Secondary Care Physicians Research Articles

Perspectives of Australian general practitioners on shared care for paediatric patients.

Australian general practitioners (GPs) are seeing proportionally fewer paediatric patients. GPs may be increasingly relying on secondary or tertiary care physicians to provide care to children with complex, chronic conditions. Shared-care initiatives may provide a solution to the apparent increasing dependence of GPs on paediatric specialists, although, currently, evidence is lacking about both the prevalence and composition of shared care for children in Australia. We invited 377 GPs in Melbourne, Australia, who had referred at least two children to specialist paediatric outpatient clinics within the 2014 calendar year, to participate in a mailed survey study. Items analysed for the present report included those relating to shared-care arrangements between GPs and paediatric specialists. Responses were received from 254 GPs (response rate 67%). The majority (90%) of GPs in our study have been involved in shared-care arrangements with outpatient paediatricians. We found wide variation in the success of these arrangements, measured through the ability of GPs to establish clear roles with paediatricians. For a national discussion around shared care to be productive, clear definitions and classifications will be crucial. Future research could investigate the reasons for variability in shared care in Australia, and examine optimal shared-care arrangements for children.

The role of general practitioners in medical school admission interview panels in the UK (2012-2014): a national survey.

ObjectiveRecent primary care workforce pressures in the UK have prompted national reviews. Recommendations to increase the proportion of medical students entering general practice have led to interest in the role of medical schools in career choices. This study sought to identify the career backgrounds of admissions leads at UK medical schools and the proportion of general practitioners on admission interview panels.DesignA national survey using a proforma circulated to all UK medical school admission leads via the Medical Schools Council.SettingUK medical schools.ParticipantsUK medical schools.Main outcome measuresPrevalence of assessment lead and panel members' professional groups.ResultsResponses were received from 18 (54.5%) of the 33 UK medical schools. General practitioners led the admissions process in 2 (11%) of these. Fifteen schools were able to furnish detailed data about interview panel composition, having held a combined total of 876 distinct interview panels during the 2012–2013 and 2013–2014 admission years; 683 panels (78%) included a secondary care physician, but only 261 panels (29.8%) included general practitioners. General practitioner representation ranged from 3.8% to 100% of individual schools’ panels; however, eight schools (about half the respondents able to offer numbers of participants) omitted general practitioner representation in more than half of their interview panels.ConclusionsDespite the UK policy focus to increase the proportion of medical students becoming general practitioners, doctors from this clinical background are not proportionately represented as admissions leads or on admissions interview panels. Increasing general practitioner involvement in admissions processes may be one way in which medical schools can support general practice as a career aspiration.

Emerging role of novel biomarkers in the diagnosis of inflammatory bowel disease.

There is currently no gold standard test for the diagnosis of inflammatory bowel disease (IBD). Physicians must rely on a number of diagnostic tools including clinical and endoscopic evaluation as well as histologic, serologic and radiologic assessment. The real difficulty for physicians in both primary and secondary care is differentiating between patients suffering from functional symptoms and those with true underlying IBD. Alongside this, there is always concern regarding the possibility of a missed, or delayed diagnosis of ulcerative colitis (UC) or Crohn's disease. Even once the diagnosis of IBD has been made, there is often uncertainty in distinguishing between cases of UC or Crohn's. As a consequence, in cases of incorrect diagnosis, optimal treatment and management may be adversely affected. Endoscopic evaluation can be uncomfortable and inconvenient for patients. It carries significant risks including perforation and in terms of monetary cost, is expensive. The use of biomarkers to help in the diagnosis and differentiation of IBD has been increasing over time. However, there is not yet one biomarker, which is sensitive of specific enough to be used alone in diagnosing IBD. Current serum testing includes C-reactive protein and erythrocyte sedimentation rate, which are cheap, reliable but non-specific and thus not ideal. Stool based testing such as faecal calprotectin is a much more specific tool and is currently in widespread clinical use. Non-invasive sampling is of the greatest clinical value and with the recent advances in metabolomics, genetics and proteomics, there are now more tools available to develop sensitive and specific biomarkers to diagnose and differentiate between IBD. Many of these new advances are only in early stages of development but show great promise for future clinical use.

