[International Network of Current Care Recommendation meeting in Lyon, December 2005].
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France↗
Biomedical subjects
Ilkka Kunnamo
Publications and source records attributed to Ilkka Kunnamo.
Electronic primary care guidelines with links to Cochrane reviews--EBM Guidelines.
In Finland, guidelines have been used in primary care since the late 1980s to bridge the gap between research evidence and practice. From the very beginning, the electronic format has been the primary source for EBM Guidelines (EBMG). Although also published on CD and in print, the guidelines are currently mostly used via the Internet. Keeping more than 1000 guidelines up to date is a great challenge to the editorial group, and several methods are used to guarantee the quality. The Cochrane Library has become the most important source of information for the guideline producers and all Cochrane reviews relevant to GPs are summarized and linked to the guidelines. In this article we present our experience of producing the electronic guidelines for GPs, the methodology used, and data on the clinical use of these guidelines and their Cochrane links. We also discuss the barriers and facilitators to our process and present ideas for future development.
Decision Support Systems, Clinical↗
[Update on current care guidelines. Deep thrombosis and pulmonary embolism].
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Anticoagulants↗
[On the way to the diagnosis. Diagnosis belongs to the doctor's basic skills, which can be improved].
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Attitude of Health Personnel↗
[Information networks and electronic access in implementing patient care guidelines].
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Female↗
Treatment of acute rhinosinusitis diagnosed by clinical criteria or ultrasound in primary care. A placebo-controlled randomised trial.
OBJECTIVES: To compare antibiotics and placebo in patients with clinically diagnosed acute maxillary sinusitis (AMS). To study whether sinus ultrasound examination would help to detect those patients who benefit from antibiotic therapy. DESIGN: A double-blind, randomised, placebo-controlled multicentre trial. SETTING: Nine primary care sites in Finland. SUBJECTS: 150 adult patients (mean age 39.7 years) with a clinical diagnosis of sinusitis. INTERVENTION: Antibiotics (amoxicillin 750 mg x 2, doxycycline 100 mg x 2 or penicillin V 1500 mg x 2) or placebo twice daily for 7 days; all patients were examined with sinus ultrasound after randomisation. MAIN OUTCOME MEASURE: Clinical success (patients' report of recovery) in telephone interview at 2 weeks. RESULTS: A total of 146 patients completed the 2-week follow-up. Patients receiving antibiotics achieved a slightly higher rate of clinical success than patients receiving placebo (80% vs 66%; p = 0.068). CONCLUSIONS: Antibiotics hasten symptom relief in AMS. Yet many patients recover in 2 weeks without antimicrobial treatment. Only half of patients with a clinical diagnosis of AMS have sinusitis in ultrasound examination.
Acute Disease↗
Acute rhinosinusitis in primary care: a comparison of symptoms, signs, ultrasound, and radiography.
In primary care, the diagnosis of acute maxillary sinusitis (AMS) is based most often only on symptoms and clinical examination. This practice leads to many false positive diagnoses and unnecessary use of antibiotics. Sinus ultrasound has been suggested as a means to improve the accuracy of AMS diagnosis. We studied the symptoms, signs, and ultrasound findings in patients with acute rhinosinusitis. Primary care physicians received small group teaching on sinus ultrasound technique. Sinus radiography was performed in a subgroup of patients, and it acted as reference standard. A total of 150 adult patients were recruited to the study, 105 women (70%) and 45 men (30%). Thirteen patients of 32 (41%) in the radiography subgroup and 74 patients of 148 (50%) with ultrasound result had AMS. The sensitivity of ultrasound compared to radiography was 92% and specificity was 95% when results were calculated per patients as unit of analysis. With practice and teaching primary care physicians can perform sinus ultrasound as accurately as specialists. Symptoms and clinical examination were not reliable in AMS diagnosis. If the criterion for AMS diagnosis were fluid in maxillary sinuses in ultrasound instead of clinical impression, the number of antibiotic prescriptions would be reduced by half in primary care.
Acute Disease↗
The impact of upper GI endoscopy referral volume on the diagnosis of gastroesophageal reflux disease and its complications: a 1-year cross-sectional study in a referral area with 260,000 inhabitants.
