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Too often, IT solutions for group practices generate, at best, a quick fix. Forward-thinking group practice managers will evaluate technology for its capacity to enhance long-term profitability.
OBJECTIVES: To determine the elements taken into account by French general practitioners to establish the initial diagnosis of benign prostatic hyperplasia (BPH) and to estimate the prevalence of BPH. MATERIAL AND METHODS: 1,698 doctors answered a questionnaire on their medical practice, and kept a register for two consecutive weeks comprising all men between the ages of 55 and 70 years seen in their practice. Men with no known BPH completed the IPSS (International Prostate Symptoms Score) questionnaire. The doctors described the management of the first three patients with an IPSS score > 8. RESULTS: The prevalence of BPH in the population of 33,077 men between the ages of 55 and 70 years consulting their general practitioner was 57.5%: 40.8% of patients had known BPH at the time of the visit and 29.9% of patients without known BPH reported voiding disorders (IPSS > or = 8). For the diagnosis of BPH, clinical interview was not systematically followed by digital rectal examination and urinalysis was rarely performed. Laboratory tests and ultrasound were the complementary investigations most frequently performed. CONCLUSION: BPH is a frequent disease whose prevalence is underestimated. This diagnosis should be considered more frequently when patients over the age of 55 consult their general practitioner.
In the revised practice guideline on hypertension from the Dutch College of General Practitioners, some changes have been made in the areas of diagnosis and therapy in comparison to the previous edition. Finding people with hypertension is a major goal for the prevention of cardiovascular disease. A systolic blood pressure > 140 mmHg (> 160 mmHg in patients > 60 years) necessitates non-pharmaceutical advice and antihypertensive therapy with diuretics, beta-blockers, angiotensin-converting-enzyme (ACE) inhibitors or calcium antagonists, either as monotherapy or in combination. In view of the ever-increasing importance of ACE inhibitors in antihypertensive therapy, we expect that the next revision of the practice guideline will soon be necessary.
The practice guideline 'Peripheral vascular disease' (PVD) from the Dutch College of General Practitioners will certainly be of benefit to the Dutch general practitioner. Its limited set of simple diagnostic steps can help the general practitioner to assess or exclude PVD in patients with intermittent claudication. The inclusion of a pretest-posttest probability scheme enhances a clear diagnostic process. This guideline differs from the previous one in one important aspect. This guideline deals not only with the specific management of peripheral arterial disease but also with the management of cardiovascular risk in general. In this way the guideline follows the recently changed international attitude reflected in the European Guidelines on cardiovascular disease prevention. Smoking cessation and exercise therapy continues to be the cornerstone as well as the stumbling block of management of most cases of PVD in general practice; a challenge for every general practitioner.
The practice guideline 'Miscarriage' has been reviewed for the second time in fifteen years. It provides the practitioner with distinct diagnostic tools for vaginal bleeding in the first sixteen weeks of pregnancy and a clear management algorithm. The management of miscarriage is based on a joint decision between the general practitioner and the woman concerned. A more reserved attitude towards the surgical termination of pregnancy is advised. The guideline sufficiently addresses the issue of informing the woman as to the expected amount of bleeding during a miscarriage and the relationship with fertility. However, the risk factors for heavy blood loss are not mentioned in the guideline. The psychological impact of early miscarriage on women is given adequate attention and is part of the counselling during the follow-up period. Finally, the medical treatment of threatened miscarriage seems to result in an earlier miscarriage with less loss of blood compared to expectant management. The guideline pays also attention to medical treatment. Future research will clarify whether medical treatment is feasible in general practice.
The new guidelines from the Dutch College of General Practitioners on sexually transmitted diseases (STDs) replace three existing practice guidelines covering a number of sexually transmitted diseases. In the Netherlands the general practitioner treats almost 75% of all patients with an STD. These include patients with symptoms, patients who are worried or anxious, and patients at high risk of an STD. STD-risk assessment should be regarded as a high priority. Chlamydia-infection remains the most prevalent STD. It is easily diagnosed by DNA-diagnostic amplification techniques. The new guidelines recommend more proactive and wider testing. There is much emphasis on counselling, prevention and notifying partners. General practice is the ideal setting for this.
The practice guideline 'Heart failure' from the Dutch College of General Practitioners will be a source of support for the general practitioner/family physician. Its clear set of diagnostic steps helps the general practitioner to assess heart failure in patients with breathlessness, fatigue, decreased exercise tolerance or ankle swelling. Testing plasma concentrations of natriuretic peptides plays a new and central diagnostic role. This guideline differs from the previous one in another important aspect. Based on many RCT's and reviews the authors have succeeded in developing a detailed but balanced treatment protocol for heart-failure patients in general practice. However, adverse effects from co- and multi-medication in the growing number of frail elderly may reduce the patients' compliance.
