[CROATIAN GUIDELINES FOR THE PHARMACOTHERAPY OF TYPE 2 DIABETES]. / HRVATSKE SMJERNICE ZA FARMAKOLOSKO LIJECENJE SECERNE BOLESTI TIPA 2.

INTRODUCTION: The Croatian Association for Diabetes and Metabolic Disorders of the Croatian Medical Association has issued in 2011 the first national guidelines for the nutrition, education, self-control, and pharmacotherapy of diabetes type 2. According to the increased number of available medicines and new evidence related to the effectiveness and safety of medicines already involved in the therapy there was a need for update of the existing guidelines for the pharmacotherapy of type 2 diabetes in the Republic of Croatia. PARTICIPANTS: as co-authors of the Guidelines there are listed all members of the Croatian Association for Diabetes and Metabolic Diseases, as well as other representatives of professional societies within the Croatian Medical Association, who have contributed with comments and suggestions to the development of the Guidelines. EVIDENCE: These guidelines are evidence-based, according to the GRADE system (eng. Grading of Recommendations, Assessment, Development and Evaluation), which describes the level of evidence and strength of recommendations. CONCLUSIONS: An individual patient approach based on physiological principles in blood glucose control is essential for diabetes' patients management. Glycemic targets and selection of the pharmacological agents should be tailored to the patient, taking into account the age, duration of disease, life expectancy, risk of hypoglyce- mia, comorbidities, developed vascular and other complications as well as other factors. Because of all this, is of national interest to have a practical, rational and applicable guidelines for the pharmacotherapy of type 2 diabetes.

Knowledge and attitudes towards evidence-based medicine of mentors in general practice can be influenced by using medical students as academic detailers.

BACKGROUND: Regular use of evidence-based medicine (EBM) among general practitioners (GP) is insufficient. OBJECTIVE: To analyse whether knowledge and attitudes about EBM can be improved among mentors in general practice by involving sixth-year medical students as academic detailers. METHODS: An interventional non-randomized before-and-after study included 98 GPs (49 in the intervention group of mentors and 49 controls) and 174 medical students attending family medicine clinical rotations. A telephone survey on knowledge and attitudes towards EBM was conducted among participating physicians before, and six months after the rotation. During the rotation, each mentor chose two cases from real life, and the students' task was to form an answerable clinical question, find the evidence-based answer and to write a brief report. The mentor reviewed the report and discussed it with the student. RESULTS: Students' EBM detailing intervention led to significant improvement in knowledge and attitudes about EBM in the intervention group of mentors in general practice compared to control GPs (relative increase in knowledge was 20 ± 46.9% vs 6 ± 12.1%, respectively; P = 0.042). Among participants with Ph.D. or specialization in family medicine, the observed effects of the intervention were similar as in the total sample, and statistically significant, but not in the group of participants with neither scientific degree nor specialization in family medicine. CONCLUSION: Knowledge and attitudes of GP mentors towards EBM can be improved by involving medical students as academic detailers. Further studies should explore the effectiveness of this method among GPs that are not mentors, and who do not have a specialization or research degree.

Deep breathing: A simple test for white coat effect detection in primary care.

AIM: White coat hypertension (WCH) is hard to differentiate from sustained hypertension without the use of 24-h ambulatory blood pressure monitoring (ABPM). This invaluable procedure is nevertheless cumbersome and expensive. A simple test of deep breathing over 30 s (DBT) was proposed as a method to unveil WCH. METHODS: Two hundred and fourteen outpatients referred for the evaluation of uncontrolled hypertension (blood pressure, BP > 140/90 mmHg despite therapy) were enrolled in a controlled clinical trial. The examinees were randomly divided in two groups: control (n = 108; sequential standard BP measurement only) and intervention (n = 106; the same+DBT), using ABPM as the reference standard. RESULTS: The relative decrease in BP was significantly larger in the intervention group than in the control group, by 15/4 mmHg (p = 0.005). The best detection of WCH was obtained at ≥ 15% systolic BP reduction following DBT, with a positive predictive value of 94.0% (95% CI 72.0-100.0). BP reduction of ≤ 8% may rule WCH out with a negative predictive value of 78.4% (95% CI 64.0 - 85.9). CONCLUSION: DBT is a reliable, inexpensive and fast test for the detection of WCH in primary care.

