KEYNOTE LECTURESMultimorbidity: hype and hope for preventive activities in patient centred general practice
Prof José M. Valderas
Health Services and Policy Research, University of Exeter Medical School, Exeter, United Kingdom. E-mail: [email protected]
The last few years have seen the emergence of a huge interest in multi-morbidity. This is in part surprising, given that this is the bread and butter of General Practice and Primary Care. However, at the same time it is an extraordinarily under- researched area. The pioneering work of Alvan Feinstein in the early seventies and subsequent work by Mary Charlson and others in the late eighties, the foundations of research in this area were laid. More recently, the late Barbara Starfield inspired advancement of research in this area by underscoring the tensions between an increasing focus on the single disease model in General Practice, perhaps best exemplified by the recognition of figure of General Practitioners with a special interest GPwSI) by the Royal College of General Practitioners in the United Kingdom and the introduction of the disease management oriented incentives schemes in General Practice and Primary Care elsewhere (with a strong focus on primary and secondary prevention), and the core values of the discipline, in particular that of providing whole person and patient centred care.
Multimorbidity provides in this respect both a useful concept and a valid approach for clinical practice and research in General Practice in general and prevention in particular. It is highly prevalent, both amongst the elderly, but also in much younger and deprived populations. It has a significant impact on health and health care, but we still know little about effective interventions in General Practice. There is a need for research in this area that specifically targets groups of patients with multimorbidity, but we also need to develop in parallel methods that allow us to make best of currently available evidence based on research with a single disease focus, while advancing our knowledge of how best to support patients in prioritising and making decisions in the face and competing and changing needs.
The problems posed by multimorbidity in daily practice are powerful reminders that General Practice cannot be reduced to the routine and standardized application of clinical models that are perfectly well suited to other settings with very different aims, but that fundamentally fail to serve the key functions of General Practice.
The Family Medicine model in the Spanish Health Care System
Dr. Domingo Orozco-Beltran
Cathedra of Family Medicine, University Miguel Hernandez, Spain. E-mail: [email protected]
The Spanish National Health Service (SNHS) is the agglomeration of public health services in Spain and it was established in 1986. The main characteristics of the SNHS are: a) Extension of services to the entire population; b) Adequate organization to provide comprehensive health care, including promotion of health, prevention of disease, treatment and rehabilitation; c) Coordination and integration of all public health resources into a single system; d) Financing of the obligations derived from this law will be met by resources of public administration, contributions and fees for the provision of certain services; and e) The provision of a comprehensive health care, seeking high standards, properly evaluated and controlled.
Management of health services has been transferred to the Spanish regions. Every region has its own health service and its own ministry of health. All of them are included in the Interterritorial Council of the SNHS to give cohesion to the system. The system is organized administratively in Health Areas (Areas de Salud) who attend around 250 000 inhabitants and have 10 health centres and one hospital. Every Health Centre attends around 25 000 inhabitants in a Basic Health Zone. Therefore, every Health Area has 10 Basic Health Zones. Depending of the characteristics of the population, a Health Zone can vary from 5 000 to 25 000 habitants. Primary and Secondary (outpatient, hospital) care are accessible free of charge for all population.
Primary Care (PC) is the basic level of patient care. Primary care includes health promotion, health education, and prevention of illness, health care, maintenance and recuperation of health, as well as physical rehabilitation and social work. Primary health care includes service provided either on-demand, scheduled, or urgently, both in the clinic as well as in the patient’s home. Secondary Care (SC) is provided at the request of primary care physicians, as the patient cannot go directly to the specialists without a previous inform from PCPs. The PC team is formed by different health professionals: a typical health centre attends 25 000 inhabitants and has 10 family physicians, 10 nurses, 4 paediatricians, 2 paediatric nurses, 1 social worker and administrative personnel. Some of them have additional services as physiotherapy, mental health, gynaecology or family planning.
Citizens’ access to health services is facilitated by use of an individual health card, as the administrative document that accredits its holder and provides certain basic data. All the records from PC and SC are electronic and the information generated in the system for each patient is linked to a unique number. This is very important for research as there are electronic records for both primary and secondary care and it is possible to have all information from the health process: diagnosis, prescription, visits, from primary care, emergency room, or hospital care.
Some examples of research in primary care using these electronic records are pointed out making possible to design whole population studies in contrast to randomized clinical trials. Finally, a whole perspective from research in primary care is done looking to difficulties to really identify all the research coming from primary care.
Primary Care Research in Spain: strengths and weaknesses
Bonaventura Bolíbar
Scientific director of the IDIAP Jordi Gol, Director of the redIAPP network. E-mail: [email protected]
There is a large variety of organisational frameworks of research in primary care according to the characteristics of each country. Some key conditions affect the organisation and success of primary care research in Spain:
Development of an own area of knowledge: there is a strong scientific association of GP (semFYC) - with its own indexed journal (Atención Primaria) -, which is leading the area of knowledge development; the role of the universities is inexistent.
Structural conditions regarding the position of the General Practitioner in the health care system: GPs have a circumscribed population and a role as gatekeeper. Interesting population-based databases from Electronic Health Records.
Conditions regarding the integration of Primary Care in the academic institutions: No integration in Spain. There are no formal chairs and departments of Primary Care at the Spanish universities. Specialized training of GP integrated to Primary Care but out of the Universities.
Conditions regarding concrete research opportunities for Primary Care (creation of organized structures): little presence of primary care in the Spanish organisation framework of health research with a bias towards basic research and hospital research; poor support and resources devoted to primary care research; non existence of dual (clinical and research) contracts.
Besides these limitations of the present situation, two successful examples will be described more in depth: A specific research institute on Primary Care (the IDIAP Jordi Gol), and a primary care research network on health promotion and disease prevention (the redIAPP). From these experiences, some of their strengths will be highlighted: creation of competitive groups, creation of support platforms and services, coordination with other research organisations to promote a translational research.