OBJECTIVES: Less than half of patients with gastroesophageal reflux disease (GERD) have endoscopic erosive esophagitis (endoscopy positive GERD). Symptomatic GERD and Barrett's esophagus (BE), however, are risk factors for esophageal and gastric cardia adenocarcinomas. The aim of the present study was to examine the prevalence of GERD-related findings on endoscopy according to the volume of referrals to upper GI endoscopy. METHODS: The following data were gathered on all GERD patients who were sent for upper GI endoscopy by general practitioners (GPs) during 1 yr in our hospital referral area of 260,000 inhabitants: the number of referrals to endoscopy in health care units, and the numbers of endoscopy positive GERD, BE, and esophageal neoplasms. Patients with symptoms or signs suggesting acute upper GI bleeding and those attending follow-up endoscopy (e.g., for BE, peptic ulcer, or dysplasia) were excluded, as were patients with previous esophagogastric surgery or Helicobacter pylori eradication therapy. RESULTS: The study population consisted of 3378 patients, with a mean age of 58.1 yr (95% CI = 57.5-58.6) and a male:female ratio of 1:1.3. Of the 760 patients who underwent endoscopy because of heartburn or regurgitation, 254 (33.4%) had endoscopy positive (erosive) GERD, 11 (1.4%) BE (one with esophageal adenocarcinoma), six (0.8%) esophageal ulcer, and one peptic esophageal stricture (0.1%). Between health care units, the referrals to endoscopy (number of endoscopies/population/yr) varied from 0.6 to 9.2/1000 inhabitants/yr (median 3.3/1000/yr). In health care units with "high" referral volumes (> or = 3.3 referrals/1000/yr, N = 15, 1297 patients) and "low" referral volumes (< 3.3/1000/yr, N = 15, 2081 patients), the numbers of endoscopy positive GERD were 281 (21.7%) versus 308 (14.9%, p < 0.001), esophageal ulcer 13 (1.0%) versus 14 (0.7%, p = 0.3), esophageal stricture five (0.4%) versus seven (0.3%, p = 0.4), Barrett's esophagus eight (0.6%) versus 16 (0.8%, p = 0.6), and esophageal neoplasm two (0.2%) versus six (0.3%, p = 0.2). Five of the neoplasms were squamous cell carcinomas, two were adenocarcinomas, and one was lymphoma. Multivariate analyses showed that independent risk factors for endoscopy positive GERD were male sex (OR = 1.4, 95% CI = 1.2-1.7), GERD symptoms (OR = 3.3, 95% CI = 2.7-4.0), dysphagia (OR = 1.4,95% CI = 1.0-2.1), and living in a high referral area (OR = 1.4, 95% CI = 1.2-1.7). Independent risk factors for BE were male sex (OR = 2.6, 95% CI = 1.1-6.1) and GERD symptoms (OR = 2.9, 95% CI = 1.3-6.6), whereas the only independent risk factor for esophageal neoplasm was dysphagia (OR = 40.0 (95% CI = 7.7-207.5). CONCLUSIONS: There is a wide variation in GPs' referrals for endoscopy. Increasing the referral volume significantly increases the proportion of endoscopy positive GERD cases, but not that of GERD complications such as BE, esophageal ulcer, peptic stricture, or esophageal neoplasms.
Adenocarcinoma↗
Primary care guidelines on consultation practices: the effectiveness of computerized versus paper-based versions. A cluster randomized controlled trial among newly qualified primary care physicians.
OBJECTIVE: To compare the effects of computerized and paper-based versions of guidelines on recently qualified physicians' consultation practices. METHODS: Two arm cluster randomized controlled trial. Physicians were randomized to receive computerized or textbook-based versions of the same guidelines for a 4-week study period. Physicians' compliance with guideline recommendations about laboratory, radiological, physical and other examinations, procedures, nonpharmacologic and pharmacologic treatments, physiotherapy, and referrals were measured by case note review. RESULTS: There were 139 recently qualified physicians working in 96 primary healthcare centers in Finland who participated in the study. Data on 4,633 patient encounters were abstracted, of which 3,484 were suitable for further analysis. Physicians' compliance with guidelines was high (over 80% for use of laboratory, radiology, physical examinations, and referrals). There were no significant differences in physicians' consultation practices in any of the measured outcomes between the computerized and textbook group. CONCLUSION: Guidelines are a useful source of information for recently qualified physicians working in primary care. However, the method of presentation of the guidelines (electronic or paper) does not have an effect on guideline use or their impact on decisions. Other factors should be considered when choosing the method of presentation of guidelines, such as information-seeking time, ease of use during the consultation, ability to update, production costs, and the physician's own preferences.
Cluster Analysis↗