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GPs' decision-making - perceiving the patient as a person or a disease running title GPs' decision-making
Background:
The aim of this study was to analyse the clinical decision making strategies of GPs with regard to the whole range of problems encountered in everyday work.
Methods:
A prospective questionnaire study was carried through, where 16 General practitioners in Sweden registered consecutively 378 problems in 366 patients.
Results:
68.3% of the problems were registered as somatic, 5.8% as psychosocial and 25.9% as both somatic and psychosocial. When the problem was characterised as somatic the main emphasis was most often on the symptoms only, and when the problem was psychosocial main emphasis was given to the person. Immediate, inductive, decision-making contrary to gradual, analytical, was used for about half of the problems. Immediate decision-making was less often used when problems were registered as both somatic and psychosocial and focus was on both the symptoms and the person. When immediate decision-making was used the GPs were significantly more often certain of their identification of the problem and significantly more satisfied with their consultation. Rules of thumb in consultations registered as somatic with emphasis on symptoms only did not include any reference to the individual patient. In consultations registered as psychosocial with emphasis on the person, rules of thumb often included reference to the patient as a known person.
Conclusions:
The decision-making (immediate or gradual) registered by the GPs seemed to have been adjusted on the symptom or on the patient as a person. Our results indicate that the GPs seem to recognise immediately both problems and persons, hence the quintessence of the expert skill of the GP as developed through experience.
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Barriers to successful recruitment of parents of overweight children for an obesity prevention intervention: a qualitative study among youth health care professionals
Background:
The recruitment of participants for childhood overweight and obesity prevention interventions can be challenging. The goal of this study was to identify barriers that Dutch youth health care (YHC) professionals perceive when referring parents of overweight children to an obesity prevention intervention.
Methods:
Sixteen YHC professionals (nurses, physicians and management staff) from eleven child health clinics participated in semi-structured interviews. An intervention implementation model was used as the framework for conducting, analyzing and interpreting the interviews.
Results:
All YHC professionals were concerned about childhood obesity and perceived prevention of overweight and obesity as an important task of the YHC organization. In terms of frequency and perceived impact, the most important impeding factors for referring parents of overweight children to an intervention were denial of the overweight problem by parents and their resistance towards discussing weight issues. A few YHC professionals indicated that their communication skills in discussing weight issues could be improved, and some professionals mentioned that they had low self-efficacy in raising this topic.
Conclusions:
We consider it important that YHC professionals receive more training to increase their self-efficacy and skills in motivating parents of overweight children to participate in obesity prevention interventions. Furthermore, parental awareness towards their child's overweight should be addressed in future studies.
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Qualitative evaluation of a local coronary heart disease treatment pathway: practical implications and theoretical framework
Background:
Coronary heart disease (CHD) is a common medical problem in general practice. Due to its chronic character, shared care of the patient between general practitioner (GP) and cardiologist (C) is required. In order to improve the cooperation between both medical specialists for patients with CHD, a local treatment pathway was developed. The objective of this study was first to evaluate GPs' opinions regarding the pathway and its practical implications, and secondly to suggest a theoretical framework of the findings by feeding the identified key factors influencing the pathway implementation into a multi-dimensional model.
Methods:
The evaluation of the pathway was conducted in a qualitative design on a sample of 12 pathway developers (8 GPs and 4 cardiologists) and 4 pathway users (GPs). Face-to face interviews, which were aligned with previously conducted studies of the department and assumptions of the theory of planned behaviour (TPB), were performed following a semi-structured interview guideline. These were audio-taped, transcribed verbatim, coded, and analyzed according to the standards of qualitative content analysis.
Results:
We identified 10 frequently mentioned key factors having an impact on the implementation success of the CHD treatment pathway. We thereby differentiated between pathway related (pathway content, effort, individual flexibility, ownership), behaviour related (previous behaviour, support), interaction related (patient, shared care/colleagues), and system related factors (context, health care system). The overall evaluation of the CHD pathway was positive, but did not automatically lead to a change of clinical behaviour as some GPs felt to have already acted as the pathway recommends.
