European General Practice Research Network meeting: Vilnius, Lithuania, September 2007

Presentation 1: Theme paper

Friday, 28 September 2007, 09.30–10.00

Burnout in European FDs

Hakan Yaman, Radost Assenova, Zaida Azeredo, Francesco Carelli Dick Churchill, Jean Pierre Desgranges, Magdalena Esteva Cantó, Peter Kotanyi, Christos Lionis, Eva Marklund, Alain Moreau, Pawel Novak, Jean-Karl Soler

Family Practice, Malta College of Family Doctors, Josephine, St Catherine Street, BZN13 Attard, Malta. Tel: [phone]; Fax: [phone]. E-mail: [email protected]

Background: The aim of this cross-sectional exploratory study was to determine the prevalence of burnout, and of associated factors, amongst family doctors (FDs) in European countries.

Research question: 1) What is the prevalence of burnout in FDs in Europe? 2) Which factors are associated with high levels of burnout in European FDs?

Method: A cross-sectional survey of FDs was conducted using a custom-designed and validated questionnaire. The questionnaire incorporated the Maslach Burnout Inventory (MBI-HSS) as well as questions about demographic factors, working experience, health, lifestyle, and job satisfaction. MBI-HSS scores were analysed in the three dimensions of Emotional Exhaustion (EE), Depersonalization (DP), and Personal Accomplishment (PA).

Results: Almost 3500 questionnaires were distributed in 12 European countries, and 1393 were returned to give a response rate of 41%. In terms of burnout, 43% of respondents scored high for EE burnout, 35% for DP, and 32% for PA, with 12% scoring high burnout in all three dimensions. Just over one-third of doctors did not score high for burnout in any dimension. High burnout was found to be associated with several of the variables under study, especially those relative to respondents’ country of residence and European region, workload indicators (volume, type, and scheduling of work), age, male sex, marital status, number of children, further qualifications, income, sick-leave utilization, job satisfaction, intention to change job, and the (ab)use of alcohol, tobacco, and psychotropic medication.

Conclusions: Burnout seems to be a common problem in FDs across Europe, and is associated with personal and workload indicators, job satisfaction, intention to change job, and the (ab)use of alcohol, tobacco, and psychotropic medication. The study questionnaire appears to be a valid tool to measure burnout in FDs. Recommendations for clinical practice and future research are made. Suggestions for improving the instrument are listed.

Points for discussion: 1) This is one of the most recent EGPRN collaborative research projects, and may act as a model for future projects. 2) Should EGPRN carry out research into new models of burnout and effective interventions? 3) Should EGPRN make recommendations to Wonca Europe?

Presentation 2: Theme paper, Ongoing study with preliminary results

Friday, 28 September 2007, 10.00–10.30

Validity of PSYCHLOPS in measuring outcomes of mental health interventions

Harm W. J. van Marwijk, Ingrid M. Bakker, Berend Terluin, Bettine Schreuders

Department of General Practice, Institute EMGO, Van der Boechorststraat 7, 1081 BT Amsterdam, the Netherlands. Tel: [phone]. E-mail: [email protected]

Background: Valid measurement of the effects of primary care mental health interventions is important. However, most instruments have found limited use in practice. A British general practice network (STaRNeT) has developed the PSYCHological Outcome Profiles (PSYCHLOPS) questionnaire. Not only is it easy to use, it also has greater sensitivity to change, presumably because of its unique patient-derived format.

Research question: To evaluate whether changes in PSYCHLOPS reflected changes in other outcomes in an RCT to evaluate effects of Minimal Intervention for Stress-related mental disorders with Sick leave (MISS) versus usual care (UC).

Method: Design: validity study within cluster-randomized controlled educational trial. Setting: Primary healthcare practices in the Amsterdam area, the Netherlands. Participants: a total of 433 patients (MISS, n=227; UC, n=206) with sick leave and self-reported elevated level of distress. Interventions: 46 primary care physicians were randomized either to receive training in MISS or to provide UC. Eligible patients were screened by mail. Outcome measures: Psychlops scores (problem #1, problem #2, functioning, wellbeing, 0–5), duration of sick leave until lasting full return to work, levels of self-reported distress, depression, anxiety, and somatization, at 6 months.

Results: Baseline psychlops scores were high (i.e., problem #1 MISS 4.16, SD 0.98; UC 4.21, 0.90), and dropped to 2.73 (1.77) for MISS, and 2.58 (1.76) for the UC group, at 6 months, which were still high. No significant differences were found between MISS and UC groups at any time point, consistent with the lack of effect observed with other instruments.

Conclusions: psychlops is a very useful tool to evaluate a primary mental healthcare intervention, both in the consulting room and in research. The next step may be to integrate this tool in care, as a means of monitoring improvement.

Points for discussion: Validity of PSYCHLOPS for evaluating mental health interventions in primary care is good. Chronicity of self-defined mental health problems is large.

