Primary Care Clinical Practice Research Articles

PRM221 - The Management of Irritable Bowel Syndrome (Ibs) in England: A Real World Study in Primary Care Clinical Practice

PRM221 - The Management of Irritable Bowel Syndrome (Ibs) in England: A Real World Study in Primary Care Clinical Practice

Evidence-based diagnosis and management of acute bronchitis.

Acute bronchitis is a common respiratory infection seen in primary care settings. This article examines the current evidence for diagnosis and management of acute bronchitis in adults and provides recommendations for primary care clinical practice.

A NEW CLINICAL GUIDELINE (2007) AND NATIONAL AWARENESS CAMPAIGN (2011) ACCELERATED BRAIN TUMOUR DIAGNOSIS IN UK CHILDREN (HEADSMART - BE BRAIN TUMOUR AWARE)

BACKGROUND: Public and professional concern about delays in diagnosis of childhood brain tumours has led to new referral guidelines and a public health campaign to raise awareness of the early features of brain tumours and the need for timely imaging. We believe this is a “world first attempt” to accelerate childhood cancer diagnosis at the primary-secondary care interface. METHODS: We investigated the referral pathways of children with a brain tumour 1989-2013 using (a) cancer registrations linked to routine records from primary care (Clinical Practice Research Datalink) and secondary care (Hospital Episode Statistics), (b) referral practice data from a multi-centre audit, and (c) data on total diagnostic interval (TDI) from a national service evaluation of HeadSmart. RESULTS: In a cohort of 181 patients (England, 1989-2006), primary care consultation rates rose 40-fold, from 3.1 per 100 person-months (pm) one year before diagnosis to 148.9 at diagnosis. In a cohort of 3,959 patients (England, 1997-2006), hospital admission rates rose 100-fold, from 1.3 per 100pm at one year before diagnosis to 134.0 at diagnosis. Emergency admissions rose from 35% to 55%. Long delays, repeated presentations in primary care and many ineffective referrals, especially in patients with low-grade brain tumours, were also identified in a multi-centre audit (2006). Headaches or convulsions were the commonest first symptoms at age 4+ years. Ophthalmic signs were more prominent in younger children, and changed most between onset (23% of patients) and diagnosis (46%). Raised intracranial pressure was the most common hospital presentation (40% of patients). During the period 2006-11, the median TDI fell by 53%, from 13.4 to 6.3 weeks. The greatest impact of HeadSmart is a 65% reduction in median interval between first clinical contact and diagnosis (P < 0.01; 730 children in 19 UK specialist centres, 2011-13). CONCLUSIONS: Longer total diagnostic intervals (TDI) were associated with slower-growing tumours, repeated presentations to primary care, ineffective referrals to hospitals and increasing likelihood of urgent admission. The referral guidance and awareness campaign shortened the interval from first contact to scanning, suggesting that professional awareness was enhanced. The campaign is ongoing, and it will be disseminated to primary care in 2013-14. TDI data are now collected routinely as part of UK cancer registration. SECONDARY CATEGORY: Pediatrics.

Quantified self and comprehensive geriatric assessment: older adults are able to evaluate their own health and functional status.

BackgroundThere is an increased interest of individuals in quantifying their own health and functional status. The aim of this study was to examine the concordance of answers to a self-administered questionnaire exploring health and functional status with information collected during a full clinical examination performed by a physician among cognitively healthy adults (CHI) and older patients with mild cognitive impairment (MCI) or mild-to-moderate Alzheimer disease (AD).MethodsBased on cross-sectional design, a total of 60 older adults (20 CHI, 20 patients with MCI, and 20 patients with mild-to-moderate AD) were recruited in the memory clinic of Angers, France. All participants completed a self-administered questionnaire in paper format composed of 33 items exploring age, gender, nutrition, place of living, social resources, drugs daily taken, memory complaint, mood and general feeling, fatigue, activities of daily living, physical activity and history of falls. Participants then underwent a full clinical examination by a physician exploring the same domains.ResultsHigh concordance between the self-administered questionnaire and physician's clinical examination was showed. The few divergences were related to cognitive status, answers of AD and MCI patients to the self-administered questionnaire being less reliable than those of CHI.ConclusionOlder adults are able to evaluate their own health and functional status, regardless of their cognitive status. This result needs to be confirmed and opens new perspectives for the quantified self-trend and could be helpful in daily clinical practice of primary care.

