An international comparative family medicine study of the Transition Project data from the Netherlands, Malta and Serbia. Is family medicine an international discipline? Comparing diagnostic odds ratios across populations.

INTRODUCTION: This is an international study of the epidemiology of family medicine (FM) in three practice populations from the Netherlands, Malta and Serbia. Diagnostic associations between common reasons for encounter (RfEs) and episodes titles are compared and similarities and differences are described and analysed. METHODOLOGY: Participating family doctors (FDs) recorded details of all their patient contacts in an 'episode of care (EoC)' structure using the International Classification of Primary Care (ICPC). RfEs presented by the patient and episode titles (diagnostic labels of EoCs) were classified with ICPC. The relationships between RfEs and episode titles were studied with Bayesian methods. RESULTS: Distributions of diagnostic odds ratios (ORs) from the three population databases are presented and compared. CONCLUSIONS: ICPC, the RfE and the EoC data model are appropriate tools to study the process of diagnosis in FM. Distributions of diagnostic associations between RfEs and episode titles in the Transition Project international populations show remarkable similarities and congruencies in the process of diagnosis from both the RfE and the episode title perspectives. The congruence of diagnostic associations between populations supports the use of such data from one population to inform diagnostic decisions in another. Differences in the magnitude of such diagnostic associations are significant, and population-specific data are therefore desirable. We propose that both an international (common) and a local (health care system specific) content of FM exist and that the empirical distributions of diagnostic associations presented in this paper are a reflection of both these effects. We also observed that the frequency of exposure to such diagnostic challenges had a strong effect on the confidence intervals of diagnostic ORs reflecting these diagnostic associations. We propose that this constitutes evidence that expertise in FM is associated with frequency of exposure to diagnostic challenges.

An international comparative family medicine study of the Transition Project data from the Netherlands, Malta, Japan and Serbia. An analysis of diagnostic odds ratios aggregated across age bands, years of observation and individual practices.

INTRODUCTION: This is a study of the process of diagnosis in family medicine (FM) in four practice populations from the Netherlands, Malta, Serbia and Japan. Diagnostic odds ratios (ORs) for common reasons for encounter (RfEs) and episode titles are used to study the process of diagnosis in international FM and to test the assumption that data can be aggregated across different age bands, practices and years of observation. METHODOLOGY: Participating family doctors (FDs) recorded details of all their patient contacts in an episode of care (EoC) structure using the International Classification of Primary Care (ICPC). RfEs presented by the patient and the diagnostic labels (EoC titles) recorded for each encounter were classified with ICPC. The relationships between RfEs and episode titles were expressed as ORs using Bayesian probability analysis to calculate the posterior (post-test) odds of an episode title given an RfE, at the start of a new EoC. RESULTS: The distributions of diagnostic ORs from the four population databases are tabled across age groups, years of observation and practices. CONCLUSIONS: There is a lot of congruence in diagnostic process and concepts between populations, across age groups, years of observation and FD practices, despite differences in the strength of such diagnostic associations. There is particularly little variability of diagnostic ORs across years of observation and between individual FD practices. Given our findings, it makes sense to aggregate diagnostic data from different FD practices and years of observation. Our findings support the existence of common core diagnostic concepts in international FM.

An international comparative family medicine study of the Transition Project data from the Netherlands, Malta and Serbia. Is family medicine an international discipline? Comparing incidence and prevalence rates of reasons for encounter and diagnostic titles of episodes of care across populations.

INTRODUCTION: This is a study of the epidemiology of family medicine (FM) in three practice populations from the Netherlands, Malta and Serbia. Incidence and prevalence rates, especially of reasons for encounter (RfEs) and episode labels, are compared. METHODOLOGY: Participating family doctors (FDs) recorded details of all their patient contacts in an episode of care (EoC) structure using electronic patient records based on the International Classification of Primary Care (ICPC), collecting data on all elements of the doctor-patient encounter. RfEs presented by the patient, all FD interventions and the diagnostic labels (EoCs labels) recorded for each encounter were classified with ICPC (ICPC-2-E in Malta and Serbia and ICPC-1 in the Netherlands). RESULTS: The content of family practice in the three population databases, incidence and prevalence rates of the common top 20 RfEs and EoCs in the three databases are given. CONCLUSIONS: Data that are collected with an episode-based model define incidence and prevalence rates much more precisely. Incidence and prevalence rates reflect the content of the doctor-patient encounter in FM but only from a superficial perspective. However, we found evidence of an international FM core content and a local FM content reflected by important similarities in such distributions. FM is a complex discipline, and the reduction of the content of a consultation into one or more medical diagnoses, ignoring the patient's RfE, is a coarse reduction, which lacks power to fully characterize a population's health care needs. In fact, RfE distributions seem to be more consistent between populations than distributions of EoCs are, in many respects.