Presentation 3: Theme paper

Friday, 28 September 2007, 11.00–11.30

GPs perceptions of structures, and care management for depressive patients

Nolwenn Kerhuel, Jean-Yves Le Reste, Alain Mercier

Faculté de Médecine de Rouen – General Practice, 22 Bd Gambetta, 76000 Rouen, France. Tel: [phone]; Fax: [phone]. E-mail: [email protected]

Background: Depression is an important health problem in developed countries. In France, the situation seems to be different, with high drug consumption and low referral to psychologists. The healthcare system is currently changing, with more restrictive access to psychiatrists. In other countries with restricted access, GPs have stated that they do not have enough time to manage depressive patients.

Research questions: To survey GPs’ perceptions and barriers to take care of depressed people; to check reasons for differences observed between French antidepressant consumption and other European countries.

Method: A questionnaire, as close as possible to questionnaires used in similar ongoing or past studies, in communication with our partners in Witten (Germany) and Sheffield (UK), has been translated and validated. It regards the management of patients that GPs consider as depressive. It has been sent to all GPs in four northwest regions of France. Firstly, we will assess and compare local differences, using Epi-Info software. Secondly, we will compare our results with those available for other countries. This study is supported by the French social security system.

Results: Thirty per cent of the GPs returned the questionnaire. Initial results show great difficulties for easy access to specialist treatment, not having enough time, and a lack of feedback information. French GPs agree with the facts they have easy access to antidepressant drugs and difficulties in referring to psychologists.

Conclusions: Paradoxically, GPs think that increasing the number of psychiatrists will resolve this problem, ignoring the fact that their numbers in France are the highest in Europe. More results will be available in September 2007.

Points for discussion: 1) Epidemiology and presentation of depressive patients may differ in different countries. 2) What consequences does this have for the conclusions? 3) Do GPs have fewer difficulties in other countries with a high referral to psychological care?

Presentation 4: Theme paper

Friday, 28 September 2007, 11.30–12.00

How do GPs manage patients with suicide ideation? A qualitative study

A. Mercier, Laurence Coblentz-Bauman, I. Aubin, S. Delichana

Faculté de Médecine de Rouen – General Practice, 22 Bd Gambetta, 76000 Rouen, France. Tel: [phone]; Fax: [phone]. E-mail: [email protected]

Background: In France, 11 000 deaths/year are due to suicide. Suicidal attempts are about 150 000/year, half of which are managed by general practitioners (GPs). Recommendations insist on targeting the severity of suicidal crisis elements, listening carefully to psychological pain, and the importance of specialized follow-up. A large number of studies have assessed suicidal risks, and few its effective management, the effective use of the healthcare system, influences of practice place, patient expectations, and real availability experienced by GPs.

Research question: Our aim is to explore GPs’ difficulties coping with a patient with suicidal ideation and choosing options to get through this difficult situation.

Method: Four researchers conducted individual face-to-face comprehensive interviews of rural and urban GPs from Paris suburbs and Normandy. The data were analysed independently for all interviews until saturation, then shared, coded, and finally discussed.

Results: Initial results confirm the high complexity of taking care of these patients in primary care. The consultation is an emotional one, and difficulties seem to come more from patient requests and physician profiles, rather than the place of practice and nearness of hospital emergency units. Physicians underline the lack of efficient communication with secondary care services and psychiatrists. The stigmatization of psychiatric wards by the patients is still present. Several patients do not want to go to emergency units, or come back from them refusing hospitalization. This situation often obliges the physician to cope with these patients alone.

Conclusions: Lowering stigmatization of mental disorders among practitioners and patients is still a difficult challenge. Further results will be available during the congress.

Points for discussion: Is such a study one that could be completed by interviewing patients or psychiatrists?

Presentation 5: Theme paper

Friday, 28 September 2007, 12.00–12.30

Depression among elderly family practice patients with type 2 diabetes mellitus

Joanna Skorupka, Witold Lukas, Ireneusz Szymczyk, Ewa Wojtyna

Medical University of Silesia, Department of Family Medicine, ul. 3-go Maja 13/15, 41-800 Zabrze, Poland. E-mail: [email protected]

Background: The clinical implications of concomitant depression and type 2 diabetes often tend to be underrated among elderly individuals. Late-life depression is estimated to affect approximately 5–10% of primary care patients, two-thirds of whom still remain undetected. Meanwhile, the coexisting depression may severely impair metabolic control and increase the risk of both macro- and microvascular complications in subjects with type 2 diabetes.

Research questions: What is the severity of symptoms of depression among elderly primary care individuals with type 2 diabetes based on the collaborative care model approach? What is the impact of depression on diabetes-related physical outcomes? What about the applicability of the Raskin Depression Scale as a screening tool among elderly family practice patients.

