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.

Family physician clinical inertia in glycemic control among patients with type 2 diabetes.

BACKGROUND: Many patients with diabetes do not achieve target values. One of the reasons for this is clinical inertia. The correct explanation of clinical inertia requires a conjunction of patient with physician and health care system factors. Our aim was to determine the rate of clinical inertia in treating diabetes in primary care and association of patient, physician, and health care setting factors with clinical inertia. MATERIAL AND METHODS: This was a national, multicenter, observational, cross-sectional study in primary care in Croatia. Each family physician (FP) provided professional data and collected clinical data on 15-25 type 2 diabetes (T2DM) patients. Clinical inertia was defined as a consultation in which treatment change based on glycated hemoglobin (HbA1c) levels was indicated but did not occur. RESULTS: A total of 449 FPs (response rate 89.8%) collected data on 10275 patients. Mean clinical inertia per FP was 55.6% (SD ±26.17) of consultations. All of the FPs were clinically inert with some patients, and 9% of the FPs were clinically inert with all patients. The main factors associated with clinical inertia were: higher percentage of HbA1c, oral anti-diabetic drug initiated by diabetologist, increased postprandial glycemia and total cholesterol, physical inactivity of patient, and administration of drugs other than oral antidiabetics. CONCLUSIONS: Clinical inertia in treating patients with T2DM is a serious problem. Patients with worse glycemic control and those whose therapy was initiated by a diabetologist experience more clinical inertia. More research on causes of clinical inertia in treating patients with T2DM should be conducted to help achieve more effective diabetes control.

Is a targeted and planned GP intervention effective in cardiovascular disease prevention? A randomized controlled trial.

BACKGROUND: The optimal intensity and duration of the intervention to achieve sustained risk reduction in patients at high and very high cardiovascular (CV) risk still need to be established. The aim of this study was to evaluate the impact of general practitioner's (GP's) systematic and planned intervention on total CV risk reduction and a change in individual CV risk factors. MATERIAL AND METHODS: This was a cluster-randomized trial (ISRCTN31857696) including 64 practices and 3245 patients aged ≥40. The participating GPs and their examinees were randomized into an intervention or to a control group (standard care). Intervention group practitioners followed up their examinees during 1, 3, 6, 12, and 18 months. The main outcome measures were change in proportion of patients with low, moderate, high, and very high CV risk, and change in individual CV risk factors from the first to the second registration. RESULTS: The proportion of patients with very high CV risk was lower in the intervention group, the same as of patients with high blood pressure, total and LDL cholesterol, and increased intake of alcohol. The mean systolic (-1.49 mmHg) and diastolic (-1.57 mmHg) blood pressure, triglycerides (-0.18 mmol/L), body mass index (-0.22), and waist (-0.4 cm) and hip circumference (-1.08 cm) was reduced significantly in the intervention group. There was no additional impact in the intervention group of other tested CV risk factors. CONCLUSIONS: Systematic and planned GP's intervention in CVD prevention reduces the number of patients with very high total CV risk and influences a change in lifestyle habits.

Lifestyle intervention in general practice for physical activity, smoking, alcohol consumption and diet in elderly: a randomized controlled trial.

The purpose of the study was to compare the effectiveness of programmed and intensified intervention on lifestyle changes, including physical activity, cigarette smoking, alcohol consumption and diet, in patients aged ≥ 65 with the usual care of general practitioners (GP). In this multicenter randomized controlled trial, 738 patients aged ≥ 65 were randomly assigned to receive intensified intervention (N = 371) or usual care (N = 367) of a GP for lifestyle changes, with 18-month follow-up. The main outcome measures were physical activity, smoking, alcohol consumption and diet. The study was conducted in 59 general practices in Croatia between May 2008 and May 2010. The patients' mean age was 72.3 ± 5.2 years. Significant diet correction was achieved after 18-month follow-up in the intervention group, comparing to controls. More patients followed strictly Mediterranean diet and consumed healthy foods more frequently. There was no significant difference between the groups in physical activity, tobacco smoking and alcohol consumption or diet after the intervention. In conclusion, an 18-month intensified GP's intervention had limited effect on lifestyle habits. GP intervention managed to change dietary habits in elderly population, which is encouraging since elderly population is very resistant regarding lifestyle habit changes. Clinical trial registration number. ISRCTN31857696.

Diversity of metabolic syndrome criteria in association with cardiovascular diseases--a family medicine-based investigation.