Performance indicators for clinical practice management in primary care in Portugal: Consensus from a Delphi study

Background: Performance indicators assessing the quality of medical care and linked to pay for performance may cause disagreement. Portuguese indicators included in recent health care reform are controversial.Objectives: To obtain consensus from opinion leaders in family medicine regarding the performance indicators for practice management used in the evaluation of Family Health Units in Portugal.Methods: Eighty-nine specialists in primary care were invited to answer the following question in an online Delphi study: ‘Which performance indicators should be assessed regarding the organization and management of clinical practice in primary care in Portugal?’A Likert scale was used to evaluate validity, reliability, feasibility and sensitivity to change. Twenty-seven experts participated in the second round and achieved a high degree of consensus. Eight categories were created for analysis.Results: The experts suggested the use of existing indicators as well as new indicators. Thirty-nine indicators suggested by the experts are currently in use in Portugal. The assessment of the number of clinical acts performed, the number of administrative acts, and evaluation of the clinical demographic profile achieved a high degree of consensus. The expert panel suggested fifty new indicators. Five categories of these new indicators had a high degree of consensus, and three categories had a low degree of consensus.Conclusion: The expert panel recommended that performance indicators of practice management should first assess the quantity of clinical and administrative activities undertaken. These indicators must take into account the human and financial resources available to the clinic and its demographic context.

Update in Pain Medicine for Primary Care Providers: A Narrative Review, 2010–2012: Table 1

This manuscript reviews peer-reviewed literature published from 2010-2012 relevant to the management of chronic pain in the primary care setting. Narrative review of peer-reviewed literature. We searched MEDLINE, PubMed, and reference lists and queried expert contacts for English-language studies related to the management of chronic noncancer pain in adult patients in primary care settings. One investigator reviewed all eligible studies for relevance, and 47 studies were reviewed by all authors and rated according to their impact on 1) primary care clinical practice, 2) policy, 3) research, and 4) quality of study methods. Through iterative discussion, nine articles were selected for detailed review and discussion. We present articles in six topic areas: interventional pain management; opioid dose and risk of overdose death; neuropathic pain; yoga for chronic low back pain; cognitive behavioral therapy; and systematic approaches to treating back pain. We discuss implications for pain management in primary care. There is growing evidence for the risks, benefits, and limitations of the multiple modalities available to primary care providers for the management of chronic pain. The dissemination and implementation of the evidence from these studies as well as novel system-level interventions warrant additional study and support from clinicians, educators, and policy makers.

Validation of the German Version of the Patient Activation Measure 13 (PAM13-D) in an International Multicentre Study of Primary Care Patients

The patients’ active participation in their medical care is important for patients with chronic diseases. Measurements of patient activation are needed for studies and in clinical practice. This study aims to validate the Patient Activation Measure 13 (PAM13-D) in German-speaking primary care patients. This international cross-sectional multicentre study enrolled consecutively patients from primary care practices in three German-speaking countries: Germany, Austria, and Switzerland. Patients completed the PAM13-D questionnaire. General Self-Efficacy scale (GSE) was used to assess convergent validity. Furthermore Cronbach’s alpha was performed to assess internal consistency. Exploratory factor analysis was used to evaluate the underlying factor structure of the items. We included 508 patients from 16 primary care practices in the final analysis. Results were internally consistent, with a Cronbach’s alpha of 0.84. Factor analysis revealed one major underlying factor. The mean values of the PAM13-D correlated significantly (r = 0.43) with those of the GSE. The German PAM13 is a reliable and valid measure of patient activation. Thus, it may be useful in primary care clinical practice and research.