Method: One hundred and eleven elderly family practice patients aged ≥65 years and diagnosed with type 2 diabetes participated in the study (59 women). The following diagnostic procedures were administered: Raskin Depression Scale, a general practitioner-rated evaluation scale; on-the-spot interview with a psychiatrist to confirm the presumptive diagnosis; physical examination and blood sampling to ascertain fasting blood glucose concentration, BMI, blood pressure values, and lipid profile.

Results: Of the subjects, 20.7%, who tested positively for depression (7 or more points according to the Raskin Depression Scale), were referred to a psychiatrist. Of these, 82.1% had their diagnosis confirmed during the psychiatric interview. The association between the severity of depressive symptoms and both fasting blood glucose and LDL cholesterol values reached statistical significance only in women.

Conclusions: The Raskin Depression Scale proved to be a reliable screening tool. A relationship observed between depression and metabolic control, particularly its impact on gender-related cardiac outcomes, requires further investigations and urges broader screening for depression among elderly primary care patients with type 2 diabetes.

Points for discussion: Why was the presented impact of depression on metabolic control so strongly modified by gender? What is the direction and what are the most feasible links in the cause-and-effect relationship between depression and type 2 diabetes? Other research?

Presentation 6: Freestanding paper

Friday, 28 September 2007, 14.00–14.30

Family doctors’ perspectives on professional behaviour

Jose Ramón Loayssa-Lara, Roger Ruiz-Moral

Department of Primary Health Care, Institute Servicio Navarro de Salud, Luis Morondo 1, 31006 Pamplona, Spain. Tel: [phone]. E-mail: [email protected]

Background: There are different approaches to ethics in medical practice and educational strategies in this area. Practising doctors’ perspectives on this matter and the relations that they perceive between ethics and the doctor–patient relationship have not been fully studied.

Research question: What are family doctors’ opinions about the main components of professional (ethical) behaviour? Which situations do they see as ethically “charged”? What are the implications of family doctors' opinions and perceptions on this subject for their education?

Method: Eighty-five family physicians (FPs) attending seven workshops were invited using a semi-structured questionnaire to identify the requirements for an ethical practice and to describe one situation with relevant ethical dimensions. Two raters classified the answers inductively and analysed the coherence between them. The results were analysed in relation to the literature.

Results: All FPs answered the questionnaire (mean age 46.3±4 years, average no. of years of clinical practice 20±5; 85% were trainers). Fifty different qualities or attributes were named in 333 statements. The majority (40%) were classified as general virtues (coherence, flexibility, honesty, diligence, humility, humanistic, sincerity, patience, prudence, tolerance, etc.), and 30% as virtues related to the doctor–patient relationship (empathy, respect, listening, etc.). Attributes regarding clinical competence were cited in 33 (10%) statements. Principles (justice, beneficence, patient autonomy) were highlights in 17 (6%) statements. The 85 described situations made reference to conflicts between patients’ demands, needs, and/or preferences and health service norms and procedures (34), clinical recommendations (21), and/or doctors’ own interests and rights (19).

Conclusions: Doctors emphasize virtues and attitudes generally considered important for ethical or virtuous professional behaviour (microethics). Most of them were related to doctor–patient communication. Nevertheless, they overlook them when identifying ethical situations in their practice. These situations were defined by conflicts between different interests and pressures. Education for professionalism should emphasize the microethical dimensions of clinical practice.

Points for discussion: Is there an incongruity between doctors’ proclaimed values and their ethical sensibility? Microethics versus traditional principles and due ethical approach: what are their relative merits and shortcomings?

Presentation 7: Freestanding paper

Friday, 28 September 2007, 14.30–15.00

Involving patients in clinical decisions: a measurement proposal from primary care

Roger Ruiz Moral, Lucía Peralta, Luis A. Pérula de Torres

Unidad Docente de Medicina Familiar, Institute SAS, Facultad de Medicina, C/ Blanco Soler, 2-14004 Cordoba, Spain. Tel: [phone]. E-mail: [email protected]

Background: Physicians are encouraged to involve patients in clinical decisions (IPCD), but this does not seem to be well defined, particularly for certain health problems and scenarios, and its measurement faces problems.

Research question: Based on a more suitable and realistic concept of IPCD for primary care (PC), can we build a valid tool for assessing IPCD?

Method: We carried out the following steps. 1) Revision of the literature (on theoretical perspectives, patients’ and providers’ opinions, and proposals for measurement) and opinions of our own doctors (focus groups). 2) We selected 14 items from our scale for measuring patient-centred approach (CICAA) and added new specific items to measure involvement. With this first 23-item instrument (CICAA-D – Decision) two raters in three iterative cycles over a 3-month period evaluated 31 diverse clinical encounters, modifying the scale and redefining the concept of patient involvement: six items were suppressed and seven reformulated. 3) Two observers evaluated 160 interviews (41 providers–diabetics, 19 doctors–standardized chronic pain patients, and 100 residents–new patients).