BACKGROUND: This study compared the association between the 3 definitions of metabolic syndrome (MetS) suggested by the World Health Organization (WHO), National Cholesterol Education Programme (NCEP ATP III), and International Diabetes Federation (IDF), and the risk of cardiovascular diseases (CVD) and shows the prevalence and characteristics of persons with MetS in continental vs. coastal regions and rural vs. urban residence in Croatia. MATERIAL/METHODS: A prospective multicenter study was conducted on 3245 participants≥40 years, who visited general practices from May to July 2008 for any reason. This was a cross-sectional study of the Cardiovascular Risk and Intervention Study in Croatia-family medicine project (ISRCTN31857696). RESULTS: All analyzed MetS definitions showed an association with CVD, but the strongest was shown by NCEP ATP III; coronary disease OR 2.48 (95% CI 1.80-3.82), cerebrovascular disease OR 2.14 (1.19-3.86), and peripheral artery disease OR 1.55 (1.04-2.32), especially for age and male sex. According to the NCEP ATP III (IDF), the prevalence was 38.7% (45.9%) [15.9% (18.6%) in men, and 22.7% (27.3%) in women, and 28.4% (33.9%) in the continental region, 10.2% (10.9%) in the coastal region, 26.2% (31.5%) in urban areas, and 12.4% (14.4%) in rural areas. Older age, male sex, and residence in the continental area were positively associated with MetS diagnosis according to NCEP ATP III, and current smoking and Mediterranean diet adherence have protective effects. CONCLUSIONS: The NCEP ATP III definition seems to provide the strongest association with CVD and should therefore be preferred for use in this population.

Association between hyperuricemia, prediabetes, and prehypertension in the Croatian adult population--a cross-sectional study.

BACKGROUND: The association between hyperuricemia, hypertension, and diabetes has been proved to have strong association with the risk for cardiovascular diseases, but it is not clear whether hyperuricemia is related to the early stages of hypertension and diabetes. Therefore, in this study we investigated the association between hyperuricemia, prediabetes, and prehypertension in Croatian adults, as well as that between purine-rich diet and hyperuricemia, prediabetes, or prehypertension. METHODS: A stratified random representative sample of 64 general practitioners (GP) was selected. Each GP systematically chose participants aged ≥ 40 year (up to 55 subjects) . Recruitment occurred between May and September 2008. The medical history, anthropometric, and laboratory measures were obtained for each participant. RESULTS: 59 physicians agreed to participate and recruited 2485 subjects (response rate 77%; average age (± standard deviation) 59.2 ± 10.6; 61.9% women. In bivariate analysis we found a positive association between hyperuricemia and prediabetes (OR 1.66, 95% CI 1.09-2.53), but not for prehypertension (OR 1.68, 95% CI 0.76-3.72). After controlling for known confounders for cardiovascular disease (age, gender, body mass index, alcohol intake, diet, physical activity, waist to hip ratio, total cholesterol, low density lipoprotein, high density lipoprotein, and triglycerides), in multivariate analysis HU ceased to be an independent predictor(OR 1.33, CI 0.98-1.82, p = 0.069) for PreDM. An association between purine-rich food and hyperuricemia was found (p<0.001) and also for prediabetes (p=0.002), but not for prehypertension (p=0.41). The prevalence of hyperuricemia was 10.7% (15.4% male, 7.8% female), 32.5% for prediabetes (35.4% male, 30.8% female), and 26.6% for prehypertension (27.2% male, 26.2% female). CONCLUSION: Hyperuricemia seems to be associated with prediabetes but not with prehypertension. Both, hyperuricemia and prediabetes were associated with purine-rich food and patients need to be advised on appropriate diet. TRIAL REGISTRATION: Current Controlled Trials ISRCTN31857696.

How well do anthropometric indices correlate with cardiovascular risk factors? A cross-sectional study in Croati.

