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PubMed2000

[Effectiveness and efficiency of ambulatory diabetes education programs. A comparison of specialty practice and general practice].

BACKGROUND AND OBJECTIVE: The increasing incidence of NIDDM requires adequate proof of the effectiveness and efficiency of out-patient programmes for diabetics. This study aimed at examining which of the two methods may promise the better results under controlled expenses--modifications of the present standardized diabetes education program in the general practice or specifically developed diabetes education programme in specialist diabetes practice. PATIENTS AND METHODS: 75 diabetics took part in the different out-patient diabetes education programmes at one special practice for diabetology or one of seven general practitioner practices, respectively. The self-developed intensive diabetes education programme of the special practice led by two specialists in diabetology and a dietician was compared with the diabetes education programme of the general practices performed by a doctor's assistant. 38 diabetics in eight training groups at the specialist for diabetology and 37 patients in seven training groups at the general practices were instructed. 32 patients in total (18 patients at the specialist practice and 14 patients at the general practices) additionally received an evaluated support programme which addressed psychosocial impediments related to the topics of a structured diabetes therapy. All patients were asked to complete a questionnaire before, right after, 3 and 6 months after the programme. Weight and glycosylated haemoglobin (HbA1c) were measured before, 3 and 6 months after the programme. RESULTS: The mean weight and glycosylated hemoglobin of all groups decreased as expected. However, the patients of the general practices achieved more lasting reduction of these objective parameters. All patients stated impairments of their quality of life, but the patients of the specialist practice felt more impaired. The motivational support programme achieved only few positive results. CONCLUSION: The standardized diabetes education programme of the general practices and the more intensive and expensive diabetes education programme achieved equally valuable results. Regarding time and expenses, the standardized diabetes education programme may be the more efficient method of NIDDM out-patient education.

Aged↗
PubMed1998

A comparison of four treatments for generalized convulsive status epilepticus. Veterans Affairs Status Epilepticus Cooperative Study Group.

BACKGROUND AND METHODS: Although generalized convulsive status epilepticus is a life-threatening emergency, the best initial drug treatment is uncertain. We conducted a five-year randomized, double-blind, multicenter trial of four intravenous regimens: diazepam (0.15 mg per kilogram of body weight) followed by phenytoin (18 mg per kilogram), lorazepam (0.1 mg per kilogram), phenobarbital (15 mg per kilogram), and phenytoin (18 mg per kilogram). Patients were classified as having either overt generalized status epilepticus (defined as easily visible generalized convulsions) or subtle status epilepticus (indicated by coma and ictal discharges on the electroencephalogram, with or without subtle convulsive movements such as rhythmic muscle twitches or tonic eye deviation). Treatment was considered successful when all motor and electroencephalographic seizure activity ceased within 20 minutes after the beginning of the drug infusion and there was no return of seizure activity during the next 40 minutes. Analyses were performed with data on only the 518 patients with verified generalized convulsive status epilepticus as well as with data on all 570 patients who were enrolled. RESULTS: Three hundred eighty-four patients had a verified diagnosis of overt generalized convulsive status epilepticus. In this group, lorazepam was successful in 64.9 percent of those assigned to receive it, phenobarbital in 58.2 percent, diazepam plus phenytoin in 55.8 percent, and phenytoin in 43.6 percent (P=0.02 for the overall comparison among the four groups). Lorazepam was significantly superior to phenytoin in a pairwise comparison (P=0.002). Among the 134 patients with a verified diagnosis of subtle generalized convulsive status epilepticus, no significant differences among the treatments were detected (range of success rates, 7.7 to 24.2 percent). In an intention-to-treat analysis, the differences among treatment groups were not significant, either among the patients with overt status epilepticus (P=0.12) or among those with subtle status epilepticus (P=0.91). There were no differences among the treatments with respect to recurrence during the 12-hour study period, the incidence of adverse reactions, or the outcome at 30 days. CONCLUSIONS: As initial intravenous treatment for overt generalized convulsive status epilepticus, lorazepam is more effective than phenytoin. Although lorazepam is no more efficacious than phenobarbital or diazepam plus phenytoin, it is easier to use.

Aged↗
PubMed2000

How do general practitioners manage hip problems in adults?