Physicians discuss the risks of smoking with their patients, but seldom offer practical cessation support.

BackgroundOur aim was to study the smoking cessation-related 1) attitudes & experiences and 2) consultation practices of Finnish physicians and to determine if there is a relationship between the two.MethodsAn online survey on smoking cessation was sent to 39 % of all Finnish physicians, with emphasis on physicians working in fields relevant to smoking cessation. A total of 1141 physicians (response rate 15 %) responded to the online survey, 53 % of whom were employed in primary health care. A total of 1066 respondents were eligible for the analysis. The questionnaire included questions on the physician’s own smoking status, their attitudes and experiences on smoking cessation, and the implementation of smoking cessation in clinical practice. Two sub-scales concerning smoking-related consultation activities were constructed: one for conversation, and another for practical actions.ResultsThe most common consultation activities (respondents who reported doing the following actions “nearly always”) were asking how much the patient smokes (65 %), marking smoking status in patient records (58 %) and recommending quitting to the patient (55 %). The least common activity was prescribing withdrawal medication (4 %). Primary care physicians were more active than those working in secondary health care in nearly all activities mapped. A positive attitude and experiences on smoking cessation were associated with actively offering withdrawal support. Those who were familiar with the local treatment guidelines for tobacco addiction were 30 % more active in offering practical cessation help to their patient. The respondents were more active in discussing smoking with their patients than in offering practical cessation help.ConclusionPhysicians offer their patients practical cessation support relatively infrequently. Practical cessation calls for continuous education of physicians about the nature of tobacco and nicotine addiction, the role of smoking as a risk factor for various diseases, and the practical measures needed for smoking cessation. Secondary care physicians should acknowledge the authority they pose toward smoking patients.

2015 Recommendations for the management of polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative

Therapy for polymyalgia rheumatica (PMR) varies widely in clinical practice as international recommendations for PMR treatment are not currently available. In this paper, we report the 2015 European League Against...

Evaluating the effectiveness of care integration strategies in different healthcare systems in Latin America: the EQUITY-LA II quasi-experimental study protocol.

IntroductionAlthough fragmentation in the provision of healthcare is considered an important obstacle to effective care, there is scant evidence on best practices in care coordination in Latin America. The aim is to evaluate the effectiveness of a participatory shared care strategy in improving coordination across care levels and related care quality, in health services networks in six different healthcare systems of Latin America.Methods and analysisA controlled before and after quasi-experimental study taking a participatory action research approach. In each country, two comparable healthcare networks were selected—intervention and control. The study contains four phases: (1) A baseline study to establish network performance in care coordination and continuity across care levels, using (A) qualitative methods: semi-structured interviews and focus groups with a criterion sample of health managers, professionals and users; and (B) quantitative methods: two questionnaire surveys with samples of 174 primary and secondary care physicians and 392 users with chronic conditions per network. Sample size was calculated to detect a proportion difference of 15% and 10%, before and after intervention (α=0.05; β=0.2 in a two-sided test); (2) a bottom-up participatory design and implementation of shared care strategies involving micro-level care coordination interventions to improve the adequacy of patient referral and information transfer. Strategies are selected through a participatory process by the local steering committee (local policymakers, health care network professionals, managers, users and researchers), supported by appropriate training; (3) Evaluation of the effectiveness of interventions by measuring changes in levels of care coordination and continuity 18 months after implementation, applying the same design as in the baseline study; (4) Cross-country comparative analysis.Ethics and disseminationThis study complies with international and national legal stipulations on ethics. Conditions of the study procedure were approved by each country's ethical committee. A variety of dissemination activities are implemented addressing the main stakeholders. Registration No.257 Clinical Research Register of the Santa Fe Health Department, Argentina.

The serological diagnostic challenges of multiple myeloma.

Serological screening tests for multiple myeloma are commonly requested by physicians in both primary and secondary care to investigate patients presenting with anaemia or renal impairment of unknown cause. This article reviews the interpretation of these tests.