BACKGROUND: Usefulness of anthropometric indices (AI) as predictors of CV risk is unclear and remains controversial. MATERIAL/METHODS: To evaluate the correlation between AI and CV risk factors in the Croatian adult population and to observe possible differences between coastal and inland regions and urban and rural settlements. CRISIC-fm (ISRCTN31857696) is a prospective, randomized cohort study conducted in GP (general practitioner) practices in Croatia. Between May and July 2008, 59 GPs each recruited 55 participants aged ≥ 40 years, who visited a practice for any reason. Height, weight, waist and hip circumference and blood pressure were measured. Blood samples were analyzed in accredited laboratories. RESULTS: Out of 2467 participants (61.9% women, 38.1% men), 36.3% were obese, with fewer in coastal than inland areas. More obese people were in rural areas. Logistic regression showed BMI was the most important predictor of hypertension, diabetes and dyslipidemia in both regions (except for diabetes in the coastal area), and for urban and rural settlements (except for diabetes in rural areas). WtHR was a significant predictor for hypertension and dyslipidemia in the coastal (but only for hypertension in the inland area), and in urban settlements (in rural only for hypertension). None of the AI showed significant correlation with total CV risk, but WC and BMI did with stroke risk. Receiver operating curve (ROC) analyses showed that WtHR was a better predictor than all other AI for hypertension and dyslipidemia. CONCLUSIONS: Results encourage the use of BMI and WtHR as important tools in predicting CV risk in GP's practice.

Continental-Mediterranean and rural-urban differences in cardiovascular risk factors in Croatian population.

AIM: To compare the distribution of cardiovascular disease (CVD) factors between continental and Mediterranean areas and urban and rural areas of Croatia, as well as to investigate the differences in achieving treatment goals by the general practitioners (GP) in different settings. METHODS: A multicenter prospective study was performed on 2467 participants of both sexes ≥40 years old, who visited for any reason 59 general practices covering the whole area of Croatia (May-July 2008). The study was a part of the Cardiovascular Risk and Intervention Study in Croatia-family medicine (CRISIC-fm) study. Patients were interviewed using a 140-item questionnaire on socio-demographics and CVD risk factors. We measured body mass index (BMI) and waist circumference and determined biochemical variables including blood pressure, total, high-density lipoprotein-, and low-density lipoprotein-cholesterol, triglycerides, glycemia, and uric acid. RESULTS: Participants from continental rural areas had significantly higher systolic and diastolic blood pressure (P<0.001), obesity (P=0.001), increased waist circumference (P<0.001), and more intense physical activity (P=0.020). Participants from coastal rural areas had higher HDL-cholesterol, participants from continental rural and coastal urban areas had higher LDL-cholesterol, and participants from rural continental had significantly higher BMI and waist circumference. CONCLUSION: Prevalence of CVD risk factors in Croatian population is high. Greater burden of risk factors in continental region and rural areas may be partly explained by lifestyle differences.

[Diet as a cardiovascular risk factor in family medicine]. / Prehrana kao rizicni cimbenik kardiovaskularnih bolesti u obiteljskoj medicini.

Although Mediterranean country by its geographic position, according to cardiovascular mortality (CVM) rate, Croatia belongs to Central-East European countries with high CV mortality. Prevention by changing nutritional habits is population (public health programmes) or individually targeted. General practitioner (GP) provides care for whole person in its environment and GP's team plays a key role in achieving lifestyle changes. GPs intervention is individually/group/family targeted by counselling or using printed leaflets (individual manner, organized programmes). Adherence to lifestyle changes is not an easy task; it is higher when recommendations are simple and part of individually tailored programme with follow- ups included. Motivation is essential, but obstacles to implementation (by patient and GPs) are also important. Nutritional intervention influences most important CV risk factors: cholesterol level, blood pressure (BP), diabetes. Restriction in total energy intake with additional nutritional interventions is recommended. Lower animal fat intake causes CVM reduction by 12%, taking additional serving of fruit/day by 7% and vegetables by 4%. Restriction of dietary salt intake (3 g/day) lowers BP by 2-8 mm Hg, CVM by 16%. Nutritional intervention gains CHD and stroke redact in healthy adults (12%, 11% respectively). Respecting individual lifestyle and nutrition, GP should suggest both home cooking and careful food declaration reading and discourage salt adding. Recommended daily salt intake is < or =6 g. In BP lowering, salt intake restriction (10-12 to 5-6 g/day) is as efficient as taking one antihypertensive drug. Lifestyle intervention targeting nutritional habits and pharmacotherapy is the most efficient combination in CV risk factors control.

[Referring process in family medicine--contribution assessment]. / Upucivanje iz ordinacije obiteljskog lijecnika--procjena doprinosa.