Conclusions:
By providing an account of our experience creating and implementing an intersectoral care pathway for CHD, this study contributes to our knowledge of factors that may influence physicians' decisions regarding the use of a local treatment pathway. An improved adaptation of the pathway in daily practice might be best achieved by a combined implementation strategy addressing internal and external factors. A simple, direct adaptation regards the design of the pathway material (e.g. layout, PC version), or the embedding of the pathway in another programme, like a Disease Management Programme (DMP). In addition to these practical implications, we propose a theoretical framework to understand the key factors' influence on the pathway implementation, with the identified factors along the microlevel (pathway related factors), the mesolevel (interaction related factors), and system- related factors along the macrolevel.
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Effectiveness of a cognitive behavioral intervention in patients with medically unexplained symptoms: cluster randomized trial
Background:
Medically unexplained symptoms are an important mental health problem in primary care and generate a high cost in health services.Cognitive behavioral therapy and psychodynamic therapy have proven effective in these patients. However, there are few studies on the effectiveness of psychosocial interventions by primary health care. The project aims to determine whether a cognitive-behavioral group intervention in patients with medically unexplained symptoms, is more effective than routine clinical practice to improve the quality of life measured by the SF-12 questionary at 12month.
Methods:
This study involves a community based cluster randomized trial in primary healthcare centres in Madrid (Spain).The number of patients required is 242 (121 in each arm), all between 18 and 65 of age with medically unexplained symptoms that had seeked medical attention in primary care at least 10 times during the previous year. The main outcome variable is the quality of life measured by the SF-12 questionnaire on Mental Healthcare. Secondary outcome variables include number of consultations, number of drug (prescriptions) and number of days of sick leave together with other prognosis and descriptive variables. Main effectiveness will be analyzed by comparing the percentage of patients that improve at least 4 points on the SF-12 questionnaire between intervention and control groups at 12months.All statistical tests will be performed with intention to treat. Logistic regression with random effects will be used to adjust for prognostic factors. Confounding factors or factors that might alter the effect recorded will be taken into account in this analysis.DiscussionThis study aims to provide more insight to address medically unexplained symptoms, highly prevalent in primary care, from a quantitative methodology. It involves intervention group conducted by previously trained nursing staff to diminish the progression to the chronicity of the symptoms, improve quality of life, and reduce frequency of medical consultations.Trial registration: The trial was registered with ClinicalTrials.gov, number NCT01484223 [http://ClinicalTrials.gov].
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Lack of adherence to hypertension treatment guidelines among GPs in southern Sweden - a case report based survey
Background:
Despite current guidelines for treatment of hypertension, General Practitioners (GP) fail to correctly adhere to these guidelines. The reasons for this are unclear, but could be related to lack of knowledge in assessing the individual patients cardiovascular risk.Aim: Our aim was to investigate how GPs in southern Sweden adhere to clinical guidelines for treatment of hypertension when major cardiovascular risk factors are taken into consideration.MethodA questionnaire with 5 authentic patient cases with hypertension and different cardiovascular risk profiles was sent to a random sample(n=109) of GP's in southern Sweden in order to investigate the attitude towards blood pressure (BP) treatment when major cardiovascular risk factors were present.
Results:
In general, responding GPs were more focused on the absolute BP target level rather than assessing the entire cardiovascular risk factor profile. Thus, cases with the highest risk of cardiovascular disease were not treated accordingly. However, there are also tendency to over-treatment among the lowest risk groups. Furthermore, the BP level for initiating pharmacological treatment varied widely (systolic BP 140-210 mm Hg). ACE-inhibitors (70%) were the most common first choice of pharmacological treatment.
Conclusion:
In this study, GPs in Southern Sweden were suggesting, for different cases, either under- or overtreatment in relation to current guidelines for treatment of hypertension. On reason may be that they failed to correctly assess individual cardiovascular risk factor profiles.