This report summarizes recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP) concerning influenza vaccination of health-care personnel (HCP) in the United States. These recommendations apply to HCP in acute care hospitals, nursing homes, skilled nursing facilities, physician's offices, urgent care centers, and outpatient clinics, and to persons who provide home health care and emergency medical services. The recommendations are targeted at health-care facility administrators, infection-control professionals, and occupational health professionals responsible for influenza vaccination programs and influenza infection-control programs in their institutions. HICPAC and ACIP recommend that all HCP be vaccinated annually against influenza. Facilities that employ HCP are strongly encouraged to provide vaccine to their staff by using evidence-based approaches that maximize vaccination rates.
Clinical practice guidelines (CPGs) are intended to provide evidence based knowledge for decision making for patient care. However, these guidelines have been poorly adopted by healthcare providers. One reason for this may be the static paper-based formats, isolated from the point of care. Biomedical informatics has provided a solution to this limitation through Computer Interpretable Guidelines (CIGs). An essential component of this process is CPG translation to a computer interpretable model. From the guideline modeling literature, the translators of CPGs typically are physicians. It is not known if other healthcare providers (i.e., Advance Practice Nurses [APNs]) comprehend CPGs similarly. This descriptive study utilized novice and expert APN and physician participants (varied by level of expertise) in a CPG comprehension task. Demographic data, verbal protocols, and recall model drawings were obtained and analyzed by description, protocol analysis, discourse analysis, and content analysis. The findings of this study indicate similar comprehension by the expert APNs and physicians suggesting that either type of expert may be utilized for modeling CPGs.
BACKGROUND: Randomised controlled trials have shown the efficacy of several treatment modalities for lower urinary tract symptoms (LUTS) in selected populations. The effectiveness in daily practice has hardly been investigated, especially in primary care and is dependent on choices between all possible treatment options and best investigated in a comprehensive study, including all treatment modalities (watchful waiting, alpha-blockers, 5-alpha-reductase inhibitors, and surgery). AIM: Assessment of the effectiveness of a comprehensive treatment protocol for LUTS in primary care. DESIGN OF STUDY: Randomised controlled trial. SETTING: Fourteen general practices in the Netherlands. METHOD INTERVENTION: treatment protocol based on a formalised expert opinion. Control condition: usual care. STUDY POPULATION: 208 subjects with moderate to severe LUTS (IPSS > or =8, median = 13). OUTCOME MEASURES: symptom severity (IPSS [International Prostate Symptom Score]), bother score (Dan-PSS [Danish Prostate Symptom Score]), and maximum urinary flow (Q(max)); incidence of acute urinary retention and urinary tract infections. RESULTS: In the intervention group markedly more subjects used an alpha-blocker at end of follow-up than in the usual care group (24% versus 6%). No significant differences were found between intervention and control group in IPSS, Q(max) or Dan-PSS. CONCLUSION: alpha-blockers and watchful waiting are the most frequent treatment modalities for LUTS in primary care. Our study showed no evidence that a protocol using well-defined indications for all possible treatment modalities based on a formalised expert opinion procedure has added value. Based on our results, we cannot recommend a broadening of the indication for alpha-blockers, which, however, seems to be the current trend.
This study prospectively examined x-rays obtained in the offices of 14 family physicians who read all their own office x-rays and then select those they want a radiologist to read. Each physician completed a standardized report form for 100 consecutive x-rays or for all x-rays obtained for three months, whichever came first. A total of 1,127 x-rays were evaluated. The results indicate that: 1) 86.5% of all x-rays were of three types (chest x-ray, 50.8%; upper extremity, 18.9%; lower extremity, 16.8%); 2) 85.3% of all x-rays were obtained to: a) confirm a clinical diagnosis, b) establish a diagnosis, c) screen for potential problems; 3) 84.8% of the referred x-rays were referred to a) confirm the family physician's interpretation, b) interpret equivocal findings, c) provide medicolegal support, d) improve interpretation skills; 4) the referral rate to a radiologist was 11.6%, with chest x-rays referred most frequently; 5) the same five major ICD-9-CM diagnostic categories were associated with 90.1% of all x-rays obtained and 86.5% of all x-rays referred; 6) the types of x-rays obtained in community practice and in a previously studied residency training practice were similar; 7) 55.6% of office x-rays were read as "normal;" and 8) the family physicians' discordancy rate with the radiologists on referred films was 12.5%.