OBJECTIVE: To investigate the medical management, and its consistency and determinants, of hip problems in adult patients. SETTING: General practice, The Netherlands. DESIGN: Observational study based on four "paper patients" and on computerised patients records (CPRs) of 400 patients (20 per general practitioner), aged 50 years and over, with new hip problems. SUBJECTS: 20 general practitioners. MAIN OUTCOME MEASURES: Examination, diagnosis and treatment of hip patients. RESULTS: Medical history and physical examination consisted mainly of questions concerning pain localisation and onset, and examining passive hip motion. The paper patients, except for the one with alarming symptoms, and the CPRs showed high variation in management between general practitioners, particularly for medication prescription and X-ray requests. Main factors influencing medical management were patients' age, number of visits and attitude of the individual general practitioner. A specific diagnosis was registered for only 32% of the 400 patients. The diagnosis osteoarthritis varied greatly between general practitioners even after adjustment for patients' age, gender and number of visits. Patients with osteoarthritis were infrequently referred to physical therapy and received nonsteroidal anti-inflammatory drugs (NSAIDs) more often than paracetamol. CONCLUSION: Diagnosis and treatment of hip problems varies widely between general practitioners. Treatment of patients with osteoarthritis is inconsistent with published recommendations.

Aged↗
PubMed2002

The relation between sale of antimicrobial drugs and antibiotic resistance in uropathogens in general practice.

BACKGROUND: Overuse of antimicrobial drugs has resulted in an alarming increase in bacterial resistance in most countries. The relevance for general practice is unknown. OBJECTIVE: To evaluate the impact of the sale of antimicrobial drugs on bacterial resistance as found in uropathogens from general practice. SETTING: General practice in Belgium and Norway. METHODS: Observational study. RESULTS: The sale of antimicrobial drugs indicated for use in the treatment of urinary tract infection was four times higher in Belgium than in Norway (18.5 vs 4.4 DDD/1000 inhabitants/day). The antibiotic resistance reported by microbiological laboratories as valid for general practice was significant higher in Belgium than in Norway (ampicillins (44% vs 27%), co-trimoxazole (28% vs 17%), fluoroquinolones (12% vs 2%) and nitrofurantoin (16% vs 11%, p < 0.0001 for all). However, the antibiotic resistance found in urine samples from dysuric women in general practice was similar (trimethoprim 14% vs 12%, co-trimoxazole 14% vs 11%, nitrofurantoin 7% vs 3%), except in the case of ampicillins (30% vs 19%, p < 0.05). CONCLUSION: The impact of the antimicrobial sale on resistance in uropathogens seems less than expected at the general practice level, even though local microbiological reports mention fairly high antibiotic resistance data. Adapted methods for following-up bacterial resistance evolution in general practice are needed.

Acute Disease↗
PubMed2006

Variation in spirometry utilization between trained general practitioners in practices equipped with a spirometer.

OBJECTIVE: To explore spirometry utilization among general practitioners and identify practitioner and practice-related factors associated with spirometry utilization. DESIGN: Multivariate multilevel cross-sectional analysis of a questionnaire survey. SETTING: Some 61 general practices involved in a spirometry evaluation programme in the Netherlands. All practices owned a spirometer and were trained to perform spirometry. SUBJECTS: A total of 144 general practitioners and 179 practice assistants. MAIN OUTCOME MEASURES: Extent of spirometry utilization for five indications from national COPD/asthma guidelines, practitioner and practice-related factors associated with spirometry utilization. RESULTS: The response rate was 97%. General practitioners used spirometry mostly to evaluate treatment with inhaled steroids (58%). Significant practitioner-related factors associated with spirometry utilization were: general practitioners' job satisfaction, general practitioners' general interest in research, and prior participation in spirometry training. Practice-related factors associated with spirometry utilization were: presence of a practice nurse, delegation of medical tasks to practice assistants, use of spirometry in different rooms, and use of protocols in practice. CONCLUSION: Practitioner- as well as practice-related factors were associated with the extent of spirometry utilization. In particular, it is essential to improve practice-related factors (e.g. presence of a practice nurse, more delegation of medical tasks to the practice assistant).

Adult↗
PubMed1998

Antibiotic treatment of acute otitis media. Criteria and performance in Danish general practice.