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The relationship between literacy and multimorbidity in a primary care setting
Background:
Multimorbidity is now acknowledged as a research priority in primary care. The identification of risk factors and people most at risk is an important step in guiding prevention and intervention strategies. The aim of this study was to examine the relationship between literacy and multimorbidity while controlling for potential confounders.
Methods:
Participants were adult patients attending the family medicine clinic of a regional health centre in Saguenay (Quebec), Canada. Literacy was measured with the Newest Vital Sign (NVS). Multimorbidity was measured with the Disease Burden Morbidity Assessment (DBMA) by self-report. Information on potential confounders (age, sex, education and family income) was also collected. The association between literacy (independent variable) and multimorbidity was examined in bivariate and multivariate analyses. Two operational definitions of multimorbidity were used successively as the dependent variable; confounding variables were introduced into the model as potential predictors.
Results:
One hundred three patients (36 men) 19-83 years old were recruited; 41.8% had completed 12 years of school or less. Forty-seven percent of patients provided fewer than four correct answers on the NVS (possible low literacy) whereas 53% had four correct responses or more. Literacy and multimorbidity were associated in bivariate analyses (p < 0.01) but not in multivariate analyses, including age and family income.
Conclusion:
This study suggests that there is no relationship between literacy and multimorbidity when controlling for age and family income.
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What challenges hamper Kenyan family physicians in pursuing their family medicine mandate? A qualitative study among family physicians and their colleagues
Background:
Since 2005, Kenyan medical universities have been training general practitioners, providing them with clinical, management, teaching and research skills, in order to enhance access to and quality of health care services for the Kenyan population. This study assesses what expectations family physicians, colleagues of family physicians and policy makers have of family medicine, what expectations family physicians live up to and which challenges they face.
Methods:
Family physicians were observed and interviewed about their expectations and challenges concerning family medicine. Expectations among their colleagues were assessed through focus group discussions. Policy makers' expectations were assessed by analysing the governmental policy on family medicine and a university's curriculum.
Results:
Roles perceived for and performed by family physicians included providing comprehensive care, health care management, teaching, and to a lesser extent community outreach and performing research. Challenges faced by family physicians were being posted in situations where they are regarded as another type of specialist, lack of awareness of the roles of family physicians among colleagues, lack of time, lack of funds and inadequate training.
Conclusions:
The ministry's posting policy has to be improved to ensure that family physicians have a chance to perform their intended roles. Creating an environment in which family physicians can function best requires more effort to enlighten other players in the health care system, like colleagues and policy makers, about the roles of family physicians.
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An evolving perspective on physical activity counselling by medical professionals
Background:
Physical inactivity is a modifiable risk factor for many chronic conditions and a leading cause of premature mortality. An increasing proportion of adults worldwide are not engaging in a level of physical activity sufficient to prevent or alleviate these adverse effects. Medical professionals have been identified as potentially powerful sources of influence for those who do not meet minimum physical activity guidelines. Health professionals are respected and expected sources of advice and they reach a large and relevant proportion of the population. Despite this potential, health professionals are not routinely practicing physical activity promotion.DiscussionMedical professionals experience several known barriers to physical activity promotion including lack of time and lack of perceived efficacy in changing physical activity behaviour in patients. Furthermore, evidence for effective physical activity promotion by medical professionals is inconclusive. To address these problems, new approaches to physical activity promotion are being proposed. These include collaborating with community based physical activity behaviour change interventions, preparing patients for effective brief counselling during a consultation with the medical professional, and use of interactive behaviour change technology.SummaryIt is important that we recognise the latent risk of physical inactivity among patients presenting in clinical settings. Preparation for improving patient physical activity behaviours should commence before the consultation and may include physical activity screening. Medical professionals should also identify suitable community interventions to which they can refer physically inactive patients. Outsourcing the majority of a comprehensive physical activity intervention to community based interventions will reduce the required clinical consultation time for addressing the issue with each patient. Priorities for future research include investigating ways to promote successful referrals and subsequent engagement in comprehensive community support programs to increase physical activity levels of inactive patients. Additionally, future clinical trials of physical activity interventions should be evaluated in the context of a broader framework of outcomes to inform a systematic consideration of broad strengths and weaknesses regarding not only efficacy but cost-effectiveness and likelihood of successful translation of interventions to clinical contexts.