Some challenges for the Spanish Primary Care research are discussed:
Human resources devoted to PC research and opportunities for part time research work
How to obtain more financial support
Participation in the financing bodies designing the characteristics of public calls and participating in the evaluation of proposals
Electronic clinical records and population based databases
Participation in European organisations and European projects
Innovation in PC
PRIZE WINNING POSTEREffectiveness of an alert in the primary care electronic medical record system to promote participation in a population-based colorectal cancer screening programme
Carolina Guiriguet, Carme Vela, Irene Rivero, Mercedes Vilarrubí, Andrea Buron, Laura Muñoz
Primary Care, Catalan Health Institute, Santa Coloma de Gramenet, Spain. E-mail: [email protected]
Background: Population participation rates in colorectal cancer screening programmes (CRCSP) in Spain remain below recommended European targets, despite being a quality indicator for ensuring their effectiveness. Reminders on electronic medical record (EMR) have been identified as a low-cost and high-reach strategy to increase participation in preventive activities although controversy exists when applied into CRCSP.
Research Question: Can an alert reminder in primary care EMR increase participation in an immunological faecal occult blood (iFOBT) test population-based CRCSP?
Method: Randomised controlled trial comparing electronic alerts to health professionals in EMR to promote CRCSP to usual care. Participants were all men and women aged between 50–69 years invited to participate in the first round of an iFOBT population-based CRCSP (n = 41 042), and all their physicians and nurses (n = 244), allocated to the eleven primary care centres of the study. The randomisation unit was the physician (n = 130). During one year, an alert for health professionals to promote CRCSP during a medical appointment was set up in intervention group patients’ EMR. The main outcome was the screening status at the end of the study. An intention-to-treat analysis was performed.
Results: In total, 19 423 patients in the control and 21 619 in the intervention group participated. CRCSP uptake was 44.1% in the intervention and 42.2% in the control group (P < 0.001); these differences were high in men, age-group over 60 years, and patients who attended primary care centres more than thrice. Adjusting for age, sex, socioeconomic deprivation index, centre, smoking, alcohol and body mass index patients with the electronic alert had a higher participation (OR = 1.11; IC95%: [1.04 – 1.18]). Health professional's response rate to alerts was 21%. In the intervention group 57.6% of patients with responded alert, participated in the CRCSP compared with 41% of those without it (OR = 1.98; IC95%: [1.84 – 2.12]).
Conclusion: An electronic alert improves participation in an iFOBT test population-based CRCSP, especially among patients with lower uptake rates.
THEME PRESENTATIONS ON PREVENTION AND HEALTH PROMOTIONPromoting health and well-being for older people in general practice: the feasibility of a new system for primary care
Kate Walters, Kalpa Kharicha, Claire Goodman, Melanie Handley, Jill Manthorpe, Mima Cattan, Steve Morris, Steve Iliffe
Primary Care & Population Health, University College London (UCL), Hampstead, London, United Kingdom. E-mail: [email protected]
Background: Population approaches to promote health and well-being for older people in primary care are needed.
Objective: Assess feasibility, costs and potential impact of the modified ‘Multi-dimensional Risk Appraisal in Older people’ (MRAO) system in routine primary care.
Method: Study design: Feasibility study, mixed methods evaluation. Setting: Five general practices in urban and semi-rural areas in East/South East England. Participants: Random sample of people aged 65 + years. Intervention: MRAO software analysed responses to health, lifestyle, social and environmental questions, then gave tailored advice for participants about services, behaviour change and local resources. Older people with new/complex problems were followed-up. Professionals debated the value of data about needs. Evaluation: 1) Quantitative: Feasibility (uptake, attrition, process); well-being (Warwick-Edinburgh Mental Well-being Scale), needs/health risks, lifestyle, quality of life (SF-12), service use and costs at baseline and 6 months follow-up.
2) Qualitative: Thematic analysis of 52 in-depth interviews and 4 focus groups with professionals and older people.
Results: In total, 454 (29%) older people responded: median age 73.2 years; 53% female; 271/454 (59.7%) had no post-16 education. Compared to UK Census 2011 data, participants were younger, more were owner-occupiers and fewer were from ethnic minority groups.
Needs/problems identified at baseline included: pain (70.3%), low physical activity levels (46.9%), deteriorating mobility (49.5%), falls (26.7%), urinary incontinence (25.2%), vision (24.2%), hearing (26.8%), depression (15.7%), impaired memory (9.9%), social isolation (10.2%) and loneliness (7.0%). Well-being increased, quality of life and service use did not change over 6 months, and intervention costs were low. Qualitative analysis suggests the process was feasible to implement and valued for identifying previously unknown needs. Participation encouraged reflection in older people, though with less reported actual behaviour change.
Conclusion: The MRAO system is feasible to implement in primary care, however, participation rates are low. Impact on changing behaviour needs to be determined.
Attitudes of elderly people towards preventive consultations in primary care
Suzanne A. Ligthart, Karin D. M. van den Eerenbeemt, A. Jeanette Pols, Eric P. Moll van Charante
Dept. General Practice, Academic Medical Center (AMC), Amsterdam, The Netherlands. E-mail: [email protected]
Background: In most of community-dwelling elderly, two or more treatable cardiovascular risk factors can be identified. Many preventive initiatives such as the preDIVA trial (prevention of Dementia by Intensive VAscular care), focus on improvement of the cardiovascular risk profile. To our knowledge, factors influencing participation of elderly people in such preventive initiatives are largely unknown.
Research Aim and Question: To gain insight in the views and experiences of community-dwelling elderly towards cardiovascular prevention consultations. What are the barriers and facilitators for participants to (dis)continue preventive interventions?
Method: In total, 15 semi-structured interviews were conducted with a purposive sample of preDIVA (ex-) participants, aged 76–82 years. Interviews were recorded and analysed until saturation achieved. The topic list was continually modified as new themes emerged from the data. Participants were encouraged to address the following domains: motivation for participation, experiences, expectations, barriers and facilitators to participation. Two independent researchers used thematic analysis to categorize data into key themes and subthemes.