OBJECTIVE: To assess implicit criteria (i.e. what the general practitioner (GP) considers good clinical practice) for and performance (i.e. what the GP actually does) with regard to antibiotic treatment of acute otitis media in Danish general practice. DESIGN: a) Criteria assessed by survey among general practitioners. b) Performance assessed by prospective registration of consultations with general practitioners related to otitis media. SETTING: General practices in three Danish counties. SUBJECTS: a) All the GPs in the three countries (n = 790). b) 368 children with acute otitis media. MAIN OUTCOME MEASURES: a) Criteria for timing of treatment and first drug of choice for acute otitis media; b) prescribed antibiotics and multivariate analysis of factors predicting antibiotic prescription. RESULTS: a) The response rate was 72%. Only 51% (95% CI 47-55) of GPs would give antibiotics to all children with acute otitis media, and 79% (95% CI 76-82) of GPs would use penicillin-V as first drug of choice. b) Seventy-four per cent (95% CI 68-81) of children with acute otitis media were given antibiotics. Factors predicting the GPs' decision to prescribe antibiotics were the general condition of the child and the factors that are normally used in diagnosing the condition. CONCLUSION: Danish general practitioners' criteria for antibiotic treatment of acute otitis media are restrictive, with non-antibiotic treatment in cases of short duration and penicillin-V as first drug of choice. Performance suggests a less restrictive pattern.

Anti-Bacterial Agents↗
PubMed2004

General joint laxity in 1845 Swedish school children of different ages: age- and gender-specific distributions.

AIM: To evaluate general joint laxity in growing children with the aim of determining a cut-off point for joint hypermobility. METHODS: Using the Beighton score, 1845 children from 48 geographically randomly selected schools were evaluated for general joint laxity. The Beighton score evaluates the ability to perform a selection of manoeuvres involving five different joints. The children made up three different age groups (9, 12 and 15 y old) at the time of testing and were approximately equally distributed concerning age and gender in all groups. RESULTS: There were significant differences in Beighton scores concerning both age and gender. Whereas boys presented significant decreases in the degree of general joint laxity with increasing age, girls presented the highest degree of general joint laxity at the age of 15. At all ages girls had a higher degree of general joint laxity CONCLUSION: Based on this study of a normal population of Swedish school children, the normal distribution of general joint laxity as well as the limits for hypermobility is age and gender specific. It is necessary to take into consideration both age and gender if setting a cut-off point for hypermobility when evaluating general joint laxity in growing individuals.

Adolescent↗
PubMed2004

The diagnostic value of IADL evaluation in the detection of dementia in general practice.

It is assumed that general practitioners can make an important contribution to the diagnosis of dementia. One of the used strategies comprises an evaluation of the Instrumental Activities of Daily Living (IADL). There are contradictory data on the value of this strategy. During one month, 21 Flemish general practitioners evaluated the IADL capacities of all subjects older than 65 years with whom they had contact. Subjects with dementia and/or living in a residential home for the elderly were excluded. Housing and living conditions, medication use and IADL were registered. The general practitioner formulated a clinical evaluation. All subjects with an IADL score > or = 1 and a random sample from the group IADL = 0 underwent a Mini Mental State Examination. Subjects with an IADL score = 4 were referred for neuropsychological and specialist examination. The average age of the 1003 registered subjects was 75.1 years (SD = 6.8). A large majority of them (85%) were totally independent. There was a large discrepancy between the family's and the patient's judgment on the presence of memory problems. There was an inverse correlation between the IADL and MMSE: when the IADL score increased, the MMSE score fell. The diagnostic value of the IADL for the diagnosis of dementia with Camdex-N as a reference standard could not be evaluated because the number of tested subjects was too small. Against the MMSE, sensitivity was 0.81 (SE = 0.03), and specificity was 0.48 (SE = 0.05). The evaluation of the IADL activities had some drawbacks as a detection method for dementia but the use of IADL data may still be clinically valuable in general practice. The correlation between the general practitioner's judgment and that of the specialist was very good. This study showed that the use of the IADL score might change the general practitioner's diagnostic judgment. Furthermore this study confirms the existence of a major threshold for the referral to a specialist of patients with suspected dementia by general practitioners.

Activities of Daily Living↗
PubMed2005

Perspectives on lifestyle intervention: the views of general practitioners who have taken part in a health promotion study.