Revisiting the concept of 'chronic disease' from the perspective of the episode of care model. Does the ratio of incidence to prevalence rate help us to define a problem as chronic?

BACKGROUND: This is a study of the epidemiology of acute and chronic episodes of care (EoCs) in the Transition Project in three countries. We studied the duration of EoCs for acute and chronic health problems and the relationship of incidence to prevalence rates for these EoCs. METHOD: The Transition Project databases collect data on all elements of the doctor-patient encounter in family medicine. Family doctors code these elements using the International Classification of Primary Care. We used the data from three practice populations to study the duration of EoCs and the ratio of incidence to prevalence for common health problems. RESULTS: We found that chronic health problems tended to have proportionately longer duration EoCs, as expected, but also a lower incidence to prevalence rate ratio than acute health problems. Thus, the incidence to prevalence index could be used to define a chronic condition as one with a low ratio, below a defined threshold. CONCLUSIONS: Chronic health problems tend to have longer duration EoCs, proportionately, across populations. This result is expected, but we found important similarities and differences which make defining a problem as chronic on the basis of time rather difficult. The ratio of incidence to prevalence rates has potential to categorise health problems into acute or chronic categories, at different ratio thresholds (such as 20, 30 or 50%). It seems to perform well in this study of three family practice populations, and is proposed to the scientific community for further evaluation.

The interpretation of the reasons for encounter 'cough' and 'sadness' in four international family medicine populations.

BACKGROUND: This is a study of the relationships between common reasons for encounter (RfEs) and common diagnoses (episode titles) within episodes of care (EoCs) in family practice populations in four countries. METHOD: Participating family doctors (FDs) recorded details of all their patient contacts in an EoC structure using the International Classification of Primary Care (ICPC), including RfEs presented by the patient, and the FDs' diagnostic labels. The relationships between RfEs and episode titles were studied using Bayesian methods. RESULTS: The RfE 'cough' is a strong, reliable predictor for the diagnoses 'cough' (a symptom diagnosis), 'acute bronchitis', 'URTI' and 'acute laryngitis/tracheitis' and a less strong, but reliable predictor for 'sinusitis', 'pneumonia', 'influenza', 'asthma', 'other viral diseases (NOS)', 'whooping cough', 'chronic bronchitis', 'wheezing' and 'phlegm'. The absence of cough is a weak but reliable predictor to exclude a diagnosis of 'cough', 'acute bronchitis' and 'tracheitis'. Its presence allows strong and reliable exclusion of the diagnoses 'gastroenteritis', 'no disease' and 'health promotion/prevention', and less strong exclusion of 'adverse effects of medication'. The RfE 'sadness' is a strong, reliable predictor for the diagnoses 'feeling sad/depressed' and 'depressive disorder'. It is a less strong, but reliable predictor of a diagnosis of 'acute stress reaction'. The absence of sadness (as a symptom) is a weak but reliable predictor to exclude the symptom diagnosis 'feeling sad/depressed'. Its presence does not support the exclusion of any diagnosis. CONCLUSIONS: We describe clinically and statistically significant diagnostic associations observed between the RfEs 'cough' and 'sadness', presenting as a new problem in family practice, and all the episode titles in ICPC.

Quality of care for hypertensive patients with type 2 diabetes in a rural area of Southern Italy: is the recording of patient data and the achievement of quality indicators targets satisfactory?

INTRODUCTION: Type 2 diabetes mellitus and hypertension are commonly associated chronic conditions which require regular structured treatment. In the UK many quality markers have been improved through an incentivisation scheme. The aim of this study was to discover if there is potential for improving the quality of care for patients with type 2 diabetes and hypertension in rural Italy, through a quality and outcome incentivisation scheme. METHODS: The study was conducted in a rural practice context in Southern Italy and seven family doctors were involved. The main outcome measures were glycated haemoglobin A1c (HbA1c), LDL cholesterol, and systolic and diastolic blood pressure. The patient characteristics examined were age, sex, educational level, behaviour-related factors such as smoking and BMI, and the presence of comorbidities. RESULTS: A poor level of registration was found for important variables such as HBA1c (61.4% compared with the UK Quality Indicator of 90%). An adequate level of registration and control was found only for blood pressure (95.7% and 82.1%, respectively), while an acceptable but not optimal level of control for HBA1c was also achieved (88.4% ≤10%). In comparison with levels in UK practices, the Italian district studied performed much less favorably, especially regarding process indicators. Intermediate outcome and treatment indicators were slightly better for blood pressure control but slightly worse for HBA1c and cholesterol control. CONCLUSION: The data confirm a poor registration level for important healthcare indicators in the study area, and that optimal levels are rarely reached for many quality indicators. A quality and outcome incentivisation scheme similar to the UK Quality and Outcomes Framework may offer a tool for achieving improvements.