Academic cooperation in family medicine: a viewpoint from Split.

UNLABELLED: The problems, current status, and opportunities of national and international collaboration between the academic family medicine institutions in Southern Europe, particularly in the region of ex Yugoslavia, as perceived from the standpoint of the Department of Family Medicine in Split University School of Medicine, Split, Croatia, are presented in this brief review. A historical survey of this department's educational, professional, and scientific development from its establishment in 1997 is given to place the regional issues in context. Family physicians are strong in number here - around 53 family practitioners per 100,000 inhabitants in Croatia, similar to surrounding countries, but weak in academic representation, with only 18 active faculty members. This compares to general internal medicine with 28 practitioners per 100,000 inhabitants and 106 active faculty members. The reasons for such a disproportion are analyzed, and the importance of collaboration is stressed. CONCLUSION: Although there have been several cooperative efforts, these activities can and should be intensified. While there is much work to be done, there are many opportunities for improvement.

A proposal for enhancement of research capacities in Croatian general practice.

UNLABELLED: Research in family medicine contributes to the increase of knowledge, and its practical application improves the work of family physicians. Although research in family medicine in the Republic of Croatia has a long tradition, no sustainable research network exists as yet. Enhancing such a network is essential to efficaciously conduct research that is specific and important for family practice. This article describes the experiences of other countries and offers a proposal for a conceptual model for the development of a permanent research network in family medicine through three key elements: recognition of research as an indicator of quality of care that is specifically funded, introducing a continuing cycle of education for family physicians/researchers in the field of scientific research and building the capacity of academic family medicine and the success of their applications for domestic and international projects and funding sources. CONCLUSION: The application of the conceptual model from Australian primary health care research, adjusted to our circumstances, could further enhance research capacity building in Croatian family medicine.

[Preventive work in family medicine--proactive approach]. / Proaktivni pristup preventivnom radu u obiteljskoj medicini.

The role of general practitioner/family physician (GP/FP) in disease prevention and health promotion is strongly supported by research and health policies. The position of GPs/FPs in the health care system and their close, sustained contact with their patients and local community makes preventive care an integral part of GP/FP routine work. The spectrum of caring for patients in general practice/family medicine is actually very large, going from intervention on health care determinants to palliative care. The prevention-related activities are more or less present at each step of this "healthcare continuum". The significant gaps between GP/FP knowledge and practices persist in the use of evidence-based recommendations for health promotion and disease prevention. We describe the role of GP/FP in preventive care and report data on preventive care activities in the Croatian Family Medicine Service. More objective evidence is needed to see what GPs/FPs actually do in practice. For this reason, it is critical that GPs/FPs systematically record the most relevant preventive and health promotion activities that they perform. Furthermore, their performance of the preventive program should be regularly monitored, evaluated and professionally and financially validated. We present the preventive program based on these principles in Family Medicine Service proposed by the Ministry of Health and Social Welfare Working Group on Reform of Primary Health Care.

[Ten years after "privatization" in primary health care]. / Deset godina nakon "privatizacije" primarne zdravstvene zastite.

Ten years after the privatization in primary health care its disadvantages have been noticed making it less quality and consequently increasing the costs of total health care of the patient. Current organization makes family practitioners inaccessible to the patient during a part of the day. Emergency health care and hospital emergency services are ever more burdened with the work that should be done by family practitioners, thus becoming hardly accessible in emergencies. Medical nurses are mostly occupied with administrative work, family practitioners are partly doing the work that should be done by nurses, while clinical specialists are doing the job of family practitioners. They all work a lot but they do the jobs that should not be in their domain and that are much under the level of their education. Health care becomes ineffective, below-quality and expensive. It is necessary to redefine the tasks of all health care participants starting from family practitioners, and to redefine the role of medical center. Solving the legal position of family practitioners working in "lease", introduction of the combined form of payment in family practice, and the possibility of interacting association of physicians could help eliminate the problems and promote the quality of health care.

[Differences between rural and urban general practice activities]. / Razlike u strukturi rada obiteljskih lijecnika na selu i u gradu.