First autochthonous case of canine Angiostrongylus vasorum in Slovakia

Angiostrongylus vasorum is a metastrongyloid nematode that may cause cardiopulmonary disease, neurological signs and coagulopathies in dogs. The parasite has an indirect life cycle with molluscs as intermediate hosts, in which the infective third larval stage develops. Recently, A. vasorum has been repeatedly reported in dogs outside the endemic areas, indicating that this parasite is widely distributed over Europe. This is the first record of an autochthonous infection in a dog from Slovakia that was casually diagnosed during routine preventive parasitological examination. A. vasorum first-stage larvae were recovered using the Baermann technique and identified by length and characteristic tail morphology. The animal originated from Slovakia and had not travelled abroad. The dog had been regularly walked on grass fields with a concentrated presence of common species of Gastropoda and frogs. The owner reported that the dog had been licking and eating grass and it had shown curiosity for molluscs and frogs. The first finding of A. vasorum-infected dog in Slovakia has confirmed that the parasite is spreading beyond the traditional hyperendemic foci, which accentuates the need for monitoring and increasing of disease awareness in primary care clinical practice.

SAT0328 Primary care for people with hip and knee osteoarthritis can be substantially improved. Results from a systematic review of studies comparing actual practice with desired practice

BackgroundEvidence-based recommendations for management of osteoarthritis (OA) have been developed to improve the quality of care by promoting interventions of proven benefit and discouraging ineffective interventions. There is remarkable consistency...

Determinants of lipid goal achievement in patients on extended-release nicotinic acid/laropiprant in primary care clinical practice

Objectives:To establish determinants of lipid goal attainment in primary care patients, with particular focus on participation in a disease management programme (DMP) on diabetes mellitus (DM) and/or coronary heart disease (CHD), with real-world practical relevance.Methods:The present analysis was based on an observational study in 2359 patients with dyslipidaemia or hypercholesterolaemia that were treated with nicotinic acid 1000 mg/laropiprant 20 mg (Tredaptive) one or two tablets daily. Subgroups were formed by DMP participation (DMP vs. no DMP). A stepwise logistic regression model with backward selection of variables was applied to investigate factors influencing the probability of reaching lipid goals. Follow-up was 23 ± 7 weeks.Results:Low density lipoprotein cholesterol (LDL-C) <100 mg/dl was achieved by 30.8% in DMP versus 26.8% (no DMP), high density lipoprotein (HDL-C) >40/50 mg/dl in 61.3% versus 66.1%, and triglycerides (TG) <150 mg/dl in 28.9% versus 31.7%. On multivariate analysis, age, sex, concomitant high-risk cardiovascular disease, or participation in a DMP appeared to have inconsistent effects on reaching LDL-C, HDL-C and TG goals. Likelihood to reach the LDL-C goal tended to be higher in males, in patients outside DMP, and in patients with DM or CHD, and those treated with 1 tablet (versus 2 tablets) extended release nicotinic acid 1000 mg/laropiprant 20 mg. The likelihood of reaching the HDL-C goal was higher in males and in patients without DM or DM+CHD (no effect of DMP). The likelihood of reaching the TG goals was higher in females, in patients outside DMP, and in patients with DM and/or CHD. Limitations include potential bias due to study design, physician and patient selection, and missing values at follow-up.Conclusion:DMP participation was not associated with overall improved lipid goal attainment. Physicians cannot predict the magnitude of effects of newly initiated lipid modifying therapy based on baseline characteristics of their patients.

Opportunistic detection of atrial fibrillation in subjects aged 65 years or older in primare care: a randomised clinical trial of efficacy. DOFA-AP study protocol