A meta-synthesis of pregnant women's decision-making processes with regard to antenatal screening for Down syndrome.

The diffusion of antenatal screening programmes for Down syndrome has triggered much discussion about their powerful potential to enhance pregnant women's autonomy and reproductive choices. Simultaneously, considerable debate has been engendered by concerns that such programmes may directly contribute to the emergence of new and complex ethical, legal and social dilemmas for women. Given such discussion and debate, an examination of women's decision-making within the context of antenatal screening for Down syndrome is timely. This paper aims to undertake a meta-synthesis of qualitative studies examining the factors influencing pregnant women's decisions to accept or decline antenatal screening for Down syndrome. The meta-synthesis aims to create more comprehensive understandings and to develop theory which might enable midwives and other healthcare professionals to better meet the needs of pregnant women as they make their screening decisions. Ten electronic health and social science databases were searched together with a hand-search of eleven journals for papers published in English between 1999 and 2008, using predefined search terms, inclusion and exclusion criteria, and a quality appraisal framework. Nine papers met the criteria for this meta-synthesis, providing an international perspective on pregnant women's decision-making. Twelve themes were identified by consensus and combined into five core concepts. These core concepts were: destination unknown; to choose or not to choose; risk is rarely pure and never simple; treading on dreams, and betwixt and between. A conceptual framework is proposed which incorporates these themes and core concepts, and provides a new insight into pregnant women's complex decision-making processes with regard to antenatal screening for Down syndrome. However, further research is necessary to determine whether or not the development of a model of decision-making may empower pregnant women in making choices about screening.

Burnout in European family doctors: the EGPRN study.

INTRODUCTION: The aim of this study was to determine the prevalence of burnout, and of associated factors, amongst family doctors (FDs) in European countries. Methodology. A cross-sectional survey of FDs was conducted using a custom-designed and validated questionnaire which incorporated the Maslach Burnout Inventory Human Services Survey (MBI-HSS) as well as questions about demographic factors, working experience, health, lifestyle and job satisfaction. MBI-HSS scores were analysed in the three dimensions of emotional exhaustion (EE), depersonalization (DP) and personal accomplishment (PA). RESULTS: Almost 3500 questionnaires were distributed in 12 European countries, and 1393 were returned to give a response rate of 41%. In terms of burnout, 43% of respondents scored high for EE burnout, 35% for DP and 32% for PA, with 12% scoring high burnout in all three dimensions. Just over one-third of doctors did not score high for burnout in any dimension. High burnout was found to be strongly associated with several of the variables under study, especially those relative to respondents' country of residence and European region, job satisfaction, intention to change job, sick leave utilization, the (ab)use of alcohol, tobacco and psychotropic medication, younger age and male sex. CONCLUSIONS: Burnout seems to be a common problem in FDs across Europe and is associated with personal and workload indicators, and especially job satisfaction, intention to change job and the (ab)use of alcohol, tobacco and medication. The study questionnaire appears to be a valid tool to measure burnout in FDs. Recommendations for employment conditions of FDs and future research are made, and suggestions for improving the instrument are listed.

Diabetes mellitus in Irish general practice: level of care as reflected by HbA1c values.