This study examined the utilization and interpretation of office x-rays in community practice. Analysis of physician and practice descriptive data obtained by survey from the Minnesota Academy of Family Physicians Research Network, a representative sample of family physicians in Minnesota, leads to these conclusions: (1) Most (87.3%) of the study physicians have on-site x-ray facilities. (2) An extensive variety of x-rays is obtained in the office. (3) Most (54.2%) family physicians interpret their own x-rays and self-select those they want re-read by a radiologist; 43.8% referred all x-rays to a radiologist. (4) Of those who self-select x-rays for referral, 68.9% refer 10% or fewer films. (5) Reasons for referral are: (a) to follow an "a priori" decision, (b) to make a diagnosis when clinical findings are inconclusive, (c) to confirm the physician's own clinical diagnosis, (d) to protect from medical-legal problems, and (e) to consult because of the seriousness of the problem. The study physicians also believe that the interpretation of office x-rays is a basic skill of the family physician, that residents should be trained to interpret 90% or more of their office x-rays, and that radiologists should be used as consultants on the basis of identified need similar to the way other consultants are used. The study also showed that decision criteria for referral are based on sound clinical and quality of care issues, that liability concerns have a definite influence on referral rates for x-ray interpretation, and that a contractual reading arrangement with a radiologist and close proximity to a radiologist both tend to increase his or her use.
We developed a survey to send alumni from the family practice program at the University of Texas Medical Branch at Galveston. Program graduates were asked how well they had been trained in 29 curricular areas during their residency program. Family practice alumni from programs in Virginia, Wisconsin, Minnesota, and Washington responded to similar questions in previous studies. The Kendal coefficient of concordance was used to determine whether or not graduates of these programs saw the same pattern of curricular strengths and weaknesses; results showed a similar pattern of training needs across the country (W = .81, P less than .001). Alumni saw a need for more training in orthopedics, rehabilitation, and office management.
UNLABELLED: The present paper describes the institutionalization of a general practitioners' quality circle and the development of management guidelines for the treatment of patients with sore throat. Doctors participating: An invitation to attend an "information meeting" on the subject quality control and a quality circle sent to 200 general practitioners and internists, evoked a response by 18 physicians, ten of whom participated in the first meeting of the quality circle. Practical procedure: Stocktaking of the procedure in the doctor's office on the basis of a documentation questionnaire, the discussion of a video of the counselling of a patient with a sore throat, interviews with patients and the personal experience of the participating physicians was compared with a current analysis of the literature. The results of the comparison were taken as a basis for the development of management guidelines following the Dutch NHG Standard (Nederlands-Huisartsen-Genootschap-Standarden). RESULTS AND CONCLUSIONS: A wide variation was found in the treatment offered to patients with sore throats in the doctor's office. Deviation from text book information does not indicate a priori any quality deficit in the GP's practice. With respect to the management guideline worked out, it was agreed that in the individual case, a wellfounded deviation can be justified.
This study investigated the timing and extent of the emotional impact of the career change of 33 selected family physicians who, after at least 15 years in private practice, moved into full-time teaching and/or administration in a family practice residency program. Their intrinsic feelings of being enthusiastic, energetic, optimistic, and enjoying associates were all diminished during the first six months, dropped further in the second six months, but began to recover during the second year. Similarly the physicians' perception of their effectiveness in their new work -- confident, competent, and fulfilled -- was relatively low during the first six months, but began to rise during the second six months and again during the second year. A comparison is made between the responses of those who held positions as directors and those who were non-directors. Changes reported were less marked in those who became directors than in those who did not. Possible causes of this phenomenon are explored. Methods to soften the impact of the career change are suggested.
This article documents the practice's achievements resulting from the planning efforts and suggests that several key factors, such as establishing and communicating a practice direction and empowering and valuing people, resulted in the physicians' successful planning.
There is a shortage of family physicians in Louisiana. This manuscript reports on the current status of primary care in Louisiana. It compares these data with national averages and assesses current needs. Finally, it proposes necessary steps by which this shortage can be decreased. Medical schools, residency programs, and practicing physicians will need to be involved in the solution to this problem. Louisiana can have a bright future in family medicine if the recommendations in this paper are thoroughly addressed. With ever increasing costs of quality medical care, well-placed funding and emphasis on family practice appear to be the right direction.
The Depression Guideline Panel of the Agency for Health Care Policy and Research in 1993 published recommendations for treating major depression in primary care practice that were often based on studies of tertiary care psychiatric patients. We reviewed reports of randomized controlled trials in primary care settings published between 1992 and 1998. This evidence indicates that both antidepressant pharmacotherapy and time-limited depression-targeted psychotherapies are efficacious when transferred from psychiatric to primary care settings. In most cases, the choice between these treatments should depend on patient preference. Studies to date suggest that improving treatment of depression in primary care requires properly organized treatment programs, regular patient follow-up, monitoring of treatment adherence, and a prominent role for the mental health specialist as educator, consultant, and clinician for the more severely ill. Future research should focus on how guidelines are best implemented in routine practice, since conventional dissemination strategies have little impact.