Results: In 31 (19.4%) interviews, some kind of IPCD was observed. In 13 (42%) encounters, this involvement was defined as “participated decision making” and in 18 (58%) as “shared decision making”; all the latter were interviews with diabetics (8) and musculoskeletal chronic pain patient (10). Only in five interviews with residents was participated decision making detected.

Conclusions: The IPCD in PC seems to be poor. Nevertheless, the tools used until now for its measurement cannot reflect how this process is carried out in consultations. Actually, we observed that the IPCD can take place at two different levels, the “participated” and the “shared”, which could force redefinition of the concept. The CICAA-D is a faced-validity scale and can be a useful instrument. Further validity and reliability studies should be carried out

Points for discussion: 1) What do we consider in involving patients in decision making? 2) What are the main features to keep in mind when measuring participated decision making in primary care consultations?

Presentation 8: Freestanding paper

Friday, 28 September 2007, 15.00–15.30

Consensus about gut feelings in general practice

Erik Stolper, Paul van Royen, M. Van de Wiel, Loes van Bokhoven, Paul Houben, Trudie van der Weijden, Geert-Jan Dinant

Department of General Practice, Maastricht University, PO Box 616, 6200 MD Maastricht, the Netherlands. Tel: [phone]; Fax: [phone]. E-mail: [email protected]

Background: General practitioners sometimes base clinical decisions on gut feelings alone, even though there is little evidence of their diagnostic and prognostic value in daily practice. Research into the validation of the determinants and into test properties of gut feelings requires precise and valid descriptions of gut feelings in general practice, which can be used as a reliable measuring instrument.

Research question: Can we obtain consensus on descriptions of two types of gut feelings–-a sense of alarm and a sense of reassurance–-and their determinants?

Method: Qualitative research including a Delphi consensus procedure with a heterogeneous sample of 27 Dutch and Belgian GPs or ex-GPs involved in university educational or research programmes.

Results: After four rounds, we found 70% or greater agreement on seven of the 11 proposed statements. A “sense of alarm” is defined as an uneasy feeling perceived by a GP when he/she is concerned about a possible adverse outcome, even though specific indications are lacking: “there's something wrong here”. This activates the diagnostic process by stimulating the GP to formulate and weigh up working hypotheses that might involve a serious outcome. A “sense of alarm” means that, if possible, the GP needs to initiate specific management to prevent serious health problems. A “sense of reassurance” is defined as a secure feeling perceived by a GP about the further management and course of a patient's problem, even though he/she may not be certain about the diagnosis: “everything fits”.

Conclusions: The sense of alarm and the sense of reassurance are well-defined concepts. These descriptions enable us to operationalize the concept of gut feelings in further research.

Points for discussion: 1) Can we generalize these descriptions, and can they be applied in other countries? 2) What research designs are suitable to validate the determinants of gut feelings?

Presentation 9: Freestanding paper

Friday, 28 September 2007, 14.00–14.30

Ongoing study with preliminary results

Conditions for research in general practice

Jouke van der Zee, Madelon Kroneman

NIVEL, PO Box 1568, 3500 BN Utrecht, the Netherlands. Tel: [phone]; Fax: [phone]. E-mail: [email protected]

Background: Research in general practice (GPr) is notably different from medical research in university hospitals. GPr is a suitable place for monitoring a surveillance of population morbidity and a wealth of clinical studies. However, sound research requires a certain professionalization of GPr. This leads to our research questions.

Research questions: 1) What conditions are necessary to develop research in general practice? 2) How have these conditions developed over time in European countries?

Method: Andrew Abbott formulated milestones for the assessment of the level of professionalization. Based on his work, milestones for GPr research were extracted. Data on these milestones were collected for six European countries (the United Kingdom, the Netherlands, Belgium, France, Spain, and Denmark) by e-mail and personal contact with country experts.

Results: The milestones for research in GPr are: 1) existence of professional associations and a vehicle for publication of research results; 2) structural conditions that facilitate a non-selective view of health problems; 3) integration of GPr in academic institutions; and 4) conditions regarding research opportunities for GPr such as group practices and financial support for research activities. The UK started with a peer-reviewed journal in 1954 and established the first chair in 1963. Spain is at the other side of the time frame, with the relatively recent introduction of a peer-reviewed journal (1984) and a GP chair (2001). France has a French peer-reviewed journal (1982), but no GP chairs as yet. Specific vocational training is present in all countries. Possibilities to obtain a doctorate are complex in Belgium and France. Financial support for research is possible in the UK and the Netherlands. Structural conditions for research are most favourable in the UK and the Netherlands, and least favourable in France and Spain.

Conclusions: The milestones extracted from the Abbott criteria are a good means to describe international differences in the professionalization of general practice.