Results: Participants highlighted the importance of the social function of their practice `nurse, next to her medical expertise. The participants preferred a coaching attitude from the nurse and considered general preventive advice unnecessary, as they were well-known. The perception of being checked-up on, being able to talk about personal circumstances and being able to contribute to scientific research (especially on dementia and aging) were facilitators to participation. Frequent change of nurses, a patronizing attitude and/or lack of experience of the nurse were identified as barriers.
Conclusion: When organizing preventive consultations for elderly people, the role of the caregiver is crucial. An intervention based solely on general preventive issues is considered useless. Attention for personal circumstances and how to fit practically in changes is as important as medical content.
Motives and attitudes of the elderly towards cancer screening - An explorative mixed-methods-study
Dolezil Doris1, A Haase1, K Jahnke1, J Thonack1, C Löffler2, C Schmidt3, JF Chenot1
1Abteilung Allgemeinmedizin, Institut für Community Medicine, Universitätsmedizin Greifswald
2Institut für Allgemeinmedizin, Universitätsmedizin Rostock
3Abteilung, Section Family Medicine, Community Medicine, Greifswald, Germany. E-mail: [email protected]
Background: The benefits of cancer screening in the elderly are uncertain. While the risk of cancer increases with age, utilization of screening is decreasing.
Research Question: The aim of the study was to explore motives and attitudes towards cancer screening among the elderly.
Method: This is a population-based explorative mixed-methods-study. We recruited a stratified sample of 120 residents aged 69 to 90 years from Northeast-Germany drawn randomly from the state population registry. Using a short telephone interview, people with cognitive deficits and/ or cancer were excluded. We conducted semi-structured face-to-face-interviews exploring previous experiences and motivation related to cancer screening. Additionally, all participants filled in a questionnaire exploring attitudes toward cancer screening based on an American study. Interviews were analysed using grounded theory. The questionnaire was analysed with simple-descriptive-statistics.
Results: Out of 630 people, 64 men and 56 women, average age 77 years (SD ± 6) agreed to participate (response rate 19 %). The majority would continue screening for colon- (77%), breast- (89%) and prostate cancer (89%) until death, 76 % disagreed that other health problems of the elderly are more important than cancer screening, 7 % agreed that they would not live long enough to benefit from screening. Motives for continuing screening were the belief in efficiency, sense of duty, regularity and fear. Fear was also a motive to discontinue screening, as well as lack of interest and assuming no necessity. Perceived benefits of screening include reassurance and an increased chance of recovery. Elderly who stopped cancer screening did not fear any disadvantages.
Conclusion: Older adults have faith in cancer screening. They overestimate the benefits and the risk of dying of cancer. An informed decision balancing the advantages and disadvantages was exceptional. Older adults should receive accurate information. Personal preferences and life expectancy should be incorporated into the decision making process.
Effectiveness of a smartphone application to promote physical activity in primary care: randomised controlled trial
Liam G Glynn, Patrick S Hayes, Monica Casey, Fergus Glynn, Alberto Alvarez-Iglesias, John Newell, Gearóid ÓLaighin, David Heaney, Martin O Donnell, Andrew W Murphy
General Practice, National University of Ireland Galway, Galway, Ireland. E-mail: [email protected]
Background: Physical inactivity is a major, potentially modifiable, risk factor for cardiovascular disease, cancer and other chronic diseases. Effective, simple and generalizable interventions to increase physical activity in populations are needed.
Research Question: This randomized controlled trial (RCT) aimed to evaluate the effectiveness of a smartphone application to increase physical activity in primary care.
Method: SMART MOVE, was an eight week, open-label RCT. Android smartphone users over 16 years of age were recruited in a primary care setting in Ireland. All participants were provided with similar physical activity goals and information on the benefits of exercise. The intervention group was provided with a smartphone application and detailed instructions on using the application to achieve these physical activity goals. The primary outcome was changed in physical activity as measured by a daily step count between baseline and follow-up.
Results: 139 patients were referred by their primary healthcare professional or self-referred, 37(26%) were screened out; 12(9%) declined to participate. Ninety (65%) patients were randomised and 78 provided baseline data (Intervention = 37; Control = 41); 77 provided outcome data (Intervention = 37; Control = 40). After adjusting, there was evidence of a significant treatment effect (P = 0.009); the difference in mean improvement in daily step count from week 1 to week 8 inclusive was 1029 (95% confidence interval 214 to 1 843) steps per day favouring the intervention. Improvements in physical activity in the intervention group were sustained until the end of the trial.
Conclusion: A simple smartphone application significantly increased physical activity in a primary care population. Such inexpensive, widely available and user-friendly technologies should be considered a component of future interventions to promote physical activity.
Health-promoting community activities in primary health care. A systematic review
Joan Llobera, Sebastià March, Elena Torres, María Ramos, Joana Ripoll, David Medina, Clara Vidal, Elena Cabeza, Oana Bulilete, Micaela Llull, Atanasio García, Edurne Zabaleta, José Manuel Aranda, Silvia Sastre
Primary health care research unit, IB-Salut, Palma, Spain. E-mail: [email protected]
Background: Promoting population healthy lifestyles and improving the health of chronic patients or older adults is a major challenge for health care systems. The role of primary care is determined by accessibility at the general population, continuity of care, and capacity to mobilize community resources.
Research Question: What is the evidence about the effectiveness of community interventions for health promotion carried out with participation of primary health care teams?
Method: A systematic review of original and review articles was performed in PUBMED, EMBASE, CINAHL, Web of SCIENCE, and Latin databases as IBECS, IME, and PSICODOC with no limit of year of publication or study design. Inclusion criteria: Health-promoting community interventions carried out by primary health care on populations over 40 years, in which the population had a high level of involvement or was a cross-sector activity. A secondary literature review of identified papers was performed.
Results: In total, 50 papers were included: 11 reviews and 39 originals (15 randomized clinical trial, 5 Quasi-experimental, 3 natural experiments, 11 pre-post, 3 descriptives and 1 cohort) from 1966 to 2012.
There is some evidence of the effectiveness of community interventions on the reduction of cardiovascular risk factors, promotion of physical exercise to improve quality of life, improvement of functional status in elderly people and reduction of blood pressure in hypertensive patients. Group education interventions with participatory methodology aimed at diabetics or other patients with chronic diseases are effective in improving clinical parameters and patient satisfaction.