BackgroundClinical Practice Guidelines recommend using peripheral blood pulse measuring as a screening test for Atrial Fibrillation. However, there is no adequate evidence supporting the efficacy of such procedure in primary care clinical practice. This paper describes a study protocol designed to verify whether early opportunistic screening for Atrial Fibrillation by measuring blood pulse is more effective than regular practice in subjects aged 65 years attending primary care centers.Methods/designAn cluster-randomized controlled trial conducted in Primary Care Centers of the Spanish National Health Service. A total of 269 physicians and nurses will be allocated to one of the two arms of the trial by stratified randomization with a 3:2 ratio (three practitioners will be assigned to the Control Group for every two practitioners assigned to the Experimental Group). As many as 12 870 patients aged 65 years or older and meeting eligibility criteria will be recruited (8 580 will be allocated to the Experimental Group and 4 290 to the Control Group). Randomization and allocation to trial groups will be carried out by a central computer system. The Experimental Group practitioners will conduct an opportunistic case finding for patients with Atrial Fibrillation, while the Control Group practitioners will follow the regular guidelines. The first step will be finding new Atrial Fibrillation cases. A descriptive inferential analysis will be performed (bivariate and multivariate by multilevel logistic regression analysis).DiscussionIf our hypothesis is confirmed, we expect Primary Care professionals to take a more proactive approach and adopt a new protocol when a patient meeting the established screening criteria is identified. Finally, we expect this measure to be incorporated into Clinical Practice Guidelines.Trial registrationThe study is registered as NCT01291953 (ClinicalTrials.gob)

Help needed in medication self-management for people with visual impairment: case–control study

Visual impairment (VI) is rising in prevalence and contributing to increasing morbidity, particularly among older people. Understanding patients' problems is fundamental to achieving optimal health outcomes but little is known about how VI impacts on self-management of medication. To compare issues relating to medication self-management between older people with and without VI. Case-control study with participants aged ≥65 years, prescribed at least two long-term oral medications daily, living within the community. The study recruited 156 patients with VI (best corrected visual acuity [BCVA] 6/18 to 3/60) at low-vision clinics; community optometrists identified 158 controls (BCVA 6/9 or better). Researchers visited participants in their homes, administered two validated questionnaires to assess medication adherence (Morisky; Medication Adherence Report Scale [MARS]), and asked questions about medication self-management, beliefs, and support. Approximately half of the participants in both groups reported perfect adherence on both questionnaires (52.5% Morisky; 43.3%, MARS). Despite using optical aids, few (3%) with VI could read medication information clearly; 24% had difficulty distinguishing different tablets. More people with VI (29%) than controls (13%) (odds ratio [OR] = 2.8; 95% confidence interval [CI] = 1.6 to 5.0) needed help managing their medication, from friends (19% versus 10%) or pharmacists (10% versus 2.5%; OR = 4.4, 95% CI = 1.4 to 13.5); more received social service support (OR = 7.1; 95% CI = 3.9 to 12.9). Compared to their peers without VI, older people with VI are more than twice as likely to need help in managing medication. In clinical practice in primary care, patients' needs for practical support in taking prescribed treatment must be recognised. Strategies for effective medication self-management should be explored.

Cardiovascular Diseases and Other Evidence for Primary Care Clinical Practice

This issue includes several articles about various cardiovascular illnesses.(1-4) and another on a disease with increased risk for heart disease: hereditary hemochromatosis.(5) Yet another explores some myth busting about mortality and diabetes.(6) Two articles provide data with the support of patient and/or family organizations (Parent Heart Watch(1) and the Iron Disorders Institute(5)). Another 2 articles address maternal-child health, one considers treatment of hyperbilirubinemia,(7) and one describes an innovative team structure for pre-, post-, and intrapartum care.(8) We also provide preliminary data on azithromycin for chronic obstructive pulmonary disease. Pop quiz: What is the common contaminant with cocaine that causes serious side effects? What are these side effects? And another: What nonliver disease should be considered for children with elevated transaminase levels? (See the brief reports for answers.) Two reviews provide up-to-the minute practical facts for vaccinations and treatment-resistant hypertension that can be immediately incorporated into clinical practice. We also have an update on physician perspectives after 2 years of electronic medical record use and another with insights about the satisfaction of family physicians who are working in health centers in the first few years out of their residency.

Evidence-based practice in primary care—An explorative study of nurse practitioners in Norway

Evidence-based practice (EBP) has been a priority in health care in recent decades. However, few studies have investigated EBP in primary care. The aim of this study was to explore the knowledge that nurses with a bachelor’s degree use in their clinical practice of primary care. Focus group interviews were used. The sample consisted of 20 nurses in primary care practice. The data were analysed with systematic text condensation. Our findings show that most nurses use their own knowledge, their colleagues’ knowledge, knowledge acquired during nursing education, nursing literature, and guidance from expert personnel, but seldom use research. We recommend improving and developing the clinical practice of primary care. Referring to and analysing specialist and scientific data about specific topics may lead nurses to critically evaluate their clinical practice, and may enhance their theoretical and scientific knowledge related to clinical practice.

