A practical approach to lifestyle change counselling in primary care.

Many contemporary medical conditions have been found to be the consequence of lifestyle choices. These adverse habit patterns have their origin in the individuals family and/or natural social network. Primary care practitioners frequently interact with their patients for the purpose of helping them resolve medical problems by clarifying issues or presenting different options. In lifestyle related conditions, the initiation and maintenance of possible behaviour changes is usually the optimal resolution. How people intentionally change well-established behaviour patterns is still not well understood, and most clinicians are not confident in their ability to help patients alter adverse behaviours. Several studies provide support for a 'stage-matched framework' of behaviour change that integrates readiness for change with intervention processes from various theoretical models. This article provides a brief overview of the current thinking with respect to self-initiated and professionally facilitated behaviour change, and then describes a generic five-step approach to individualized lifestyle counselling for use in primary care clinical settings.

Putting prevention into practice.

In primary medical care settings, disease prevention services are delivered at lower rates than recommended. Furthermore, practitioners tend to overestimate the rate at which they perform them. There are essentially two steps in delivering evidence-based preventive services: (1) knowing what the evidence is for performing various detection and intervention manoeuvres, and (2) integrating the preventive services into daily practice. The first is a scientific process and is carried out in Canada by the Canadian Task Force on the Periodic Health Examination. However, after a decade of experience with evidence-based guidelines, we now know that guidelines are not enough. Integrating clinical prevention into busy practices is a political and logistical process. This truth is best captured by the quip, "An ounce of prevention requires a pound of office system change". A number of studies have demonstrated that continuing medical education (CME) courses and workshops for physicians are not enough to ensure that clinical preventive services are incorporated into practice. According to Lomas, the traditional CME educational approaches need to be complemented by strategies from such paradigms as the social influence model, the diffusion of innovation model and the adult learning model. Battista, in "From Science to Practice," points out the complexity of the communication process required for the diffusion of innovation into practice. Walsh's Systems Model of Clinical Preventive care best captures the interacting factors that mediate between practitioners' intentions and their actions when it comes to delivering clinical prevention services. This paper reports on a practical example of helping family practitioners develop a "sustaining office system in prevention" that minimizes barriers, focuses energy and integrates clinical prevention into office routines. The key components are (i) a practice coordinator for prevention, (ii) clear clinical prevention-related job descriptions for all persons who deal with patients, (iii) an information management system that reinforces prevention, and (iv) a practice feedback and problem solving strategy.

Case-control study of prenatal ultrasonography exposure in children with delayed speech.

OBJECTIVE: To determine whether there is an association between prenatal ultrasound exposure and delayed speech in children. DESIGN: Case-control study. SETTING: Network of community physicians affiliated with the Primary Care Research Unit, University of Calgary. SUBJECTS: Thirty-four practitioners identified 72 children aged 24 to 100 months who had undergone a formal speech-language evaluation and were found to have delayed speech of unknown cause by a speech-language pathologist. For each case subject the practitioners found two control subjects matched for sex, date of birth, sibling birth order and associated health problems. MAIN OUTCOME MEASURES: Rates of prenatal ultrasound exposure and delayed speech. RESULTS: The children with delayed speech had a higher rate of ultrasound exposure than the control subjects. The findings suggest that a child with delayed speech is about twice as likely as a child without delayed speech to have been exposed to prenatal ultrasound waves (odds ratio 2.8, 95% confidence limit 1.5 to 5.3; p = 0.001). CONCLUSION: An association between prenatal ultrasonography exposure and delayed speech was found. If there is no obvious clinical indication for diagnostic in-utero ultrasonography, physicians might be wise to caution their patients about the vulnerability of the fetus to noxious agents.

Reducing the Risk of Coronary Artery Disease: Helping patients change.

Lifestyle and prevention are increasingly emphasized as ways to promote cardiovascular health. Family physicians will play a central role in detecting risk and encouraging lifestyle changes. This article outlines an effective preventive approach to coronary artery disease. The steps and skills involved are discussed as well as aspects of practice cultures that influence family physicians' activities.

Detecting Elevated Cholesterol Levels: Part 1: How accurate is the Reflotron?