AIMS: The aim of the study was to follow and analyze patient referrals from general practice (GP) to diagnostic procedures and specialist consultations. Data on the kinds of diagnostic procedures, specialist consultations and requests for referrals were collected. Specific aim was to assess the contribution of referring for definitive diagnosis and to compare the frequency and contribution of first and repeat consultations. METHODS: This prospective study was conducted in the course of one month at six GP practices (three urban and one rural practice in inland area, and one urban and one rural practice in coastal area of Croatia). Patient sociodemographic data (age and sex), referral request (by patient, GP, GP and specialist in agreement, specialist only) and kind of visit (first, follow-up) were collected. The contribution of referrals was assessed by GPs using modified Likert's scale (1-markedly significant, 2-significant, 3-undetermined, 4-small and 5-insignificant). On comparison of frequencies chi square test was used. Statistical analyses were done by use of licensed software (SAS Institute Inc, Cary, NC, USA). RESULTS: During one month, 1815 patients were referred, 979 for diagnostic procedures and 836 for specialist consultation (mean age 55.25 +/- 19.70; male 56.30 +/- 19.10, female 54.50 +/- 20.30). Most frequent diagnostic procedures requested were biochemical laboratory in primary health care setting (n = 331; 33.41%) and secondary care (n =1 18; 12.05%), basic radiology (n=106; 10.83%), ultrasonography (n=87; 8.80%) and microbiological laboratory (n = 68; 6.95%). The contribution of diagnostic procedures was mostly assessed as significant (54.84%). When GP and specialist indicated diagnostic procedure concordantly, its contribution was mostly assessed as significant (61.90%) and markedly significant (10.12%). Specialist consultations were used as follows: physical medicine in 131 (19%), surgeon in 90 (13%) and psychiatrist in 69 (10%) patients from inland area, cardiologist in 53 (37%), psychiatrist in 17 (12%) and oncologist in 12 (8%) patients from coastal area. Both in rural and urban practices in inland and coastal area surgeon consultations were assessed as markedly significant. Urban GPs assessed the contribution of first and follow-up check ups as undetermined or small more often than rural GPs (first check ups Xchi =21.66; P<0.0001; follow-up check ups chi2 = 196.38; P < 0.0001). Rural GPs assessed the contribution of first check ups more often as undetermined or small than significant (chi2 = 12.02; P = 0.0005), with the same tendency recorded for follow-up check ups (Xchi =32.01; P < 0.0001). CONCLUSION: GP should maintain the gatekeeping role to assure good quality of care and rationality in using available resources. Cooperation between GPs and specialists is essential to achieve good quality of care. GPs should restore role in indicating follow-up check ups.

Treatment of hypertension by general practitioners and antihypertensive drugs expenditure in an urban environment.

Aim of our study was to determine the treatment habits of hypertension by general practitioners (GPs) as well as the monthly costs of prescribed antihypertensive drugs and their share in the total prescription drug expenditure approved by the Croatian Institute for Health Insurance (CIHI), the compulsory health insurance system. The study was performed in six GPs offices in Zagreb, serving 8,866 patients, in December 2005. The monthly costs of antihypertensive drugs prescribed by the GPs was obtained by summarizing the prices of all antihypertensive drugs prescribed in one month and then comparing the sum with total monthly prescription drug expenditure approved by the CIHI. The type and dosage of prescribed antihypertensive drugs were also analyzed. Hypertension was diagnosed in 2,342 (26.4%) patients. The monthly costs of prescribed antihypertensive drugs accounted for 52.33% of the total amount approved for medications by the CIHI. 945 (40.0%) hypertensive patients were taking antihypertensive monotherapy. The most frequently prescribed drugs as monotherapy were ACE inhibitors (38.3%), calcium-channel blockers (26.7%), beta blockers (18.6%), and diuretics (10.3%). a antagonists (3.6%). Angiotensin receptor blockers (2.5%) were rarely prescribed. As combination therapy, ACE inhibitors and diuretics (30.4%) were most frequently used. More than 50% of the funds allocated to GPs for medications were spent for the treatment of only one disease. The most used antihypertensive drugs were ACE inhibitors.

Statin prescription by Croatian family doctors lack of systematic proactive approach to cardiovascular disease prevention.