Points for discussion: This is a six-country study. We would like to extend our study to the rest of Europe. Therefore: 1) We would like to set up a European database with information on medical schools and chairs, which reflects not only the situation today.

Presentation 10: Freestanding paper

Friday, 28 September 2007, 14.30–15.00

General practitioners with specialist interest in the UK

.Sunil H. Vyas, J. L. Handa

c/o ENT Department, Glan Clwyd Hospital, Sarn Lane, Boddelwyddan, Ll18 5UJ Rhyl, North Wales, UK. Tel: [phone]. E-mail: [email protected]

Background: As general practice as a speciality has developed over the years, now in the UK there is a trend towards general practitioners with a speciality interest. Potentially, this could provide better care and reduce the burden on an already overstretched national health service. This would also help improve waiting times for specialist consultations in the hospital.

Research questions: Here, we assess: 1) What proportion of general practitioners have a speciality interest? 2) Is it beneficial for the patient?

Method: A postal questionnaire was sent to 250 general practitioners, asking about their speciality interests, qualifications, experience, any extra duties performed and, finally, whether it was beneficial for their patients.

Results: Of 250 questionnaires sent to general practitioners, 180 replied: 102 (56.7%) declared a speciality interest, and 78 (43.3%) did not have any specific interest.

Speciality interests were: 40 (22.2%) in general medicine, 35 (19.4%) in general surgery, 20 (11.1%) in obstetrics and gynaecology, four (2.2%) in ENT surgery, and three (1.7%) in ophthalmology. Postgraduate qualifications were: 105 (58.3%) MRCGP; 73 (40.6%) MRCP; 17 (9.4%) FRCS; one (0.6%) FRCS(OTO); 14 (7.8%) MRCS; and 28 (15.6%) other diplomas. Fifty-one (28.3%) performed extra duties and other procedures. Overall, 122 (67.8%) of all general practitioners felt it was beneficial to have a speciality interest.

Conclusions: In the UK there are a great number of general practitioners with a variety of specialist interests and qualifications, a number of whom provide extra duties and carry out procedures that previously were only available in hospitals. This is of considerable benefit to patients.

Points for discussion: General practitioners with a specialist interest have a role to play in primary healthcare, so, in the future, should all trainees be encouraged to take some form of specialization? Should it be part of the trainee curriculum?

Presentation 11: Freestanding paper

Friday, 28 September 2007, 15.00–15.30

What measures could be implemented to persuade young doctors to establish a private practice?

G. Levasseur, F. X. Scweyer, C. Mari, Sandrine Huge, N. Girard

Department of General Practice (Young Researcher), Rennes 1 France, 5 rue Alain Colas, 56250 Saint Nolff, France. Tel: [phone]. E-mail: [email protected]

Background: In France, the establishment of doctors is considered a public problem that justifies a response focusing on the creation of regulatory methods regarding the provision of mobile medical care.

Research question: What measures could we implement in order to persuade young general practitioners to establish a private practice, particularly in areas of sociological or economic fragility?

Method: The study was qualitative and involved semi-directed interviews conducted in two phases with three groups of people: interns in general medicine, substitutes, and young general practitioners in private practice. The initial phase of interviews aimed at gathering young doctors’ opinions about available aid and conditions of establishment of a private practice. The measures suggested by the analysis of these interviews were then submitted to the same population for the second phase of interviews for verification and ranking.

Results: Young practitioners have no precise professional objective. Their own practice is in competition with many other options. The steps to be taken are personal and not necessarily logical: everything depends on the opportunities available.

1. Establishing a private practice is considered difficult. Administrative and managerial tasks, work organization, and fear of isolation are some of the discouraging factors.

2. They have little say in how their work is organized. They criticize the current method of organization but they have little ability to mobilize.

3. Two measures seem to have a consensus: a marketing campaign to improve public opinion of the importance of general practitioners and co-financed managerial aid. Two other measures appear promising to them: practice in groups in health facilities and implementing support groups to help young practitioners establish their practice.

Conclusions: The multiplicity of initiatives to help doctors establish their practice is not coherent and pertinent. Most of the initiatives are financial but young practitioners’ establishing problems are most of all sociological.

Presentation 12: Theme paper

Friday, 28 September 2007, 15.50–16.20

Improving depression care in primary healthcare

Jochen Gensichen, M. Peitz, M. Torge, H. Wendt-Hemainski, K. Mergenthal, J. Koenig, F. M. Gerlach

Institute for General Practice, Johann Wolfgang Goethe University, Theodor-Stern-Kai 7, D-60590 Frankfurt a.M., Germany. Tel: [phone]; Fax: [phone]. E-mail: [email protected]

Background: While improvements in primary depression care have been noted, there is still considerable room for better quality. Collaborative care approaches are effective interventions in highly structured US Health Maintenance Organizations (HMO). However, little is known about the effectiveness of case management in settings like self-owned, small-size primary care practices.