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An explanatory randomised controlled trial of a
nurse-led, consultation-based intervention to
support patients with adherence to taking glucose
lowering medication for type 2 diabetes
Background:
Failure to take medication reduces the effectiveness of treatment leading to increasedmorbidity and mortality. We evaluated the efficacy of a consultation-based intervention tosupport objectively-assessed adherence to oral glucose lowering medication (OGLM)compared to usual care among people with type 2 diabetes.
Methods:
This was a parallel group randomised trial in adult patients with type 2 diabetes andHbA1c[greater than or equal to]7.5% (58 mmol/mol), prescribed at least one OGLM. Participants were allocated to aclinic nurse delivered, innovative consultation-based intervention to strengthen patientmotivation to take OGLM regularly and support medicine taking through action-plans, or tousual care. The primary outcome was the percentage of days on which the prescribed dose ofmedication was taken, measured objectively over 12 weeks with an electronic medicationmonitoringdevice (TrackCap, Aardex, Switzerland). The primary analysis was intention-totreat.
Results:
211 patients were randomised between July 1, 2006 and November 30, 2008 in 13 Britishgeneral practices (primary care clinics). Primary outcome data were available for 194participants (91.9%). Mean (sd) percentage of adherent days was 77.4% (26.3) in theintervention group and 69.0% (30.8) in standard care (mean difference between groups 8.4%,95% confidence interval 0.2% to 16.7%, p = 0.044). There was no significant adverse impacton functional status or treatment satisfaction.
Conclusions:
This well-specified, theory based intervention delivered in a single session of 30 min inprimary care increased objectively measured medication adherence, with no adverse effect ontreatment satisfaction. These findings justify a definitive trial of this approach to improvingmedication adherence over a longer period of time, with clinical and cost-effectivenessoutcomes to inform clinical practice.Trial registrationCurrent Controlled Trials ISRCTN30522359
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Monitoring physical functioning as the sixth vital sign: evaluating patient and practice engagement in chronic illness care in a primary care setting--a quasi-experimental design
Background:
In Canada, one in three adults or almost 9 million people report having a chronic condition. Over two thirds of total deaths result from cardiovascular disease, diabetes, cancer and respiratory illness and 77% of persons ≥65 years have at least one chronic condition. Persons with chronic disease are at risk for functional decline; as a result, there is an increased awareness of the significance of functional status as an important health outcome. The purpose of this study was to determine whether patients who receive a multi-component rehabilitation intervention, including online monitoring of function with feedback and self-management workshops, showed less functional decline than case matched controls who did not receive this intervention. In addition, we wanted to determine whether capacity building initiatives within the Family Health Team promote a collaborative approach to Chronic Disease Management.
Methods:
A population-based multi-component rehabilitation intervention delivered to persons with chronic illnesses (≥ 44 yrs) (n = 60) was compared to a group of age and sex matched controls (n = 60) with chronic illnesses receiving usual care within a primary healthcare setting. The population-based intervention consisted of four main components: (1) function-based individual assessment and action planning, (2) rehabilitation self-management workshops, (3) on-line self-assessment of function and (4) organizational capacity building. T-tests and chi-square tests were used for continuous and categorical variables respectively in baseline comparison between groups.
Results:
Two MANOVA showed significant between group differences in patient reported physical functioning (Λ = 0.88, F = (2.86) = 5.97. p = 0.004) and for the physical performance measures collectively as the dependent variable (Λ = 0.80, F = (6.93) = 3.68. p = 0.0025). There were no within group differences for the capacity measures.
Conclusion:
It is feasible to monitor physical functioning as a health outcome for persons with chronic illness in primary care. The timeline for this study was not sufficient to show an increase in the capacity within the team; however there were some differences in patient outcomes. The short timeline was likely not sufficient to build the capacity required to support this approach.Trial registrationNCT00859638
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