OBJECTIVES: It is an established opinion that doctors working in rural setting are the "real general practitioners" doctors who have a broader working and responsibility range when compared to their colleagues who work in urban setting. AIM: The aim of the study was to explore whether there were differences in health care service between an urban and a rural GP office by comparing the number of visits, physical examinations, house calls and treatment costs, and to determine the impact of different age groups (regardless of the number of patients under GP care) on the frequency and type of visits to GP office, drug utilization and prescription. METHODS: The study was conducted at an urban GP office (Pozega) and a rural GP office (Velika) with a catchment population of 2063 and 2031 individuals, respectively (both offices employ family medicine specialists). Data were collected from monthly reports containing information on age groups, total number of visits, physical examinations, house calls, prescriptions and referrals during 2003. In addition, financial costs associated with prescribed drugs were compared between the two offices. On data analysis, descriptive distribution and distribution analysis were used. Differences between data were estimated by use of chi2-test. RESULTS: In the urban and rural GP offices 97.3% and only 69.6% of the population was older than 18, respectively. In urban GP office there was a mean of 7.35 visits per user per year, whereas in rural GP office the respective figure was 6.43, yielding a statistically significant difference (chi2 = 15.86; df = 1; p < 0.001). In urban GP office there were more house calls, the difference being statistically significant (chi2 = 51.91; df = 1; p < 0.001). Urban GP office also recorded a statistically significantly higher rate of referrals than rural office (chi = 31.22; df = 1; p < 0.001). The urban and rural GP offices differed in the mean number of prescriptions per patient (8.96 vs. 5.81), mean prescription cost (63.60 vs. 55.54 HRK); mean prescription cost per person (570.19 vs. 323.05 HRK), and index of financial expenditure of the predetermined amount assigned to drugs (135.7% vs. 92.32%). CONCLUSIONS: Results of this study showed the different age group structure (regardless of the catchment population size) to determine the number of visits to GP office, total prescription cost and number of referrals. It is therefore of utmost importance to acknowledge the importance of patient age group structure as it has great influence in determining the type of care a GP has to offer and the cost associated with it.

[Medical students' interest in general practitioners career]. / Stavovi studenata medicine o zvanju obiteljskog lijecnika.

AIM: To assess the reasons for entering medical school, to explore the attitudes and opinions of final year students regarding medical education and their future career preferences, including family medicine. METHODS. During four years period, 111 (73%) final year students of Split Medical School were surveyed [31 (96,8%) of them in academic year 1996/7, 23 (62%) in 2001/2, 30 (62,5%) in 2003/4 and 27 (77%) in 2004/5]. Semi-structured questionnaire about motivations and expectations was used and answered during the family medicine course. RESULTS: . Most of the students 59/111 (53%) entered medical school by their own wish, 34 (31%) were not sure about their choice at the entry and in 17 (16%) students, it was a result of circumstances. The main motivations were interest in medical knowledge (35.6%) and (24.8%) desire to work with patients and to help people. Clinical specialization was the future career of first choice in 62%, family medicine in 16.2% of them, while 16.2% were still undecided. In rating social esteem and reputation (scale 1-6), the students rated surgeons on average: surgeon 5.48, cardiologist 4.85, gynaecologist 4.6, psychiatrist 2.70, family physician 2.30 and specialist in preventive medicine 1.27. DISCUSSION: The essential reasons to enter a medical school are humanistic and not socioeconomic. Students prefer clinical specializations to family medicine. Final year medical students from Split Medical School suggest more practical work and field practice in order to improve the study quality. CONCLUSION: Although the majority of the polled students stated to have chosen medicine for humanistic reasons, more than half of them prefer to work in a hospital, and less than quarter as family physician in a city. Substantial changes in curriculum including an early contact with family physicians could motivate medical students to select family medicine as their future career more often.

[Disease duration, patient compliance and presence of complications in diabetic patients]. / Trajanje bolesti, suradljivost bolesnika i postojanje komplikacija u bolesnika s dijabetesom.