OBJECTIVE: To assess the level of care given to people with diabetes by general practitioners and factors affecting it. METHODS: A cross-sectional study of Irish general practitioners, looking at practice characteristics and patient care over the previous 2 years; a nationally representative sample of 27 general practitioners. A total of 1030 people with diabetes were studied, of whom 201 were type 1 and 829 were type 2. RESULTS: The response rate was 27 out of 52 (52%). HbA1c values were not related to the patient's socioeconomic status. The average HbA1c for type 1 people with diabetes was 7.81%, and for type 2 it was 7.1%. HbA1c values were measured 3.02 times for type 1 and 3.16 times for people with type 2 diabetes. This is a good standard of care, especially for type 2 disease. Computerized practices and those patients whose care was shared with the hospital achieved better control, even though HbA1c levels were checked less frequently with computerization. The use of a protocol in the practices also improved care. Those practices employing a nurse had increased frequency of measurement of HbA1c and better control on univariate but not on multivariate analysis. Possible reasons for this are discussed. CONCLUSION: Diabetes Mellitus is treated to a good standard in Irish general practice, especially type 2 disease. This standard appears to be independent of the patient's socio-economic status, is improved by GPs being computerised, in group practices and by providing care according to a protocol. Shared care also improves control. Employing a practice nurse may also improve care.

[Insomnia and sleeping disorders in the elderly in general practice]. / Schlaflosigkeit und Schlafstörungen bei älteren Patienten in der Allgemeinpraxis.

Sleeping disorders in general practice are common, but as the main reason for seeking help they only account for 1% of all consultations in all age groups. The aim of our study was to find out the overall frequency and consulting patterns for sleeping disorders in patients (over sixty years old) in general practices in eastern Austria. In this age group, sleeping disorders accounted for 7% of all reasons for seeking consultation. This percentage increased to 45% if the patients were asked if they suffered from insomnia. Half of the patients reported nycturia, but not every patient interpreted this occurrence as a real sleeping disorder. In accordance with the literature, we found a high prevalence of sleeping disorders in the unselected elderly patients visiting the surgery for highly different reasons.

A pilot study of pulmonary rehabilitation in primary care.

Pulmonary rehabilitation is an effective intervention for patients with chronic obstructive pulmonary disease (COPD). It is usually available only through selected hospitals. A pilot study was undertaken to see if pulmonary rehabilitation performed by the primary health care team in one practice was feasible. Fourteen patients were recruited; 13 completed the programme and one year of follow-up. The programme was well received by patients and staff. There were not enough suitable patients among a practice list of 10,500 to justify the running of this programme for a single practice; one primary care group would suffice

The role of the practice nurse in the management of chronic obstructive pulmonary disease (COPD).

AIMS: To assess the range of activities performed by practice nurses in COPD management and their training for these tasks. METHODS: A postal questionnaire was sent to the nurse with prime responsibility for respiratory care in 179 practices in Cornwall and Southwest Devon. RESULTS: The response rate was 64%. Spirometers were available in 64% of practices (range 0-6 per practice). Of these, spirometry was performed by nurses alone in 72%; in 44% spirometry was performed less than once a week. Spirometry was used for diagnosis in 91%; monitoring in 87% and screening asymptomatic smokers in 45%. Reversibility testing was performed by 61% of the practices. Formal training in spirometry had been undertaken by 52%, informal training in 41% and none in 7%. They would like to see the development of one-stop COPD clinics, support from specialist nurses and pulmonary rehabilitation, preferably based in the community. CONCLUSION: Nurses face many problems managing COPD in general practice including equipment, training and professional support.

The role of the practice nurse in the management of asthma.

BACKGROUND: The role of the practice nurse may include diagnosis and management of asthma, this study examines the range of activities performed by nurses and their training. AIMS: To ascertain the role and confidence levels of the practice nurse in diagnosis and management of asthmatic patients. METHODS: A postal questionnaire sent to the named respiratory nurse in 179 practices in Cornwall and Southwest Devon, to assess the number of practice nurses offering asthma management, extent of services and confidence level of nurses in this role. RESULTS: The response rate was 64%: Dedicated asthma clinics operated in 47% of practices, 87% undertaken by the nurse alone. Responsibilities undertaken by nurses alone included: instruction of inhaler technique 93%, supervising self-management plans 87%, changing medication dosage 71%, withdrawing treatment 53%, diagnosing asthma 45% and managing acute exacerbations 29%. Nurses initiated treatment alone, without consulting a doctor, as follows; inhaled bronchodilators 55%, long acting bronchodilators 54%, inhaled steroids 56%, oral steroids 15%, anti-leukotrienes 5% and theophyllines 3%. The confidence level of the nurses performing these tasks was high. Formal training had been undertaken by 74% of respondents. There were statistically significant associations between performance of organisational tasks and training, but surprisingly no apparent statistical associations with training and independent initiation of treatments. CONCLUSIONS: Practice nurses are performing activities previously undertaken by doctors. A minority have not had formal training and performing these activities, without well-defined shared care protocols, may be outside current legal frameworks.