AIM: A study was carried out to discover the views of Danish general practitioners on the possibility of intervening in their patients' lifestyles in general and on the obstacles to doing so, based on their experience of participating in a health promotion study. METHOD: A focus group interview was conducted with five general practitioners who had participated in "The Ebeltoft Health Promotion Study" to assess their views on their preventive role. RESULTS: The general practitioners have internalized the view advanced by society and the medical profession that they have an important role to play in preventing lifestyle-related illness. However, they are sceptical about the effectiveness of intervention and have ethical concerns about giving lifestyle advice. They are also somewhat irritated by the fact that patients are chiefly interested in having their health checked, rather than in following up by changing their behaviour. The general practitioners differ in their views as to when, and how actively, they should initiate discussions with individual patients to encourage them to change their lifestyles. CONCLUSIONS: If the medical profession and those responsible for overall health policy wish to make general practitioners change their behaviour towards their patients, it is important that they understand the aims, values, and working conditions of general practitioners that underlie their present attitudes and behaviour.

Adult↗
PubMed2005

General practitioners and mental health staff sharing patient care: working model.

OBJECTIVE: The paper describes a shared care programme developed by mental health services and general practitioners for shifting patients with chronic psychiatric disorders to the care of a general practitioner. The programme is characterized by: (i) a dedicated mental health service general practitioner liaison position to manage the programme and provide support to both patients and doctors; (ii) a multidisciplinary care planning meeting that includes mental health staff, the patient, the general practitioner and a carer; and (iii) a jointly developed individual management plan that specifies patient issues, strategies to deal with these issues, persons responsible for monitoring and a review date. METHODS: The shared care protocol, the results of a review of patient mental health indicators and general practitioner satisfaction with the programme are described. RESULTS: Outcomes to date suggest that patients' mental health is not compromised and may be enhanced by transfer to general practitioners within the shared care model. Indicators of mental health outcomes (Health of the Nation Outcome Scale and Life Skills Profile scores) show improved patient symptomatology and functioning in most cases. CONCLUSIONS: The programme fits the model of recovery-based mental health services and complies with current local, state and Commonwealth policies that encourage integrated and collaborative approaches by mental health services and general practitioners in delivering mental health care to persons with chronic mental illness.

Australia↗
PubMed2003

Healthy eating: the views of general practitioners and patients in Scotland.

BACKGROUND: Scotland has one of the poorest health records of all Western countries, and this has been linked to poor diet. A key part of efforts to improve health has been an action plan to improve the Scottish diet. General practice has been identified as an important setting for health promotion and the provision of healthy eating advice. OBJECTIVE: The objective was to investigate the views of general practitioners (GPs) and their patients about healthy eating and the provision of healthy eating advice in general practice. DESIGN: This qualitative research study used semistructured in-depth interviews with 15 general practitioners (8 female and 7 male) and 30 patients (15 married couples in social class 3, 4, or 5 with young children). RESULTS: The study found that health was only one priority in patients' everyday lives and that these patients were also questioning the relevance of healthy eating advice. GPs were divided in their opinions, with greater enthusiasm being displayed by the younger and female doctors. However, despite their differing views, GPs felt that general practice was better suited to specific rather than general health advice. CONCLUSIONS: If programs in general practice to address dietary inequalities are to succeed, both patients' views and GPs' views must be taken into account.

Attitude of Health Personnel↗
PubMed1994

Hodgkin's disease in patients with HIV infection and in the general population: comparison of clinicopathological features and survival.