Conclusion: Community interventions for health promotion are effective in reducing cardiovascular risk factors, promoting physical exercise and improving self-care abilities on patients with chronic conditions. However, more research is needed to overcome important design limitations and the scarcity of evidence in some relevant topics.
Who hits the street? Factors related to the development of health-promoting community activities in Spanish primary health care
Sebastià March, Joana Ripoll, Matilde Jordan Martin, Edurne Zabaleta del Olmo, Carmen Belén Benedé Azagra, Lázaro Elizalde Soto
Primary health care research unit, IB-Salut, Palma, Spain. E-mail: [email protected]
Background: Although Spanish health regulations give primary care teams, the responsibility of carrying out health-promoting community activities, their implementation is not widespread.
Research Question: What are the factors related to participation of health care teams or individual professionals in health-promoting community activities?
Method: Two case-control studies. Study 1: cases are teams performing community activities; controls are those, which do not. Study 2: conducted exclusively on teams performing community activities: cases are professionals who develop them and controls are those who do not. Setting: Primary care in five Spanish regions. Community activities were identified after checking inclusion criteria. Controls were randomly selected. Information was collected through questionnaires administered to team managers and individual professionals, and from secondary sources.
Results: The study included 203 health care teams, of which 103 were cases. Adjusted team factors associated with performing community activities were: percentage of nurses in teams (OR = 1.07, CI95 = 1.01–1.14); community socio-economic status (OR medium-low/low on high/medium-high 2.16, CI95 = 1.18–3.95) and having undergraduate training at the centre (OR = 0.44, 0.21–0.93), 569 professionals responded to the questionnaire, of which 241 were cases and 328 were controls in the same health care centres. Adjusted professional factors associated with performing community activities were: profession (physicians do fewer community activities than nurses, social workers do more than nurses); specific training in community activities (OR = 1.9, CI95 = 1.2–3.1); team support (OR = 2.9, 1.5–5.7); years at the centre (OR = 1.06, 1.03–1.09); being nursing tutors (OR = 2, 1.1–3.5); having more motivation (OR = 3.7, 1.8–7.5); collaboration with NGOs (OR = 1.9; 1.2–3.1) and participation in neighbourhood activities (OR = 3.1, 1.9 - 5.1).
Conclusion: Professional characteristics seem to have greater influence than team/community factors on performing community activities, especially their social sensitivity and motivation. In contrast to the opinion expressed by professionals, workload is not related. Nurses and social workers have a fundamental role in the development of community activities.
Is it acceptable to check the weight of children in General Practice?
Brendan O’ Shea, Ladewig E, Reulbach U, Kelly A, O Dowd T.
Public Health and Primary Care, Trinity College Dublin, Trinity Teaching Centre, Tallaght Hospital, Tallaght, Dublin 24, Ireland. E-mail: [email protected]
Background: Childhood overweight is important. GPs are reluctant to act systematically, citing fear of upsetting parents and children, and uncertainty regarding intervention. This study examines acceptability of weighing children in general practice.
Research Question: Is it acceptable for GPs to check weight of children attending for routine care? We hypothesise GPs are conflicted, because of fear of upsetting parents and children, but that parents and children are not upset when GPs weigh the child.
Method: Study in two parts. First, postal survey of 20% sample of Irish GPs on their practices in childhood overweight. Second, a practice based study of parents and children (aged 5–12 yrs)(n = 457) serially attending 11 GPs. After presenting problems were addressed, weight/ height/ BMI of the child were noted by the GP, categorising children as normal, overweight or obese. Parents were subjected to telephone survey at 2 weeks, checking reaction/ acceptability.
Results: GP survey response rate was 80.2% (393/490). When consulting with an overweight child, only 8.1% of GPs indicated they always raise the issue in consultation. In the second part, among parents (n = 434) of children weighed, 96.3% indicated weighing had no or positive impact on their child. Most parents (98.6%) indicated it would be helpful to have the child weighed in this manner by their GP. Just over 1 in 4 obese children were reported by their parents to have been anxious, angry or upset on weighing.
Conclusion: GPs do not consistently check weight of children, and are concerned regarding acceptability. Most parents whose child had their weight checked reported positively on the experience, with 98.5% of parents (n = 434) indicating it is useful for the weight of their child to be checked by their GP when attending for routine care; over 1 in 4 obese children were upset by weighing.
Efficacy of communication skills training on colorectal cancer screening by GPs: A cluster- randomized controlled trial
Isabelle Aubin-Auger, Cédric Laouénan, Josselin Le Bel, Alain Mercier, Dan Baruch, Jean Pierre Lebeau, Anne Youssefian, Tu Le Trung, Lieve Peremans, Paul Van Royen
Family medicine, Paris Diderot University, Soisy sous Montmorency, France. E-mail: [email protected]
Background: Colorectal mass screening has been implemented in France since 2008 with a guaiac faecal occult blood test. Participation rates remain too low.
Research Question: Could the implementation of a training course focused on communication skills among GPs increase the delivery of gFOBT and CRC screening participation among the target population?
Method: A cluster randomized controlled parallel groups study was conducted in the Val d’Oise department in France with GP's practice as a cluster unit. Among all practices in this department (n = 585), 50 were randomized per arm. GPs from practices in the control group were asked to continue their usual care. GPs in the intervention group received a four hour educational training, built with previous qualitative data on CRC screening focusing on doctor-patient communication with a follow up of six months for both groups. The effect of the intervention on the primary outcomes (patient participation rate) was analysed taking into account the design effect due to cluster sampling using generalized linear-mixed effects model with group (intervention vs. control) as fixed effect and practice as random effect.
Results: At the end of the study period, 17 GPs (16 practices) in intervention group and 28 GPs (19 practices) in control group participated. The baseline characteristics of participating GPs in both groups were comparable in terms of sex, age, and year of practice setup, certification and location. The primary outcome measure was the patients’ participation rate in the target population for each GP of CRC screening in the intervention group 6 months after the educational training (36.7%) versus the patients’ participation rate for each GP in the control group (24.5%) (P = 0.03).