Research question: “PRimary care Monitoring for depressive Patients Trial” (PRoMPT) tests the effectiveness of community-based case management for patients with major depression (MDD) in primary healthcare practices.

Method: Cluster randomized intervention trial in 76 primary care practices in Germany (1–2 general practitioners, 1–2 medical assistants). Six hundred and twenty-four patients with MDD (DSM IV) (sex: female 75.6%; mean age 50.3 years; education 74.1% up to 10 years). Intervention: telephone monitoring by a trained practice-based practice nurse for 10 patients, to assess patient's self-reported depression symptoms, adherence, side effects of medication; and structured reports of the results to their general practitioner for 1 year. Control: care as usual.

Results: Preliminary results show an improvement in depression symptoms after 6 months (PHQ-9 I = 17.23; C = 17.30 at baseline and I = 12.05; C = 13.19), which differs significantly between interventions and controls (adjusted for depression severity and cluster, p<0.05). We will present 12 months’ data.

Conclusions: The community-based case management model exemplifies a system of care that supports both the primary care delivery system and patient-centred care. Although the positive effect is small, the study is of high clinical relevance because this care model can be applied to a large number of patients in a primary care setting.

Points for discussion: We would appreciate thoughts and suggestions from our international colleagues to better understand our results and consequences for primary depression care in different settings.

Presentation 13: Theme paper, Ongoing study, no results yet

Friday, 28 September 2007, 16.20–16.50

The surveillance of new cases of depression in a Belgian network of sentinel family practices

Nicole Boffin, V. Van Casteren

Epidemiology Unit, Scientific Institute of Public Health, J. Wytsmanstraat 14, 1050 Brussels, Belgium. Tel: [phone]. E-mail: [email protected]

Background: Depression is high on the agenda of policy makers and healthcare providers in Belgium, as elsewhere. A Belgian guideline on the management of depression in family practice is nearly finished. On several occasions, the members of the network suggested depression as a registration theme. Meanwhile, the epidemiology of depression in Belgian family practice and characteristics of patients and practices are largely unknown. Therefore, we set up a study on the feasibility of the registration of new cases of depression.

Research questions: The registration aims to describe the incidence of depression and quality of care in family practice. Patient characteristics include symptoms, risk factors, incapacity to work, and health services use. GP management of depression will be described in reference to the guideline. In our pilot study, we asked GPs to register five new cases of depression and to complete their follow-up forms afterwards. We also asked for comments on the registration and the completeness and clarity of instructions and registration forms.

Method: Using the Belgian guideline and a literature review, a research protocol and registration forms were developed and discussed with experts and the steering group. In April 2007, all the members of the sentinel network were asked to volunteer for the pilot. In mid-June 2007, participants received five registration forms, an instruction sheet, and a questionnaire. They were asked to describe 1) prospectively three new cases between mid-June and mid-August, and 2) retrospectively two new cases seen between March and April. After 2 months, they will receive follow-up forms. The follow-up covers 6 months for patients registered in March or April, and 2 months for patients registered between mid-June and mid-August.

Results: Ninety-eight of 170 eligible GPs volunteered for the pilot. The main results of the pilot will be presented.

Conclusions: Preliminary conclusions of the pilot will be presented.

Points for discussion: Feasibility of registration of patients with a new or repeated diagnosis of depression in family practice

Presentation 14: Theme paper

Friday, 28 September 2007, 15.50–16.20

Estimating partner abuse in primary care

C. Lygidakis, Stella Argyriadou, Anastasia Lygera, J. Anifantakis

Health Centre of Chrisupolis, General Hospital of Kavala, Cyprou 1, 64 200 Chrisupolis, Greece. Tel: [phone]/22062; Fax: [phone]. E-mail: [email protected]

Background: Domestic violence, including child, elderly, and spousal abuse, is a serious health problem with physical and mental implications. It is related to psychosocial problems such as alcoholism, financial problems, etc. Although routine screening of female patients for physical abuse by male partners is recommended in primary care internationally, there is a lack of data from GPs in Greece.

Research question: To report on the domestic violence and identify patients at risk

Method: Fifty-four women among the patients of the Health Centre of Chrisupolis (HCC) reported sustained violence, usually from their husband. A semi-structured questionnaire was applied, composed of demographics, medical history, and chronic drug therapies. The Conflict Tactics Scale (CTS) for violence assessment (form and heaviness) and the Symptoms Checklist-22 (SCL-22) for anxiety, depression, somatization, and low self-esteem evaluation were also performed. Moreover, the habits of the husband were investigated (alcohol consumption, drugs intake), the possible existence of psychiatric disorders, and questions if they had reported previous violent occurrences to their GP.

