Appropriateness of magnetic resonance imaging requested by primary care physicians for patients with knee pain.

OBJECTIVE: To evaluate the appropriateness of magnetic resonance imaging (MRI) of the knee requested by primary care physicians. DESIGN: Retrospective observational study. SETTING: Six primary care centres in the Elche Department of Health of the Valencian Community, Spain. PARTICIPANTS: Three hundred patients with knee pain who were prescribed MRI. MAIN OUTCOME MEASURES: Data were collected from the electronic clinical history, which allowed us to assess the appropriateness and inappropriateness of the MRI requests for the knee based on the American College of Radiology (ACR) criteria. A multivariate logistic regression model was used to identify factors associated with an inappropriate request. RESULTS: About 45% (41-49%) of knee MRI prescriptions were assessed as inappropriate. The frequency was higher in female patients (odds ratio, OR = 1.96; P = 0.03). A history of knee trauma and urgent use of MRI were associated with a lower frequency of inappropriate requests (OR = 0.14, P < 0.001 and OR = 0.32, P = 0.03, respectively). In 82% of cases, the request for MRI was deemed inappropriate because it was used as the initial imaging test. The availability of a previous radiograph of the knee significantly reduced the rate of inappropriate requests (OR = 0.05, P < 0.001); only 47% of the patients had a previous radiograph. CONCLUSIONS: The percentage of inappropriate knee MRI prescriptions is high. Protocols should be put in place to improve the appropriateness of MRI requests by promoting understanding of the appropriate use of MRI among primary care physicians.

Incumplimiento de los pacientes con las citas en atención primaria / Failure to patients with appointments in primary care

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Concordancia entre sistemas de estratificación e identificación de pacientes crónicos complejos en Atención Primaria / Concordance between stratification systems and identification of patients with multiple chronic diseases in Primary Care

Objetivo. Conocer la prevalencia de pacientes crónicos complejos en el ámbito de Atención Primaria utilizando los criterios de pluripatología y los Clinical Risk Groups y el grado de concordancia entre estos 2 sistemas de identificación de los pacientes que precisan gestión de caso. Material y método. Estudio observacional transversal de 240 pacientes, seleccionados por muestreo aleatorio de 16 cupos asistenciales de 2 centros de salud de Atención Primaria de un área sanitaria. Solicitado consentimiento informado para acceder a su historia clínica electrónica con fines de investigación. Se registró la edad, el sexo, el estado de salud según los Clinical Risk Groups, nivel de gravedad, los criterios de pluripatológico e índice de Charlson por su médico durante la práctica clínica. Se excluyeron 3 pacientes por datos incompletos. Resultados. La prevalencia de pacientes pluripatológicos, siguiendo los criterios del Ministerio de Sanidad entre los demandantes, fue del 4,1% (IC 95% 2,1-7,3). La frecuencia de pacientes con Clinical Risk Groups de alto riesgo denominados G3 en la estrategia de cronicidad de la Comunidad Valenciana fue del 7,5% (IC 95% 4,7-11,7), que sumó los pacientes estado de salud 6 con nivel de complejidad 5 y 6 y los estados de salud 7, 8 y 9. La concordancia entre ambas clasificaciones fue baja con un índice kappa 0,17 (IC 95% 0-0,5). Conclusiones. Las prevalencias no difirieron significativamente de lo esperado y la concordancia entre ambas estratificaciones fue muy débil, no seleccionando a los mismos pacientes de alta complejidad para gestión de casos (AU)

Objective. To determine the prevalence of patients with multiple chronic diseases in Primary Care using the multiple morbidity criteria and Clinical Risk Groups, and the agreement in identifying high-risk patients that require case management with both methods. Material and method. A cross-sectional study was conducted on 240 patients, selected by random sampling of 16 care quotas from two Primary Health Care centres of a health area. Informed consent was obtained to access their electronic medical records for the study, and a record was made of age, sex, health status of Clinical Risk Groups, severity, multiple morbidity criteria, and Charlson index by physicians during clinical practice. Three patients were excluded due to incomplete data. Results. The prevalence of patients with multiple chronic diseases following the criteria of the Ministry of Health among users was 4.11 (95% CI; 2.13-7.30). The frequency of patients with high risk Clinical Risk Groups (G3) in the chronicity strategy of Valencian Community was 7.59 (95% CI; 4.70-11.70), which includes patients with health status 6 and complexity level 5-6, and health status 7, 8, and 9. Agreement between the two classifications was low, with a kappa index 0.17 (95% CI; 0-0.5). Conclusions. The prevalence did not differ significantly from that expected, and the agreement between the two stratifications was very weak, not selecting the same patients for highly complex case management (AU)

[Concordance between stratification systems and identification of patients with multiple chronic diseases in Primary Care]. / Concordancia entre sistemas de estratificación e identificación de pacientes crónicos complejos en Atención Primaria.

OBJECTIVE: To determine the prevalence of patients with multiple chronic diseases in Primary Care using the multiple morbidity criteria and Clinical Risk Groups, and the agreement in identifying high-risk patients that require case management with both methods. MATERIAL AND METHOD: A cross-sectional study was conducted on 240 patients, selected by random sampling of 16 care quotas from two Primary Health Care centres of a health area. Informed consent was obtained to access their electronic medical records for the study, and a record was made of age, sex, health status of Clinical Risk Groups, severity, multiple morbidity criteria, and Charlson index by physicians during clinical practice. Three patients were excluded due to incomplete data. RESULTS: The prevalence of patients with multiple chronic diseases following the criteria of the Ministry of Health among users was 4.11 (95% CI; 2.13-7.30). The frequency of patients with high risk Clinical Risk Groups (G3) in the chronicity strategy of Valencian Community was 7.59 (95% CI; 4.70-11.70), which includes patients with health status 6 and complexity level 5-6, and health status 7, 8, and 9. Agreement between the two classifications was low, with a kappa index 0.17 (95% CI; 0-0.5) CONCLUSIONS: The prevalence did not differ significantly from that expected, and the agreement between the two stratifications was very weak, not selecting the same patients for highly complex case management.

[Diagnostic consistency between primary care physicians and rheumatologists]. / Concordancia diagnóstica entre los médicos de atención primaria y los reumatólogos.

OBJECTIVE: To assess the concordance between the diagnoses on referral from Primary Care to the Rheumatology Clinic and the final diagnoses made by the Rheumatologist. DESIGN: Crossover study. SETTING: Rheumatology clinic in a specialist centre. PATIENTS: The study covered the first 308 patients referred consecutively from Primary Care by Family or General practitioners after the opening of the clinic in 1989. INTERVENTION: A form for referring the patient to the Rheumatologist and filling in the basic data was composed. The referring doctor was also asked to classify the patient in one of five possible diagnostic categories. These diagnoses were compared with the opinion of the Rheumatologist. MEASUREMENTS AND RESULTS: The Family Doctor referred 105 patients and the General Practitioner, 203. The concordance between diagnoses as measured by the Kappa index was 0.61 (C.I. 0.81-0.41) for Family Doctors and 0.38 (C.I. 0.23-0.53) for General Practitioners. CONCLUSIONS: The concordance of diagnoses between Family Doctors and Rheumatologists is good, whereas it was only regular/moderate for General Practitioners, which seems to indicate a superior objective training of Family Doctors in the diagnosis of these patients.