Conclusion: An intervention focused on doctor-patient communication showed efficiency in enhancing patients’ participation
Harmful alcohol consumption and use of tranquillizers: screening and brief intervention at primary health care settings
Christophe Berkhout, Néfertên Rizzioli
Dept. General Medicine, University of Lille, Nord de France, Lille 2, Faculte de Medecine, Lille Cedex, France. E-mail: [email protected]
Background: Hazardous or harmful alcohol consumption may cause anxiety or sleeping trouble. This study was a part of an education project implementing screening and brief alcohol intervention (SBAI) in general practice with GP trainees. SBAI aims to screen for hazardous and harmful non-addictive alcohol consumption to promote a preventive and therapeutic intervention.
Research Question: To evaluate the feasibility of screening and the rate of excessive alcohol consumption in patients consulting in general practice, to confirm social risk factors, and to investigate whether excessive alcohol consumption could be linked to the use of tranquillizers.
Method: Multicentre cross-sectional study in a population consulting in general practice in Northern France. Data collection was based on the French validated FACE five questions alcohol screening test and looked after the prescription of tranquillizers in the medical record. Multivariate analysis was performed with R software (version 2.15.1).
Results: Implementation of SBAI was disturbing for the organization of the trainers’ consultation planning. We included 392 patients between November 2011 and May 2012. Among these, 22.00% (95% CI: 18.41–26.90) were screened positive for hazardous and harmful alcohol consumption (FACE score between 4 and 8). Sex ratio: 1.44. The rate reached 25.24% in males (OR: 1.87 [95% CI: 1.05–3.34]). Use of tranquillizers was linked with alcohol consumption in patients scoring > 4 (OR: 2.07 [95% CI: 1.12–3.82]). The dwelling and the socio-professional category of the patients were poor predictors of hazardous and harmful alcohol consumption.
Conclusion: SBAI with the FACE questionnaire is difficult to implement for mass screening in French general practice. In Northern France, alcohol consumption has mainly to be investigated in males and in patients consuming tranquillizers.
How do you change the habits of a lifetime? A qualitative study of healthy ageing and health promotion for older people
Kalpa Kharicha, Steve Iliffe, Claire Goodman, Melanie Handley, Jill Manthorpe, Mima Cattan, Kate Walters
Primary Care and Population Health, University College London, London, United Kingdom. E-mail: [email protected]
Background: There is limited evidence on the best approaches to health and well-being in later life. Qualitative studies are important to understand older people's engagement with health promotion activities.
Research question: To explore older people's perspectives of healthy ageing, and to identify barriers and facilitators to health promotion in later life.
Method: Design: Qualitative study. Setting: Five general practices in urban and semi-rural areas in East/South East England. Participants: Purposive sample of 30 community dwelling older people aged 65+. Data collection: Semi-structured interviews, audio recorded and transcribed. Analysis: Framework approach was used. A coding framework of higher and lower level themes was developed from the data. Data were organised into matrices, enabling case-based and thematic analysis. Key concepts were defined, considering both the dominant and alternative views.
Results: Older people's engagement in health promoting activities was highly variable. Individuals’ responses to health promotion advice were influenced by the extent and complexity of their health needs, information and support already available, and their expectations for their future. Maintaining independence and avoiding cognitive impairment were considered important for future healthy ageing. Personality, life events, energy levels and health professional involvement were both facilitators and barriers to behaviour change. Additional facilitators/barriers included confidence using public transport, and motivation to change. Knowledge of local services for health promotion was good but experiences of using these services were mixed. Trigger factors for change included personal health ‘scares’ such as receiving a new medical diagnosis.
Conclusion: Uptake of health promotion activities in later life appears to be determined by the interaction between biographical factors (personality, life events), contextual factors (information and support available), priorities (fear of dementia and dependence) and health status (complexity, energy, new threatening diagnosis). A complex understanding of such interactions is needed to change habits developed over a lifetime.
Can old cholesterol values be used for cardiovascular risk assessment in primary prevention?
Jean-François Chenot, Carsten Oliver Schmidt, Aniela Angelow
Dept. of General Practice, University Medicine Greifswald, Greifswald, Germany. E-mail: [email protected]
Background: Total cholesterol (TC) is essential to assess cardiovascular disease (CVD) risk in primary prevention. The optimal TC screening interval is unclear and actual TC is not readily available in the consultation. However, previous TC measurements are often available and could be used to estimate CVD risk.
Research Question: Can CVD risk in primary prevention be correctly assessed using old TC measurements?
Method: We analysed data of the population-based cohort Study of Health in Pomerania covering a 10-year period. TC was calculated for all subjects without prior history of myocardial infarction or stroke and complete data on TC for those who attended baseline and follow-up examinations. 10-year-CVD risk was estimated using ESC SCORE Germany at 5- and 10-year follow-up using current and baseline TC for subjects aged 40 to 69 years. Descriptive statistics were calculated for TC. Agreement between the CVD risk estimated with current versus previously measured TC was assessed using Cohen's Kappa coefficient.
Results: A total of 1916 subjects (mean age 46.8 years, SD 13.4 years) were included at baseline. Mean TC decreased from 5.77 mmol/l (SD ± 1.24) at baseline to 5.59 (SD ± 1.14) and 5.51(SD ± 1.12) after 5 and 10 years of follow-up. 10.37% and 11.10% of subjects were estimated to be at a fatal 10-year-CVD risk of > 5% using current TC values. When 5- and 10- year old TC values were used, 11.07% and 12.85% of subjects were predicted to be at high CVD risk. Cohen's kappa was 0.87 (95%-CI 0.83–0.92) and 0.84 (95%-CI 0.80–0.89) for CVD risk at 5- and 10-year follow-up. The estimated coefficients were consistent with a very good agreement.
Conclusion: Available older TC measurements can be used to estimate CVD risk in primary prevention. This allows prompt identification of high risk patients and can reduce medical resource use and costs.