The aim of this study was to investigate statin prescription by family doctors (GP) in primary (PP) and secondary (SP) prevention of cardiovascular diseases (CVDs). Patients' socio-demographic data, total cholesterol (TC) and LDL-cholesterol (LDL-C) thresholds for statin prescription, indications, data on GP and practices were registered. Statins were prescribed in 11.2% enlisted patients (64.11% PP, 35.88% SP), mostly aged 70+. In PP, thresholds were TC 6.2 +/- 1.09 mmol/L, LDL-C 3.6 mmol/L, in SP 5.4 +/- 1.26 mmol/L, 2,7 mmol/L, respectively. Most frequently prescribed statin in PP was 10 mg atorvastatin (49.28%), in SP it was 20 mg simvastatin (48.36%). Participating GPs were women, aged 39 +/ 5.49, working for 13 +/- 6 years, the average number of enlisted patients per GP 1562 +/- 299. There was statistically significant difference in statin prescription in PP (chi2 = 752.9; p < 0.001) and SP (chi2 = 64; p < 0.001). Statin prescription in PP is due to pharmaceutical marketing and lack of independent continuing medical education. The fact that statins are most frequently prescribed in patients aged 70+ (35.28% in PP 49.35% SP) reveals lack of preventive proactive CVDs approach in younger age groups, which is concerning.

[Who works in the prevention and early detection of benign prostatic hyperplasia and prostate cancer in Croatia?]. / Tko provodi rano otkrivanje benigne hiperplazije prostate i karcinoma prostate u Hrvatskoj?

INTRODUCTION: Benign prostatic hyperplasia (BPH) is the most common benign tumor and prostate cancer is the second most common cause of cancer death in Croatia. The number of new cases of prostate cancer is expected to increase by more than half in the next 25 years. Due to limited evidence, there are different opinions about the usefulness of screening for BPH and prostate cancer. OBJECTIVES: The aim of this study was to investigate the screening activities for BPH and prostate cancer in family practice in Croatia. METHODS: The survey included all male patients over age of 40 (n = 614) attending two GP offices (one of them specialist in family medicine) during one year, 2003. Data on the risk factors for BPH and prostate cancer (positive family history, urinary problems), IPSS questionnaire, digitorectal examination, urine test, creatinine and prostate specific antigen blood test were collected from their medical records. chi2-test was used on statistical analysis. RESULTS: The results of the survey showed 55 (9%) patients to be diagnosed with BPH and 22 (3.6%) with prostate cancer; 56 (9.1%) patients were asymptomsatic. Digitorectal examination was not performed at either GP office, and 481 (78.3%) patients received no information about lower urinary tract symptoms. There were no differences in screening for BPH and prostate cancer between the specialist of family medicine and physician. CONCLUSIONS: In primary care, physicians rarely work on the prevention and early detection of BPH and prostate cancer, irrespective of their education level. There is the need of a common protocol of BHP and prostatic cancer prevention for urologists and general practitioners, since a comprehensive approach is lacking in Croatia.

Drug therapy of cardiovascular risk factors: guidelines versus reality in primary health care service.

AIM: To determine the monthly costs of prescription drugs for the treatment of hypertension, hypercholesterolemia, and diabetes mellitus and their share in the total prescription drugs expenditures allowed by the Croatian Institute for Health Insurance. METHODOLOGY: Hypertension, hypercholesterolemia, and diabetes mellitus were diagnosed in 4,916 patients in three general practitioner (GP) offices in the Zagreb area in January 2005. The monthly cost of medications prescribed by the GPs for the treatment of these three diseases was obtained by summarizing the prices of all antihypertensive, lipid-lowering, and antidiabetic drugs prescribed in one month. The monthly medication costs for each disease separately and all three diseases together were compared with the total prescription drug expenditures approved by the Croatian Institute for Health Insurance. RESULTS: Hypertension was diagnosed in 1,112 (22.6%), hypercholesterolemia in 324 (6.5%), and diabetes mellitus in 359 (7.3%) patients. Monthly cost of all medications prescribed for these three diseases accounted for 81.2% of the total amount approved for medications by the Croatian Institute for Health Insurance. Antihypertensive drugs accounted for 51.1%, antidiabetic drugs for 11.7% for, and lipid-lowering treatment for 18.4%. The medications were prescribed most often to patients older than 65 years (93.6%). CONCLUSION: GPs are strongly obligated by the annual contract with the Croatian Institute for Health Insurance to keep the medication expenses within the approved amount. However, the approved amount is spent mostly on the drug treatment of hypertension, hypercholesterolemia, and diabetes mellitus as the main cardiovascular risk factors.