Management and modeling of balance disorders using decision support systems: the EMBALANCE project.

In this work, we present the concept, the methodological ideas and the architecture of the EMBALANCE platform. EMBALANCE platform extends existing but generic and currently uncoupled balance modeling activities, leading to a multi-scale and patient-specific balance Hypermodel, which is incorporated to a Decision Support System (DSS), towards the early diagnosis, prediction and the efficient treatment planning of balance disorders. Various data feed the intelligent system increasing the dimensionality and personalization of the system. Human Computer Interaction techniques are utilized in order to develop the required interfaces in a user-intuitive and efficient way, while interoperable web services enhance the accessibility and acceptance of the system. The platform will be validated using both retrospective as well as prospective experimental and clinical data. The final tool will be a powerful web-based platform provided to primary and secondary care physicians across specialties, levels of training and geographical boundaries, targeting wider clinical acceptance as well as the increased confidence in the developed DSS towards the early diagnostic evaluation, behaviour prediction and effective management planning of balance problems. Currently we focus and present the management and modeling of the balance disorders.

EHMTI-0381. Visual images can prove to be an important tool to aid in the diagnosis of cluster headaches

Background Cluster headache is one of the most distressing and painful clinical conditions seen in medical practice, and affect 1-2 % of the population. Although its clinical presentation does not vary widely in terms of the symptoms experienced by patients, it still presents a significant diagnostic challenge particularly to the primary and secondary care physicians. This results in patients having to bear with agonizing symptoms before they are given the correct diagnosis and appropriate therapy. The time taken to diagnose cluster headache has reduced from 22 years in the 1970’s to 3.4 years about 8 years ago1 and on average a patient sees 5 doctors before receiving the correct diagnosis., however, the severity of the condition merits early recognition.

SP0037 Eular ACR Guidelines for the Treatment of Polymyalgia Rheumatica

Treatment of PMR is subject to wide variations among clinicians as it may be managed in primary or secondary care by general practitioners, rheumatologists and non-rheumatologist. Particularly the initial corticosteroid...

PROSPECTIV—a pilot trial of a nurse-led psychoeducational intervention delivered in primary care to prostate cancer survivors: study protocol for a randomised controlled trial

BackgroundProstate cancer survivors can experience physical, sexual, psychological and emotional problems, and there is evidence that current follow-up practices fail to meet these men's needs. Studies show that secondary and...

G67(P) Variation in response to vitamin D therapy in a series of children referred to a paediatric bone disease service

AimsGuidelines for treatment of vitamin D deficiency (VDD) vary. We aimed to review the range of treatment regimens used locally to treat VDD and their effectiveness.MethodsWe conducted a retrospective review...

Pediatric Asthma – do we need more innovation for treatment?

Pediatric Asthma – do we need more innovation for treatment?

Approach to malaria in rural hospitals

Malaria is one of the most common parasitic infections in the developing countries. In Rural India, most patients would be treated by primary and secondary care physicians. This article is aimed at providing a feasible approach to the cases of malaria in mission hospitals and other rural hospitals taking into account all the resource limitations. A study done over one year on patients detected to have malaria at Jiwan Jyoti Christian Hospital in Sonbhadra district has helped the authors to identify the various challenges faced by doctors working in the rural hospitals. The article has looked at the various complications associated with malaria and their management. It has also stressed upon the increasing incidence of chloroquine resistance.