FREESTANDING PRESENTATIONSUse of primary care services before cancer diagnosis among adolescents and young adults
Jette Møller Ahrensberg, M. Fenger-Grøn, P. Vedsted
The Research Unit for General Practice, Dept. of Public Health, Aahus University Bartholins Aarhus, Denmark. E-mail: [email protected]
Background: Reducing time to diagnosis for cancer patients has recently become a main issue. Yet, the rarity of cancer in adolescents and young adults (AYA) combined with a non-specific clinical picture may lead to repeated consultations in primary care before referral to secondary care. Health-care seeking patterns in primary care prior to diagnosis may provide new clues for cancer detection by extending the ‘diagnostic window,’ which may enhance early diagnosis of cancer in AYA.
Research Question: Can we determine the time of the first early cancer symptoms in AYA seen in primary care by using health-care utilization as a proxy for symptoms?
Methods: A population-based matched comparative study was conducted using nationwide registry data. Cases: all young persons (15–39 of age) diagnosed with cancer (January 2002 − December 2011) were included (n = 12 310). Controls: 10 persons per case matched on gender, GP and year of birth were randomly selected (n = 123 100). Data on use of primary health care services (daytime contacts, out-of-hours contacts and diagnostic procedures) during the two years preceding the index date (i.e. date of diagnosis) will be measured for cases and controls while accounting for cancer type, age and gender.
Results: Our previous study showed an increase in health care use six months prior to diagnosis of childhood cancer. Children with brain tumours had more consultations than controls during the entire year before diagnosis. These findings indicate that symptoms may develop months or even longer before the diagnosis. In the present study, analyses are ongoing. Increased use of primary care prior to diagnosis is expected, possibly even earlier than observed for young children.
Conclusion: Preliminary results indicate that some symptoms of cancers in AYA do not seem to raise suspicion in primary care. This lack of suspicion tends to prolong the diagnostic pathway.
The care for terminally ill cancer patients – is there an advantage for home hospice care?
N. Bentur, S. Resnizky, R. Balicer, Sophia Eilat-Tsanani
Family Medicine, Faculty of Medicine, Bar Ilan University, Clalit Health Services, Give’at Ela-Israel. E-mail: [email protected]
Background: Care for terminally ill patients is designed to alleviate suffering. In the North Region of Clalit Health Services (CHS), hospice care is provided at home.
Research Question: What is the extent of use of hospice care? Is there a difference between the pattern of care provided to terminally ill cancer patients by Home Hospice Team (HHT) and other health care providers?
Methods: The care provided to the patients was evaluated by data about utilization of 430 deceased cancer patients retrieved from the central database. The quality of care was evaluated by interviews with 193 family caregivers (FCs) using a structured questionnaire.
Results: In the last 6 months of their lives, 95% of patients had weekly contact with their GPs, 87% were hospitalized, and 25% were cared by HHT. The FCs estimated the terminal period as an average of 77 days. The FCs reported, which health care service was the dominant care provider during the terminal care stage: the primary care team (36%), oncology ambulatory service (20%), hospital (18%), nursing home (16%), and HHT (10%). Opiates were prescribed to 59% of the patients, more to patients cared by HHT compared to others (95% and 68% respectively). The evaluation of the quality of palliative care as perceived by FCs presents a consistent difference between those who considered HHT as a dominant care provider, those cared for by HHT but not as the dominant provider and those who were not cared by HHT.
The adequacy of treatment for pain experienced by the patient (87%, 73% and 72% respectively); the treatment for anxiety and depression (88%, 78%, 33%respectively). A similar trend was noted in the rate of dying at home (84%, 38%, and 26% respectively).
Conclusion: Our data shows that the FCs of terminally ill patients reported better care when treated by the HHT and when HHT perceived as the dominant care provider.
Investigations for cancer in Danish General Practice
Jacob Reinholdt Jensen, H. Møller, J.L. Thomsen, M.B. Christensen, P. Vedsted
The Research Unit for General Practice, Dept. of Public Health, Aarhus University, Aarhus C, Denmark. E-mail: [email protected]
Background: One in three will get cancer before the age of 75, one in four will die from cancer, and in the next 10 years, the incidence of cancer will increase by at least 20%. For 85% of cancer patients, the diagnostic process starts in general practice. General practice thus plays an important and crucial role in ensuring an early and expedited cancer diagnosis. Three months prior to diagnosis, cancer patients have twice as many consultations in general practice than a reference population. The diagnostic window, therefore, seems to open several months before the actual diagnosis is made. Thus, we need detailed knowledge about the initial diagnostic pathway for cancer patients in general practice.
Research Question: How often do GPs suspect cancer after random consultations and why?
Which initial investigations are performed by GPs for suspected cancer?
Method: A national survey among 400 Danish GPs. An electronic pop-up questionnaire will be developed. Participating GPs will be exposed to the pop-up questionnaire after random consultations with patients aged 50 or older. The study will include 70 000 consultations. Questions on the questionnaire. -Do you consider cancer a possible explanation for the clinical picture seen in this consultation? -Why do you find cancer a probable reason for the clinical picture seen in this consultation? -Which further investigations have you planned for the patient after this consultation?
Results: The results will show how often and why GPs suspect cancer, how they perform the initial investigations, and whether this process can be supported and further optimised.
Conclusion: Deeper insight into the initial diagnostic process in general practice may support the GPs in the future diagnosis of cancer patients. This may provide earlier treatment and better survival for Danish cancer patients.
Informing intervention design in multimorbidity: An exploration of difficult decision making using chart stimulated recall
Carol Sinnott, Sheena Mchugh, Colin Bradley
General Practice, University College Cork, Cork-Ireland. E-mail: [email protected]
Background: To date, research on improving the management of multimorbidity in primary care has concentrated on organisational and patient-orientated interventions. Few studies have examined the role of professional-orientated interventions.
Research Question: To explore how GPs currently deal with challenges in managing multimorbidity, for identifying targets suitable in professional-orientated interventions.
Method: Design: In-depth qualitative interviews incorporating chart stimulated recall, a clinical assessment tool that uses a medical chart to stimulate a physician's recall of a case and its management. Setting: Primary care in the Republic of Ireland. Participants: GPs purposively sampled from continuing professional development groups, using sampling criteria of: length of time qualified; location (rural/ urban); and practice size (single/ group practices). Analysis: Interviews were coded using the grounded theory method of constant comparison and theory was developed iteratively.