UNLABELLED: Diabetes mellitus (especially type 2) is one of the most common metabolic diseases in care of general/family physician. AIM: The aim of the study was to investigate the duration of the disease, association of the disease duration with the onset of complications, and physician's assessment of patient compliance. The study was a part of the international Health Monitoring Project carried out by the Chair of Family Medicine, Andrija Stampar School of Public Health, School of Medicine, Zagreb, in cooperation with The Netherlands Institute of Primary Health Care (NIVEL). The aim was to assess the value of data on the incidence and prevalence of diabetes mellitus in primary health care. SUBJECTS AND METHODS: Family physicians, general/family practice specialists, teachers and heads of general/family practice practical teaching who were collecting data for the questionnaire structured for this purpose were included in the study. Description and distribution analysis was used on data analysis, and chi2-test on testing of differences. RESULTS: Out of 96 general/family physicians who agreed to participate in the study, 58 (60.4%) collected data on 3065 patients: 1275 (41.6%) men and 1790 (58.4%) women. In 1044 (34.1%) patients the disease lasted for 1-5 years, in 990 (32,3%) for 6-10 years and in 1031 (33.6%) for more than ten years. Complications were recorded in 1521 (49.62%) patients, showing a statistically significant correlation with the duration of the disease (chi2 = 627.889; df = 2; p < 0.001). Physicians estimated that good compliance was established in 1579 (51.52%) patients. There were significantly less complications in these patients (chi2 = 6.098; df =2; p = 0.047). DISCUSSION AND CONCLUSION: The number of complications in diabetes mellitus increased proportionally with the length of the disease, while the number of complications was lower in cases with better patient compliance. In the care for a patient with diabetes mellitus family physician should train the patient in self-care, tending to establish partnership in long lasting treatment, which is a precondition for good compliance.

[Acute infections of the upper respiratory tract--factors that contribute to diagnosis and antibiotic prescription decisions]. / Akutne infekcijev gornjeg disnog sustava--sto pridonosi dijagnozi, a sto odluci o propisivanju antibiotika?

UNLABELLED: Acute infections of the upper respiratory tract contribute to over 20% of the morbidity of the population in ambulatory care, with the highest incidence in children. A noted problem in the treatment of these diseases is overprescription of antibiotics. In addition, there is a high degree of variability among physicians in the frequency and cost of antibiotic prescription. AIM: The aim of this study was to evaluate the factors that contribute to the diagnosis, and those that affect the decision of a family care physician or otolaryngologist to prescribe an antibiotic to a patient suffering from an upper respiratory tract infection. PATIENTS AND METHODS: In this prospective study, data were collected on 75 patients with acute middle ear infection, 49 with acute tonsillitis, 57 with acute sore throat, and 39 with a streptococcal sore throat and tonsillitis, in 6 family physician offices and otolaryngological practices in Zagreb University Hospital and Osijek University Hospital, Osijek. The questionnaire included general patient data, data on the current disease (patient history and the relevant clinical status), diagnostic and therapeutic procedures and patient follow-up. Doctors noted patients' symptoms and rated (from one to five) the influence of a particular symptom to arriving at the diagnosis, and to deciding to prescribe antibiotics. The physicians also noted any additional factors that influenced antibiotic prescription. The data were analysed using appropriate statistical measures, such as chi2-test, chi2-test using the hypothesis of rectangular distribution and t-test for independent samples. RESULTS AND CONCLUSION: The results show that diagnostic criteria for these diseases and decisions for prescribing antibiotics are based on clinical criteria and in concordance with current guidelines. Otolaryngologists recommended microbiological analyses for 54% of patients, while GPs did so for only 4.2% of the patients. While the clinical status is the most important factor for antibiotic prescription, the results of this study indicate that other additional factors such as familiarity with the patient, likelihood of complications, and knowing the patient's living circumstances and his/her ability to use health care facilities should be considered in the complex process of antibiotic prescribing.

[Private contracted primary health physician: today and tomorrow]. / Privatni ugovorni lijecnik: danas i sutra.

Contracted primary health physician is the cornerstone of health care system. He is the main provider of all contracted obligations. It is necessary to evaluate the role of other contributors and organizational forms. Not the practice ownership but contract with the Croatian Institute of Health Insurance is fundamental for the status of general practitioners. Primary care should be based on Group Practice and Primary Health Trusts.