Pain Medicine in Crisis—A Possible Model toward a Solution: Empowering Community Medicine to Treat Chronic Pain

Pain medicine in Israel and in the world has reached a crisis. The lack of available pain medicine services is resulting in the unsatisfactory treatment for chronic pain sufferers. The main causes of this crisis are: 1) the high prevalence of chronic pain, reaching levels of 17% in the adult population;2) the lack of appropriate training of primary care physicians in the field of chronic pain management; and 3) the paucity of consultation services in the field of chronic pain. In this journal article, we propose a possible model for the solution of the problem, based upon levels of treatment according to the severity of the disease and upon training of primary and secondary care physicians in the treatment of pain. According to the model, the vast majority of treatment and management will take place in the community after appropriate training of primary care physicians. More complex cases will be referred to secondary care community-based pain clinics manned by physicians with further in-depth training. Only the most complex of patients, or those needing specialized treatment such as invasive analgesic therapy, will be referred to tertiary pain centers manned by specialists in pain medicine. Implementation of this model will necessitate training of primary care physicians and the establishment of secondary care facilities and can, in our opinion, pose a pragmatic solution for the hundreds of thousands of patients suffering from chronic pain.

Pain Medicine in Crisis—A Possible Model toward a Solution: Empowering Community Medicine to Treat Chronic Pain

Pain medicine in Israel and in the world has reached a crisis. The lack of available pain medicine services is resulting in the unsatisfactory treatment for chronic pain sufferers. The main causes of this crisis are: 1) the high prevalence of chronic pain, reaching levels of 17% in the adult population;2) the lack of appropriate training of primary care physicians in the field of chronic pain management; and 3) the paucity of consultation services in the field of chronic pain. In this journal article, we propose a possible model for the solution of the problem, based upon levels of treatment according to the severity of the disease and upon training of primary and secondary care physicians in the treatment of pain. According to the model, the vast majority of treatment and management will take place in the community after appropriate training of primary care physicians. More complex cases will be referred to secondary care community-based pain clinics manned by physicians with further in-depth training. Only the most complex of patients, or those needing specialized treatment such as invasive analgesic therapy, will be referred to tertiary pain centers manned by specialists in pain medicine. Implementation of this model will necessitate training of primary care physicians and the establishment of secondary care facilities and can, in our opinion, pose a pragmatic solution for the hundreds of thousands of patients suffering from chronic pain.

Avascular Necrosis of Femoral Head

Avascular necrosis (AVN) of the femoral head is a relatively uncommon complication following an extracapsular hip fracture. Although it can occur following fixation of unstable 3-part or 4-part intertrochanteric fractures with significant posteromedial and posterolateral comminution, it remains a rare complication. We present a case of AVN of the femoral head following fixation of a stable 2-part intertrochanteric fracture in spite of good healing at the hip fracture site. This is a rare but eminently treatable cause of persisting hip pain after hip fracture surgery, and primary or secondary care physicians should be aware of this possibility.

Rotigotine improves executive functions in patients with vascular dementia

background activity but no interictal discharges suggestive of epilepsy. Neuropsychological evaluations with 2-year intervals showed progressivewordfinding difficulties, attentionand memory-deficits. He became nearly mute and apathetic and was unable to continue his work as a process-controller. The MRI was repeated 8-year after symptom-onset showing prominent atrophy of the left hemisphere (figure), consistent with the clinical diagnosis progressive non-fluent aphasia. Case-management was still lacking at referral to our memory clinic. The presence of epilepsy in the presented patient with PPA has led to a long-lasting delay in clinical diagnosis and adequate care. Patients with subtle speech difficulties usually seek medical attention on average 2-3 years after symptom-onset. Primary and secondary care physicians often do not recognise PPA-symptoms adding a further diagnostic delay. Complaints are often attributed to psychogenic factors (burnout, mood or anxiety) or to other comorbid conditions, which even led to a diagnostic delay of 8 years in our case. Conclusions: An atypical age-at-onset, slow disease progression, absence of cognitive or behavioural problems are all factors delaying referral to a memory clinic in PPA. Diagnostic delay is even more pronounced in the presence of comorbid conditions which may affect speech.

Improving the Accuracy of Death Certification among Secondary Care Physicians

Improving the Accuracy of Death Certification among Secondary Care Physicians

AB0207 Assessment of cardiovascular risk in patients with rheumatoid arthritis, where are we in 2012?

BackgroundIncreased rates of morbidity and mortality in rheumatoid arthritis have been attributed to higher risk of cardiovascular events.1-3 For this reason, patients should be assessed annually to calculate, address and...