Results: Twenty interviews were conducted. The data demonstrates how decision making in multimorbidity requires integration of information from multiple sources, including the patient, specialists, evidence based medicine, and the expertise of GP themselves. These factors vary in importance on a case-by-case basis, and their relative contributions are integrated and ‘balanced’ by the GP to make the most appropriate decision for that patient. Difficulties arise when a factor contributes too much or too little, unbalancing the decision making process. GPs respond to this using strategies such as ‘broadening the loop’ to include other professionals, ‘maintaining the status quo’ or acting as a ‘final arbitrator.’ Imbalances most commonly arose when GPs were isolated from the support of other generalists (GPs/ specialists), or had difficulties in the doctor-patient relationship.
Conclusion: This study identified potential weaknesses in decision making in multimorbidity, such as GPs’ ability to access professional support and communication with patients. These findings will inform the development of a professional-orientated intervention, to assist the provision of multimorbidity care.
Frailty and the risk of confinement, institutionalization or death in an elderly cohort
Francesc Orfila, Carme Garrofé, Celia Tajada, Ignasi Lopez Pavon, Francisco Cegri
USR Barcelona, Institut Català de la Salut, Barcelona, Spain. E-mail: [email protected]
Background: Frailty is a geriatric syndrome whose definition has not reached consensus yet, and puts individuals at risk of losing independence to live in the community.
Research Question: To evaluate the characteristics associated with risk for inclusion in home care, institutionalization or death in a cohort of frail elderly with a follow up of seven years.
Method: A prospective multicenter study with a follow-up of seven years of a cohort of 691 individuals who were 70 years or more in 2005. Individuals were recruited at the general practitioner's office. Baseline measures included an ad hoc screening tool for assessing the following frailty dimensions: vision, hearing, incontinence, falls, functional capacity, mobility, cognitive and emotional status, social risk, polypharmacy, nutrition, comorbidity and perceived health, as well as the following geriatric tests: Barthel Index, Lawton and Brody scale, Yesavage test, Folstein MMSE and Gijon social test. Follow up evaluated inclusion in home care, institutionalization and mortality. Survival analysis with Cox regression was performed.
Results: 56% of women. Baseline age 76.7 years, 55% had three or more dimensions of frailty affected. Overall event rate of 36.6% at 7 years. Died 23.6%, were in home care 9.4%, and 3.6% in institutions. Survival analysis adjusted for age and sex showed that events in the follow-up were mainly explained by functional capacity (HR = 2.1; CI95% 1.6–2.9), mobility (HR = 1.4; CI95% 1.01–1.9) and polypharmacy (HR = 1.7; CI95% 1.3–2.2). Analysing each event separately, the risk of homecare was explained mainly by mobility (HR = 2.89; CI95% 1.3–6.7), institutionalization by social risk (HR = 10.5; IC95% 2.5–27.2), and death by functional capacity (HR = 4.5; CI95% 2.5–8.0) and polypharmacy (HR = 1.9; CI95% 1.1–3.1).
Conclusion: Actions aimed at improving the screening and intervention in mobility problems, functional capacity and social risk would help the elderly maintain their autonomy and independence in the community, this being a priority in caring for this group.
Effectiveness and cost-effectiveness of a proactive, goal-oriented, integrated care model in general practice for older people. A cluster randomized controlled trial: Integrated Systematic Care for older People – the ISCOPE study
Jeanet W. Blom, W. P. J. den Elzen, A. H. van Houwelingen, M. Heijmans, T. Stijnen, W. B. van den Hout, J. Gussekloo
Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands. E-mail: [email protected]
Background: Care for older persons with a combination of somatic, functional, mental and/or social problems in general practice needs to shift from vertical disease-oriented care aiming at improvement of outcomes per disease, to horizontal goal-oriented care.
Research Question: What is the feasibility and cost- effectiveness of a pro-active and integrated way of working for older people in general practice with regard to functioning of the older people?
Method: Cluster randomized trial including all persons aged ≥ 75 years in 59 general practices (30 interventions, 29 controls), introducing a horizontal care plan for participants with a combination of problems, as identified with a structured postal questionnaire with 21 questions on four health domains. For participants with problems on ≥ 3 domains, general practitioners (GPs) made an integral care plan using a functional geriatric approach. Control practices continued care as usual.
Outcome measures: These were i) competence to perform activities of daily living independently, ii) quality of life (QoL), iii) satisfaction with delivered healthcare and iv) cost-effectiveness of the intervention, at 1-year follow-up.
Results: Of the 11 476 registered eligible older persons, 7 285 (63%) participated in the screening, 1 921 (26%) had problems on ≥ 3 domains. For 225 randomly chosen persons, a care plan was made. No beneficial effects were found on patients’ functioning, QoL or healthcare use/ costs. GPs experienced better overview of care needs and stability in the care for individual patients.
Conclusion: This study indicates that GPs prefer proactive integrative care in general practice. Horizontal care using care plans for older people with complex problems can be a valuable tool in general practice. However, since no direct beneficial effect was found for older persons, we cannot recommend this intervention to improve patient outcomes in general practice.
Chronic hepatitis B and C in an urban health setting: Prevalence, impact of the sociocultural environment, and relationship with diabetes mellitus type 2
Adriana James, Nuria de Villasante Fuentes, Clara Albaiges Rafols, Anna Massana Raurich, Dani Roca Lahiguera, Josep Franch Nadal, Marta Sendra Pons, Isabel Plaza Espuña, Francisca Panadero Rivero
General Practice, Cap raval sud, Barcelona, Spain. E-mail: [email protected]
Background: Chronic viral hepatitis (CVH) constitutes a health problem due to the potential long-term consequences (cirrhosis and hepatocellular carcinoma). Pakistan has one of the highest prevalence rates globally (type B 2–3% and C 3–5%). Our Primary Healthcare Centre in Raval Sud in Barcelona is located in an urban setting, with a young, predominantly male (63.2%) population of low socioeconomic status, of which 23.3% is of Pakistani origin. Studies show a close relationship between the presence of CVH and diabetes mellitus type 2 (DM2) development.