Results: The mean age of the abused women was 26.7 (SD 4.3) years, 47 of whom were married. The most common types of violence were verbal (48 women) and physical (37 women). Twenty-four were repeatedly (more than three times) victims of violence, and 16 sustained very serious physical injuries according to CTS. All four subscores of SCL-22 were increased in abused women; the most common symptoms after forced violence included stomach ache/nausea (17/54), pain in urogenital areas (15/54), dyspnea (13/54), and back pain (12/54) (p<0.001). Alcohol consumption, unemployment, and depression were found to be strongly related to abuse (p<0.001).

Conclusions: Violence in families seems to be common, and GPs should be prepared to recognize abuse and to be able to provide support for victims.

Points for discussion: Knowledge of the risk situation justifies suspicion of abuse for further enquiry by the GP. The strong relation between family violence and psychosocial problems may reflect the extent to which these problems are under recognized by GPs.

Presentation 15: Theme paper

Friday, 28 September 2007, 16.20–16.50

Effects of a group-work intervention for women survivors of domestic violence

Yvonne Winants, E. Slits, M. Vinkenroye, N. Nicolson

Department of General Practice, University of Maastricht, PO Box 616, 6200 MD Maastricht, the Netherlands. Tel: [phone]. E-mail: [email protected]

Background: The Women's Health Centre (WHC) in Maastricht developed in 2003–2006 a women survivors’ group-work programme for victims of partner violence. The screening of 63 female victims, referred by police and social services, resulted in the selection of 25 women suitable to participate in the 18-week group-work intervention and in the study. The intervention comprised both psycho-education, counselling, working through the trauma of partner violence, and empowerment.

Research questions: Profile of the group survivors of domestic violence; the effects of the group intervention on mental wellbeing, self-confidence, self-efficacy, and sense of social support

Method: Qualitative and quantitative methods (pre post patient controlled evaluation study design) were used to evaluate the effects in terms of psychopathology, level of posttraumatic stress (PTSD), self-confidence, and social support. Validated scales were used such as SCL-90 (Symptom checklist), PPS (Perceived Stress Scale), Self-esteem (Rosenberg), etc. Measurements and in-depth interviews were at baseline, halfway, and at the end of the intervention.

Results: Profile: The women survivors–-mean age 37 years–-had a low level of education, no or low paid jobs, and had mostly (young) children. Sixty-four per cent had stopped the relation with the violent partner; 36% had not. The women showed at baseline high levels of psychopathology (scores on SCL-90 were comparable with psychiatric patients) and high levels of stress. Fifty per cent of the group appeared to meet the criteria of PTSD. Effect of intervention: All symptoms of psychopathology and stress scores were reduced significantly. The percentage of women with PTSD was reduced from 50% to 13% (n=3). Levels of self-esteem and self-efficacy showed a significant increase after the intervention.

Conclusions: The group-work intervention appeared to be effective in helping battered women to overcome their experiences of domestic violence and to move on with their lives.

Points for discussion: What role can GPs play in the process of rehabilitation and support of female victims of domestic violence? How can GPs stimulate implementation of effective social and emotional support for this group?

Presentation 16: Theme paper

Saturday, 29 September 2007, 09.30–10.00

Mental suffering in general practice

C. Noumbissi, P. Bail, E. Hummers-Pradier, Jean Yves Le Reste

Dept. Médecine Générale, Université de Bretagne Occidentale, Rue Camille Desmoulins, 29200 Brest, France. Tel: [phone]. E-mail: [email protected]

Background: Mental suffering (MS) is a very large concept. It covers not only psychiatric diseases but often psychological or behavioural difficulties. In France, GPs receive almost 80% of those patients and have to deal with an “unorganized illness”, as Michael Balint said. GPs’ working patterns are not well known and seem mostly based on their professional experience. The research hypothesis was that GPs have to design operative and pragmatic patterns to care for MS.

Research question: What kind of operative and pragmatic knowledge do French GPs develop for caring for patients with mental suffering?

Methods: Qualitative study using participant observation during consultations with complementary interviews. Acceptance and coherence of the observations were assured by physicians who retrieved patients. Completeness was assured by triangulation of data; saturation was used to stop data recording. Notes and verbatim transcripts were analysed with content analysis.

Results: Sixty-eight cases were retrieved from 1100 consultations. After the perception of “suffering”, GPs first eliminated an organic aetiology, then searched for an incident in the patient's life. Medical proceedings included calming the MS using patients’ expectations, personality, social context, professional context, and knowledge. Listening was the first action of GPs as a part of support psychotherapy and was found in every case. This was followed by drug prescription, sick-leave certification, specialized exams, and psychiatric exams. Drug prescription needed to be persuasive because patients did not want to use psychotropic drugs and were afraid of dependence.

Conclusions: GPs understood the causes of the MS by the identification of critical incidents in the patients’ life. Rather than putting a psychiatric diagnosis on MS, they intend to calm it. Support psychotherapy was their tool for doing so. All this requires a strong connection between GPs and patients.