BACKGROUND: Hodgkin's disease (HD) has been described in patients with HIV infection in association with unfavourable prognostic factors. Similarly, HD in the older general population has a poorer prognosis than in younger patients. PATIENTS AND METHODS: With the aim of comparing the clinicopathological features and survival of HD in HIV-infected patients and in the general population, we analysed 176 patients with HD from 1986 to 1992. We divided the 84 HIV-negative patients into two groups: group A included patients less than 55 years old, group B patients of 55 years or older. This division was made in order to compare HD in HIV-infected patients with the less favourable group of patients with HD in the general population, i.e., older patients. RESULTS: Patients of the older group and HIV-infected patients had a significantly lower frequency (31% and 21%, respectively) of nodular sclerosis subtype compared to the younger group (85%). Mixed cellularity (MC) is significantly more frequent both in the older group and in HIV-infected patients. Lymphocyte predominance is more frequent (16%) in older patients than in the other two groups. HIV-infected patients are more likely to show advanced stages, B symptoms, and extranodal involvement. Chemotherapy (CT) alone has been the most widely used (83%) treatment in HIV-infected patients, while CT plus radiotherapy (RT) has been mostly employed in the general population. Twelve (14%) HIV-infected patients did not receive any treatment. Complete remission was achieved in 51% of the cases in the HIV-infected patients, and around 90% of the cases in the general population. The estimated 4-year survival rate in the HIV-infected patients is much lower (33%) than in the other two groups (100% in group A, and 88% in group B). CONCLUSION: While MC is the most common histological subtype both in HIV-infected patients and in the older general population, HD in HIV-infected patients has a worse prognosis than in the older general population, not only because of underlying HIV infection, but also because of the more unfavourable clinicopathological features at presentation.

Actuarial Analysis↗
PubMed1994

Asthma in adolescents and young adults: screening outcome versus diagnosis in general practice.

The objectives of this study were to investigate underdiagnosis of asthma in adolescents and young adults in general practice and to examine the influence of patient characteristics. The results of screening on asthma (questionnaire, spirometry) were compared with the diagnosis made in general practice. Screening results served as the reference standard. Four general practices forming the Continuous Morbidity Registration, Nijmegen were used. Five-hundred and fifty-one subjects aged 10-23, registered since their birth till the year of the study (1989) on the practice lists of these practices were involved in the study. The data collected included: (i) all episodes of respiratory morbidity in their life presented in general practice; (ii) socioeconomic level and family history of asthma; and (iii) current respiratory status, allergy to inhalant allergens and smoking behaviour (questionnaire, spirometry, histamine-challenge test and Phadiatop-test). The screening identified asthma in 19% of the study subjects, of whom 56% not had been recognized in general practice. Of the asthmatics recognized in general practice, significantly more were boys, had presented acute bronchitis in the last 5 years preceding this study and had a family history of asthma than those not recognized. Of the latter, 30% had not presented any respiratory disease in the last 5 years to their general practitioner (GP). This study suggests underdiagnosis of asthma in adolescents and young adults. Asthmatics are more likely to be recognized by their GPs in case of male sex, previous diagnosis of acute bronchitis and a family history of asthma. Reluctance of some patients to consult their doctor and low perception of symptoms may play a role in underdiagnosis.

Adolescent↗
PubMed1995

Consumer use of multiple general practitioners: an Australian epidemiological study.

The aim of this Australian study was to explore the reasons for peoples' choice of general practitioner (GP) in an environment where they have freedom of choice of doctor on every occasion of attendance. A questionnaire was administered by trained research assistants to 555 people during an hour-long interview. Utilization of more than one general practitioner was examined in terms of sociodemographic factors, health status and satisfaction with the last general practice visit. Respondents were more likely to see more than one general practitioner if they had more visits; were dissatisfied with their last consultation with a general practitioner; were younger; were female; and were highly qualified. Further, respondents who described good communication as the rationale for their satisfaction rating for their last general practitioner visit were less likely to have seen more than one general practitioner.

Adult↗
PubMed1996

The menopause and hormone replacement therapy: Australian general practitioners' self-reported opinions, attitudes and behaviour.

OBJECTIVES: We describe the attitude and views of general practitioners towards the menopause and hormone replacement therapy (HRT) in metropolitan Brisbane, Australia. METHODS: A total of 216 general practitioners were nominated by a random sample of urband-welling women aged 45-54 years who formed the Brisbane Women's health study. A 20-30 minute face-to-face questionnaire with the general practitioners was administered and analysed by demographic characteristics. RESULTS: There was a 93% response rate. Management of the menopause and HRT was routinely undertaken by general practitioners for their own patients. After deciding to initiate HRT, > 60% of general practitioners ordered five investigations or more. They may have confused the risk of thrombo-embolism from oestrogens used in the post-menopause with that for contraception. There were differences between male and female practitioners in some areas. Male general practitioners, in particular, reported more difficulty with tailoring and adjusting regimes. CONCLUSIONS: Specific areas for further education are explored to meet the educational needs of general practitioners.