Research Question: What is the prevalence of CVH in the Raval Sud population, its socio-demographic profile and its relationship with DM2?
Method: Observational study conducted in the Raval Sud area. The medical records of patients with recorded diagnoses of CVH from January 2005 to June 2012 were retrieved from the electronic health record, and epidemiological information obtained. Code diagnoses (CIM10) included were: B18, B18.0, B18.1 and B18.2. The medical records of patients with diagnoses of DM2 were also retrieved for the same period. Prevalence and prevalence ratios were calculated. Statistical analysis was performed using z test comparison of proportions. Data were analysed using SPSS v.17.0 and Epidat 3.1 computer applications.
Results: In total, 693 patients diagnosed with CVH were identified from the database. CVH prevalence was 2.34% (B 18.1%, C 78.4%, both 2.6%, unspecified 0.9%). Males constituted 68% of cases (median age 52.5 years). Prevalence among Pakistanis was 2.7%. DM2 prevalence among the total population was 4.82%, whilst that among those with CVH was 14.57%, giving a ratio of 3.02 (95% CI, 2.52–3.85).
Conclusion: The prevalence of DM2 is 3 times higher among patients with CVH. CVH prevalence in Raval Sud is 2.34% and follows the distribution of male predominance in accordance with the total population, although its prevalence among Pakistanis is higher than that of the total.
Clinical trial on the efficacy of exhaled carbon monoxide measurement in smoking cessation in primary health care
Joana Ripoll, Elena Torres, Helena Girauta, Maria Esteva, Agnés Pastor, Cristina Alvarez-Ossorio, David Medina
Primary Care Research Unit of Mallorca, Balears Health Services-IbSalut Mallorca, Palma de Mallorca, Spain. E-mail: [email protected]
Background: Brief advice given by a healthcare professional can achieve between 1–3% smoking cessations. Exhaled carbon monoxide (CO) measurement in smokers could be an indicative test of harm to their health because of smoking and this could increase their motivation to stop smoking.
Research Question: Is the exhaled CO measurement plus brief advice for smoking cessation at 12 months in smokers in contemplation or precontemplation stage more effective compared with brief advice alone?
Method: Parallel randomized controlled trial with blind evaluation. Setting: Majorca Primary Health Care. Participants: Smokers > = 18 years in contemplation or precontemplation. Sample: 471 subjects per group to detect a difference > = 5%. Patients were randomly assigned to control (CG) or intervention (IG). Intervention: In CG was brief advice, in IG brief advice plus exhaled CO measure. A general practitioner or a nurse conducted interventions. Outcomes: point smoking cessation confirmed by urine cotinine test and self-reported, sustained smoking cessation (at 6 and 12 months), reducing cigarette consumption, and variation in stage of smoking cessation.
Results: 914 subjects, IG: 443 and CG: 471. At 12 months after the intervention, no statistically significant differences were found between groups with respect to smoking cessation: 8.6% stopped smoking in IG versus 9.3% in CG. Referring to sustained abstinence; 3.2% in IG and 5% in CG quit smoking at 6 month and remained at 12. There were no differences in cigarette reduction or in the change in motivation to quit smoking (Prochaska and Diclemente transtheoretical model). In addition to analysis by intention to treat, we performed analysis per protocol obtaining very similar results.
Conclusion: We could not demonstrate the efficacy of exhaled CO measurement plus brief advice for smoking cessation, cigarettes reduction and change in the motivation to quit smoking.
Comparative efficacy of two interventions to discontinue long-term benzodiazepine use: a cluster randomised controlled trial in primary care. The BENZORED study
Caterina Vicens Caldentey, Ferran Bejarano, Ermengol Sempere, Catalina Mateu, Francisca Fiol, Isabel Socias, Alfonso Leiva
Centro de Salud Son Serra-La Vileta, Palma de Mallorca, Spain. E-mail: [email protected]
Background: Benzodiazepines are extensively used in primary care, they are relatively safe, and however long-term use is associated with adverse health outcomes and dependence.
Research Question: The aim of this study was to analyse the efficacy of two structured interventions in primary care to discontinue long-term benzodiazepine use.
Method: A multicentre three-arm cluster randomised controlled trial, with randomisation at general practitioner level. A total of 532 patients taking benzodiazepines for at least 6 months participated. After all patients were included, general practitioners were randomly allocated (1:1:1) to usual care, a Structured Intervention with Follow-up visits (SIF) or a Structured Intervention with Written instructions (SIW). The primary endpoint was the last month self-declared benzodiazepine discontinuation confirmed by prescription claims at 12 months. Secondary outcomes included benzodiazepine discontinuation at 6 months, anxiety and depression symptoms, sleep satisfaction, alcohol consumption and reported withdrawal symptoms related to benzodiazepine discontinuation.
Results: At 12 months 76/ 168 (45.2%) patients in the SIW and 86/ 191 (45%) in the SIF groups had discontinued benzodiazepine use compared with 26/ 173 (15%) in the control group. After adjusting by cluster, the relative risks for benzodiazepine discontinuation were 3.01 (95% CI: 2.03 to 4.46; P < 0.0001) in the SIW and 3.00 (95% CI: 2.04 to 4.40; P < 0.0001) in the SIF group. There were no increases in anxiety and depression symptoms, sleep dissatisfaction or alcohol consumption at 6 and 12 months in the intervention groups. The most frequently reported withdrawal symptoms were insomnia, anxiety and irritability.
Conclusion: Both interventions led to significant reductions in long-term benzodiazepine use with no increase in anxiety or depressive symptoms, sleep dissatisfaction or alcohol consumption. A structured intervention with a written individualised stepped-dose reduction is less time-consuming and as effective in primary care as a more complex intervention involving follow-up visits.
Supplementary material available online
Supplementary Appendix to be found online at http://www.informahealthcare.com/doi/abs/10.3109/13814788.2014.938630.