A qualitative study exploring the experience of the partners of cancer survivors and their views on the role of primary care

The partners of cancer survivors may experience distress, anxiety, fear and uncertainty whilst also caring for and supporting a partner who is ill. As they concentrate on the cancer survivor's needs, their own needs may remain unaddressed. Primary care staff may be well placed to support partners as they are generally accessible and may have a better knowledge of the patient's background and family relationships. However, their current involvement in the cancer survivor's and partner's cancer-related care is unclear. This study aimed to describe the experience of the partners of cancer survivors in dealing with cancer-related issues in the first 3 years post-diagnosis, their use of primary care services in relation to these issues and the barriers in doing so and their views on the role that primary care could potentially play in supporting them as carers during this period. Semi-structured interviews with 22 partners of cancer survivors diagnosed within the last 3 years and recruited through six GP practices in the Thames Valley Region of the UK were analysed using the 'framework' approach to thematic analysis. Three issues were identified as of particular concern to partners: providing practical support, providing emotional support and managing their own health and well-being. Few partners had sought or received support from primary care specifically for cancer-related issues, indicating confidentiality, lack of knowledge of family relationships and the greater need of the cancer survivor as barriers. Most partners would welcome a proactive approach from primary care and felt that this would provide an opportunity to discuss issues they were concerned about. Needs and concerns of the partners of cancer survivors in caring for patients are often not addressed. There is a scope for primary care to elicit these needs and provide greater support. Changes to clinical practice in primary care could lead to greater involvement of and to better outcomes for cancer survivors and their partners. A proactive approach to patients and their partners or other close family members at the time of diagnosis through an offer of support and the inclusion in a designated review appointment at the end of initial treatment would be useful.

Intervenciones preventivas en el ámbito de la atención primaria. El ejemplo del PAPPS. Informe SESPAS 2012

ObjectivesThe Program for Prevention and Health Promotion (PPHP) of the Spanish Society of Family and Community Medicine was launched at the end of the 1980s and its main objective is to integrate preventive and health promotion activities in daily clinical practice in primary care. The aim of the present study was to determine the level of compliance with the preventive activities of the PPHP. MethodsWe performed a comprehensive literature search of PPHP publications to assess the implementation and impact of the program. ResultsThe distinct evaluations carried out since the beginning of the program show that both compliance and registration of preventive activities have improved over time. The PPHP has been positively evaluated by both health professionals and patients. Family physicians in Spain carry out preventive activities more often than other European family physicians. ConclusionsThe PHPPS continues to operate 24 years after its initiation. However, some adaptations are needed since the Spanish health system is changing. Proposed modifications are related to accessibility and to providing a more effective response to users. In elderly patients, life expectancy should be assessed and priorities for preventive interventions should be set accordingly.

Nuevas alternativas en el tratamiento del síndrome de hombro doloroso

Shoulder pain is a common complaint in clinical practice in Primary Care and affects 20% of the general population. The usual form of treatment is based on NSAIDs, rest, rehabilitation and, as an alternative, a local injection into the joint. There are also radiofrequency techniques on the suprascapular nerve in the cases of refractory pain to these therapies.Radiofrequency can be used in two ways: Conventional Radiofrequency, using high temperatures to the target tissue with the aim of producing a thermal neurolysis and Pulsed Radiofrequency where the temperatures are lower and produces a temporary non-destructive blockage; the latter being the most common technique in the management of shoulder pain.Although the analgesic mechanism of action of Radiofrequency is unknown, recent studies have shown that it is safe, effective and lasting. Radiofrequency of the suprascapular nerve is a valid, effective and with few complications in the treatment of shoulder pain refractory to other therapies.

EBM in primary care: a qualitative multicenter study in Spain.