Adult↗
PubMed1999

The effects of shifts in the balance of care on general practice workload.

BACKGROUND: The consequences of the move towards a primary-care-led NHS are shifts in activity from secondary care to primary care and more involvement of GPs in purchasing decisions. Although there are many anecdotal reports of an increasing primary care workload, there is little empirical evidence on the extent of such shifts. This paper reports the results of a survey of GPs in Grampian, in the north-east of Scotland, in which we attempted to gather information on the effects of shifts in the balance of care on general practice. OBJECTIVE: We aimed to examine GPs perceptions of the extent to which general practice workload has changed due to planned and unplanned shifts in the balance of care. METHODS: The design of the study was a self-reported questionnaire, which was administered in general practices in the Grampian Health Board, Scotland. The subjects were senior partners of all general practices and the main outcome measures were the types of changes which have taken place in general practice, their source, their effect on practice workload and how practices have reacted. RESULTS: A 60% response rate was achieved (52/86); 85% (44/52) of GPs claimed that their workload had increased due to shifts in the balance of care and that 72% of the shifts were initiated outside the practice. Geriatric care, early discharge and psychiatric and psychology services, as well as nursing home care, were reported to have had the greatest impact on workload. The main aspects of practice workload which had increased included the number of GP consultations, general stress at work and number of home visits, whereas the net income of the practice and health outcome of patients were reported to have decreased. Practices have dealt with the increase in workload by shifting tasks from GPs to nurses and absorbing the workload into existing practices/patterns. Responders reported that ideally more nursing and GP staffing would be required. Overall, GPs welcomed the shifts in the balance of care, were more concerned about poor communication rather than actual increases in workload and claimed that morale had fallen. CONCLUSION: GPs perceive that the move towards a primary-care-led NHS is increasing the workload in general practice. If the shift in the balance of care away from secondary care is to be successful, then more information is required about such shifts to support practices as change continues.

Attitude of Health Personnel↗
PubMed2002

An evaluation of general practice websites in the UK.

BACKGROUND: General practice websites are an emerging phenomenon, but there have been few critical evaluations of their content. Previously developed rating instruments to assess medical websites have been criticized for failing to report their reliability and validity. OBJECTIVES: The purpose of this study was to develop a rating instrument for assessing UK general practice websites, and then to evaluate them critically. METHODS: The STaRNet Website Assessment Tool (SWAT) was developed listing criteria that general practice websites may meet, which was then used to evaluate a random sample of websites drawn from an electronic database. A second assessor rated a subsample of the sites to assess the tool's inter-rater reliability. The setting was an information technology group of a general practice research network using a random sample of 108 websites identified from the database. The main outcome measures were identification of rating criteria and frequency counts from the website rating instrument. RESULTS: Ninety (93.3%) sites were accessible, of which 84 were UK general practice websites. Criteria most frequently met were those describing the scope of the website and their functionality. Apart from e-mail to practices, criteria related to electronic communication were rarely met. Criteria relating to the quality of information were least often met. Inter-rater reliability kappa values for the items in the tool ranged from -0.06 to 1.0 (mean 0.59). Values were >0.6 for 15 out of 25 criteria assessed in 40 sites which were rated by two assessors. CONCLUSIONS: General practice websites offer a wide range of information. They are technically satisfactory, but do not exploit fully the potential for electronic doctor-patient communication. The quality of information they provide is poor. The instrument may be developed as a template for general practices producing or revising their own websites.

Family Practice↗
PubMed1985

Audit: a project on peer review in general practice.

A project of group-based peer review by general practitioners is described. Attention is given to the motivation of general practitioners to participate in audits, to the threat posed by peer review and to the use of criteria. The recruitment and motivation were successful. A total of 253 general practitioners took part, divided into 23 groups. This represented approximately 30% of all general practitioners in the area and 72% of all general practitioners specifically approached by us. The threat posed by audit disappears rapidly for most physicians once they have started auditing. The use of predefined criteria developed by 'experts', representing an optimal way of work for the general practitioner, appeared to be quite feasible in this project. From the results several conclusions are drawn as regards the planning and implementation of peer review under general practitioners.

Attitude of Health Personnel↗