are clearly needed.

Physicians' Antibiotic Prescribing Habits for Upper Respiratory Tract Infections in Turkey

The aim of this study was to evaluate the antibiotic prescription rates for upper respiratory tract infections (uRTIs) by primary care physicians in Samsun, Turkey. Data were obtained from the records of 2083 visits to 8 primary care areas. Trained research students were stationed on site at each of the 8 primary care areas during the study period. Clinical features of patients were documented on a standardized form. Patients who had acute pharyngitis, acute sinusitis, acute otitis media (AOM) and common cold were included in the study. This survey was conducted between June 1, 1999 and July 1, 1999. A total of 2083 office visits were recorded and 502 (24.1%) of the patients had uRTIs. Physicians approached these conditions empirically, with only 2.9% of patients having a diagnostic test at initial examination. Antibiotics were prescribed for 461 patients (91.8%) with uRTIs (common cold: 41.9%, acute pharyngitis: 94.7%, acute sinusitis: 94.1% and AOM: 100%). 11.5% of the antibiotic prescriptions were inconsistent with current recommendations derived from the literature. Inadequate antibiotic prescribing was documented in 29.7% of antibiotic prescriptions. Errors were frequent in relation to dosage, dosage interval and duration of therapy. Overuse of antibiotics is widespread in our geographic area. Both administrative and educational intervention should be implemented to improve antibotic prescribing habits at the primary health care level to reduce the unnecessary use of antimicrobial agents.

Factores que influyen en la prescripción de benzodiacepinas y acciones para mejorar su uso: un estudio Delphi en médicos de atención primaria

To identify the factors that affect the prescription of benzodiazepines and similar drugs and the actions that can be taken to reduce their prescription.Design. Consensus method. Delphi technique. Four primary care areas in Asturias. Participants. 39 doctors from primary care teams agreed voluntarily to take part in the study, and 32 completed the study. They belonged to 20 health centres. They were sent by mail three questionnaires one after the other. The second and third questionnaires were worked out on the basis of the analysis of the information from the replies to the preceding questionnaire. Those who did not send in a reply were reminded by phone. The 5 most influential factors in benzodiazepine prescription were agreed: reduction in the threshold of tolerance of emotional discomfort; increase of the prevalence of pathologies; lack of time in the consulting-room; social and economic conditioning factors; properties of the benzodiazepine family. The 5 most important actions that could reduce prescription of these drugs were agreed: general health education; reduction in case loads; making doctors more conscious of prescribing correctly; strengthening the social support network; doctors fomenting use of effective alternative treatments. The prescription of benzodiazepines and their analogues is a multi-factorial action with social and psychological roots. The action most voted on to reduce their prescription was general health education.

Formación continuada en atención primaria: necesidades formativas de sus profesionales

To find professionals' suggestions for training contents, the value they place on various options, the difficulties they detect for attending activities and their preferences for time-table and format of courses. Cross-sectional, descriptive study. Primary Care Area 7 in Madrid. Medical and office workers from the area (n=1,053). An anonymous self-filled questionnaire. 39% replied (46% nurses; 42% administrative assistants, and 40% doctors). The subjects for courses most often requested by doctors were dermatology, minor surgery and radiology; by nurses, emergency, functional bandages and computer skills; and by administrative assistants, computers, management of health service delivery and Internet. The continuing education options valued most highly were courses/workshops in the area's continuing education programme, self-training sessions and rotations. The main difficulties for attending courses were the lack of budget for cover and time-tables outside working hours. 42% preferred mornings; and 35%, courses lasting more than 20 hours. The training needs expressed by doctors and nurses are mainly clinical in content, whereas those of office staff are mainly computer-related. The most highly valued training options are the courses/workshops in the area's continuing education programme. The main difficulty for attending courses is the lack of cover for their job.

Factores condicionantes del gasto en farmacia en los centros de atención primaria de un área de salud

To identify the factors affecting drug expenditure.Design. Cross-sectional study.Setting. Madrid Primary Care area. 21 health centres. Association of the drug expenditure per inhabitant of each health centre during 1999 with the characteristics of its staff and operation of the centre. Expenditure on drugs per inhabitant, 14360 plus minus 3040 pesetas (86.31 plus minus 18.27; general practitioners, 19.62 plus minus 23.8%; doctors working as locums, 40.48 plus minus 20.72%; women doctors, 59.76 plus minus 13.36%; family doctors, 38.57 plus minus 21.35%; team nurses, 86.6 plus minus 18.27%; population over 65, 18.03 plus minus 7.73%; patients per day attended by each general practitioner, 32.82 plus minus 3.81; number of sessions per year on prescription profiles, 5 plus minus 3.91; prescription avoidable because of health card: 3106 plus minus 808 pesetas (18.67 plus minus 4.86 ); compliance with service offer, 1.7 plus minus 3.78. Drug expenditure per inhabitant dropped when sessions on prescription profiles (p = 0.013), the percentage of women doctors (p = 0.067) and the percentage of family doctors (p = 0.035) increased; and it dropped too when the over-65 population (p = 0.099) and the amount of prescription avoidable through the card (p = 0.034) dropped. In the multivariate analysis, the sessions on prescription profiles (ss = -843), the percentage of nurses in the reformed model (ss = -155), the percentage of family doctors (ss = -142) and the percentage of doctors from the traditional model (ss = -121) explain 71.2% of the variability in drug expenditure per inhabitant (F = 6.909; p = 0.002). The sessions to discuss prescription profiles, the presence of nurses from the reform model, postgraduate medical training and the employment of doctors under the traditional model are the factors that our study finds are linked to lower drug expenditure per inhabitant.