BackgroundEvidence based medicine (EBM) has made a substantial impact on primary care in Spain over the last few years. However, little research has been done into family physicians (FPs)' attitudes related to EBM. The present study investigates FPs' perceptions of EBM in the primary care context.MethodsThis study used qualitative methodology. Information was obtained from 8 focus groups composed of 67 FPs from 47 health centers in 4 autonomous regions in Spain. Intentional sampling considered participants' previous education in EBM, and their experience as tutors in family medicine or working groups' members of the Spanish Society of Family Practice. Sociological discourse analysis was used with the support of the MAXqda software. Results were validated by means of triangulation among researchers and contrast with participants.ResultsFindings were grouped into three main areas: 1) The tug-of-war between the "science" of EBM and "experience" in the search for good clinical practice in primary care; 2) The development of EBM sensemaking as a reaction to contextual factors and interests; 3) The paradox of doubt and trust in the new EBM experts.The meaning of EBM was dynamically constructed within the primary care context. FPs did not consider good clinical practice was limited to the vision of science that EBM represents. Its use appeared to be conditioned by several factors that transcended the common concept of barriers. Along with concerns about its objectivity, participants showed a tendency to see EBM as the use of simplified guidelines developed by EBM experts.ConclusionsThe identification of science with EBM and its recognition as a useful but insufficient tool for the good clinical practice requires rethinking new meanings of evidence within the primary care reality. Beyond the barriers related to accessing and putting into practice the EBM, its reactive use can determine FPs' questions and EBM development in a direction not always centred on patients' needs. The questioning of experts' authority as a pillar of EBM could be challenged by the emergence of new kinds of EBM texts and experts to believe in.

FUMEPOC: early detection of chronic obstructive pulmonary disease in smokers.

BackgroundCurrently is not feasible using conventional spirometry as a screening method in Primary Care especially among smoking population to detect chronic obstructive pulmonary disease in early stages. Therefore, the FUMEPOC study protocol intends to analyze the validity and reliability of Vitalograph COPD-6 spirometer as simpler tool to aid screening and diagnosis of this disease in early stages in primary care surgery.Methods / DesignStudy design: An observational, descriptive study of diagnostic tests, undertaken in Primary Care and Pneumology Outpatient Care Centre at San Juan Hospital and Elda Hospital. All smokers attending the primary care surgery and consent to participate in the study will undergo a test with Vitalograph COPD-6 spirometer. Subsequently, a conventional spirometry will be performed in the hospital and the results will be compared with those of the Vitalograph COPD-6 test.DiscussionIt is difficult to use the spirometry as screening for early diagnose test in real conditions of primary care clinical practice. The use of a simpler tool, Vitalograph COPD-6 spirometer, can help in the early diagnose and therefore, it could improve the clinical management of the disease.

Case-Based Training of Evidence-Based Clinical Practice in Primary Care and Decreased Mortality in Patients With Coronary Heart Disease

We investigated the 10-year mortality rates in a trial that tested a case-based intervention in primary care aimed at reducing the gap between evidence-based goals and clinical practice in patients with coronary heart disease (CHD). A prospective randomized controlled pragmatic trial was undertaken in a primary care setting. New evidence-based guidelines, with intensified lipid-lowering recommendations in CHD, were mailed to all general practitioners in the region and presented at a lecture in 1995. General practitioners (n = 54) and patients with CHD (n = 88) were assigned according to their primary health care center to 2 balanced groups and randomly allocated to usual care as a control or to an active intervention. General practitioners in the intervention group participated in repeated case-based training during a 2-year period. Patients whose CHD was treated by specialists (n = 167) served as an internal specialist comparison group. Altogether, 255 consecutive patients were included. Cox regression analysis was used to detect any survival benefit of the intervention. At 10 years, 22% of the patients in the intervention group had died as compared with 44% in the control group (P = .02), with a hazard ratio of 0.45 (95% confidence interval, 0.20-0.95). This difference was mainly due to reduced cardiovascular mortality in the intervention group (P = .01). In addition, the mortality rate of 22% in the intervention group was comparable to the rate of 23% seen in patients treated by a specialist. Use of case-based training to implement evidence-based practice in primary care was associated with decreased mortality at 10 years in patients with CHD.