To assess accuracy of blood cholesterol measurements in the office, fingerprick blood cholesterol assays by a dry reagent chemistry analyzer were compared in 151 patients with simultaneous venipuncture cholesterol assays by standard laboratory methods. Compared with the laboratory assay, seven of eight analyzers had total absolute biases less than 5%. Variability in results was comparable to that of community laboratories.

Detecting Elevated Cholesterol Levels: Part 2: Prevalence and feasibility considerations.

The Reflotron dry chemistry reflectance photometer was studied as a case-finding method in physicians' offices. A total of 713 adult patients had their risk factor profiles determined along with fingerprick blood cholesterol measurements. Blood cholesterol levels were classified into three categories, (<5.2 mmol/L), 51%; borderline high (5.2 to 6.1 mmol/L), 28%; and high (≥6.2 mmol/L), 21%. The physicians' predictions from clinical risk factor profiles of which patients had elevated serum cholesterol levels were inaccurate.

Pharyngitis 1987: a survey of physicians' attitudes and practices in southern Alberta.

A questionnaire survey concerning Streptococcal pharyngitis was completed by 85 southern Alberta family physicians. The data revealed a significant trend to overtreat pharyngitis with antibiotics because of the unreliability of clinical diagnosis and the lack of diagnostic manoeuvres with suitable ability to influence management. These data and a further questionnaire survey directed to the appreciation of other bacterial pharyngitides, demonstrate the importance of laboratory reports in biasing treatment, and further suggest that significant overtreatment of non-Streptococcal pharyngitis also occurs.

One approach to demystifying research in primary care.

"Research" means different things to different people. "Organized curiosity" has been proposed as a suitable description for family-practice research. Studies involving patients in community practices are becoming recognized as a unique type of research that contributes new understanding to matters relating to primary care. Such research, however, requires an infrastructure that makes a study as unobtrusive as possible in participating practices. One approach is the development of a primary care research unit (PCRU): a central co-ordinating communications office which can provide the human and technical resources needed to assist each community office with protocol and data-collection steps. The author of this article describes the functional components of a PCRU in five groupings: namely, technical, human, communication and support systems, a network of community physicians, and facilities. Finally, several important principles about funding primary care research are suggested.

The impact of preventive cardiology on coronary artery disease.

Ischemic heart disease continues to be the leading cause of death among middle-aged people in industrialized countries. However, in North America the rates of death and disability from coronary artery disease (CAD) have declined, mostly because of a reduction of the main modifiable risk factors (high serum cholesterol levels, smoking and hypertension). Intervention trials have consistently shown that the lowering of the severity of risk factors decreases the incidence of CAD. These studies have introduced the goals of preventive cardiology to clinicians but have not provided the necessary knowledge and skills to achieve them. Unfortunately, with the exception of hypertension, the risk factors for CAD are infrequently assessed and managed in ambulatory patients. Incorporation of detection and intervention strategies derived from recent epidemiologic, behavioural and biomedical research into the existing primary health care system may be the most efficient and effective approach to further reducing the impact of CAD. The family physician's office is the ideal location to implement behavioural change strategies. However, primary care intervention to decrease the risk of ischemic heart disease among people at high risk has yet to be studied. In addition, whether the same clinicians who render primary care can assume the responsibility for surveillance and preventive care has to be demonstrated.

Do the beta-hemolytic non-group A streptococci cause pharyngitis?

Implication of the beta-hemolytic non-group A streptococci (BHNAS) as pharyngeal pathogens has been based predominantly on reports of a few outbreaks, small case clusters, and anecdotes. These organisms have long been noted to constitute a significant number of the beta-hemolytic streptococcal isolates from throats of symptomatic and asymptomatic patients in a variety of populations. Laboratory studies have demonstrated the usefulness of anaerobic atmosphere and prolonged incubation in maximizing isolation of the BHNAS. More recently, genetic studies have furthered our appreciation of the taxonomy and have defined two major groups: Streptococcus anginosus-milleri group and large-colony BHNAS; the latter can be further separated on the basis of serogrouping and biotyping. Recognition of this diversity gives justification to the reexamination of the epidemiology and disease course of BHNAS pharyngitis. Treatment studies will also be required if all or subsets of these organisms can be confirmed as pharyngeal pathogens.