Changes in consultation mode during different phases of the COVID-19 pandemic in Croatian family medicine: a cross-sectional study.

OBJECTIVES: To describe the changes in the type, length and reasons for consultations in primary healthcare during the COVID-19 pandemic in Croatia. This study aimed to test a hypothesis regarding the increased workload of general practitioners (GPs) by introducing more virtual consultations (VCs). DESIGN: The study design was cross-sectional and comprised two phases: retrospective and prospective. The retrospective phase included data from April, May and June of 2019, 2020 and 2021, and the prospective phase included data from 2 weeks in June 2021. Additionally, the number, length and reasons for face-to-face consultations (FTFC), VCs and telephone consultations (TCs) with nurses were collected. SETTING AND PARTICIPANTS: Overall, 6 GPs from different regions in Croatia with 10 125 enlisted patients. MAIN OUTCOMES MEASURES: The retrospective phase compared data for consultation types obtained from electronic medical records. The prospective phase collected the number, length and reasons for FTFCs, VCs and TCs with nurses. RESULTS: FTFCs decreased from 58.1% of the total number of visits in 2019 to 41.2% in 2020, while VC increased from 41.9% in 2019 to 58.8% in 2020. Furthermore, an eightfold increase in email consultations was recorded. The average lengths of an FTFC and TC were 7.13±3.38 and 4.01±2.09 min, respectively; FTFCs were significantly longer than TCs (t=7.038, p<0.0001). There was an increase in the total workload (9.4%) in 2021 compared with 2019. CONCLUSION: Croatian GPs faced changes in work organisation along with increased workload during the pandemic. Despite the shortening of time in FTFCs, the workload has increased due to the increase in VCs. An appropriate legal framework should be implemented for this new form of consultation. Future research is needed to address the impact of these changes on healthcare quality.

Lifestyle behaviours in patients with established cardiovascular diseases: a European observational study.

BACKGROUND: Patients who have experienced a cardiovascular clinical event such as a myocardial infarction or stroke qualify for intensive risk factor evaluation and management. The aim of this study is to explore lifestyle changes as well as the achievement of targets for risk factors in patients with established cardiovascular disease. METHODS: Cross-sectional study conducted in primary care practices. The study was carried out in six European countries (Croatia, France, Portugal, Slovenia, Spain and Turkey). Patients with established cardiovascular disease (coronary heart disease and stroke) attended in primary care were selected and assessed from January to June 2016. Patients were recruited and assessed at the practice by research assistants between 6 months and 3 years after the event. Statistical comparisons were done with the unpaired two-sided Student's t-test for continuous variables and Chi-square test for categorical variables. RESULTS: Nine hundred and seventy-three patients (32.4% females) were assessed. About 14% of them were smokers, 32% were physically inactive, and 30% had nutritionally poor eating behaviours. LDL cholesterol target value below 70 mg/dl was achieved in about 23% of patients, and in general, women were less cardio-protected by drugs than men. CONCLUSIONS: Many patients with established cardiovascular disease who attended in general practice still fail to achieve the lifestyle, risk factor, and therapeutic targets set by European guidelines. These results are relevant to general practitioners because these patients have a high risk of subsequent cardiovascular events, including MI, stroke, and death.

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.

[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.