Points for discussion: This is a short study; it could be done at a larger scale. Would you be interested in doing so? Do you know whether that type of study has been done in other countries, and what the results are of those studies?

Presentation 17: Theme paper

Saturday, 29 September 2007, 10.00–10.30

Comparison of instruments to evaluate psychological treatment in primary care

Bettine Schreuders, Harm W. J. van Marwijk, P. van Oppen

Department of General Practice, EMGO VU University Medical Centre, Van der Boechorststraat 7, 1081 BT Amsterdam, the Netherlands. Tel: [phone]. E-mail: [email protected]

Background: Patient-generated outcome measurements concerning psychological problems stay close to how patients perceive their own problems, and focus less on disorder concepts, such as depression and anxiety. Although psychological problems are pervasive in primary care, we know little of how patients with psychological symptoms perceive their problems. As patient-generated instruments best describe the problems from the perspective of the patient, they may therefore also show higher sensitivity to change when used to evaluate treatment for mental health problems in primary care.

Methods: In an RCT with 100 participating patients, we evaluated a psychological intervention in primary care. Patients also filled in the Hospital Anxiety and Depression Scale (HADS) and also the “Psychological Outcome Profiles” (PSYCHLOPS). To describe how patients report psychological problems, and to explore whether these resemble depression and anxiety symptoms, answers to the “open” questions of the PSYCHLOPS were categorized according to the International Classification of Primary Care (ICPC). To evaluate sensitivity to change, effect sizes of PSYCHLOPS and the HADS were compared.

Results: Social problems were mentioned most frequently about relationships in the first place and about work in the second place. Depressive or anxious symptoms were seldom mentioned. The PSYCHLOPS showed a higher effect size than the HADS (1.26 vs 0.54).

Conclusions: Psychological problems were mostly perceived to be social issues. PSYCHLOPS proved to be feasible, and more sensitive to change than the HADS. Therefore, this study supports further use of PSYCHLOPS as a promising outcome instrument for both practical and research purposes. Conventional outcomes like the HADS give lower effect sizes and may underestimate the effects of interventions.

Points for discussion: How best to evaluate mental health interventions in primary care? Is Psychlops an alternative to current scales?

Presentation 18: Theme paper

Saturday, 29 September 2007, 10.30–11.00

Mental health in the Transition Project

Jean Karl Soler, Inge M. Okkes

Family Practice, Malta College of Family Doctors, Josephine, St Catherine Street, BZN13 Attard, Malta. Tel: [phone]; Fax: [phone]. E-mail: [email protected]

Background: This study uses Transition Project data to study the contribution of patients’ reasons for encounter and doctors’ interventions, including blood investigations, to the final diagnoses of mental health problems in family practice.

Research question: What are the relative contributions of patients’ symptoms and complaints, and family doctors’ interventions to the diagnoses of mental health problems made in family practice?

Method: The Transition Project database, collected from the electronic patient records of family doctor practices in six countries since the 1990s, was used to study the epidemiology of family medicine. Data on patients’ reasons for encounter and doctors’ interventions and diagnostic labels were captured, studied, and analysed using the International Classification of Primary Care (version 2 electronic; ICPC-2-E) within an episode-of-care data structure model. Episodes of care were defined and coded by family doctors using ICPC-2-E. The statistical significance of these relationships was determined through probabilistic statistical methods using Bayesian techniques.

Results: The relationships between patients’ reasons for encounter and doctors’ interventions and the diagnosis within episodes of care of mental health problems, as coded in the doctors’ EPR using ICPC-2-E, are described.

Conclusions: The epidemiology of mental health problems in family practice in six countries is studied, and specific conclusions are postulated.

Points for discussion: 1) Discussion of the use of the ICPC within EPR to study diagnosis within GP and FM; 2) discussion of the methodology and statistical analysis; 3) discussion of the potential to expand this project within EGPRN

Presentation 19: Theme paper

Saturday, 29 September 2007, 09.30–10.00

Effects of case finding of early-detected persons with dementia and family caregivers

A. Jansen, Hein van Hout, G. Nijpels, W. Stalman, H. van Marwijk

Department of General Practice, VU University Medical Centre, EMGO Institute, Van der Boechorststraat 7, 1081 BT Amsterdam, the Netherlands. Tel: [phone]; Fax: [phone]. E-mail: [email protected]

Background: General practitioners (GPs) are frequently unaware of the presence of dementia in their older patients. Consequently, their family caregivers remain unnoticed by healthcare professionals, often until they are at a point of crisis. By identifying patients with dementia symptoms and their caregivers earlier, managed care interventions may be offered to prevent adverse consequences.

Research question: To evaluate the effects of case management among early-detected community-dwelling persons with dementia symptoms and their family caregivers

Method: Randomized clinical trial with measurements at baseline and after 6 and 12 months among 99 pairs of community-dwelling older patients with dementia symptoms and their primary family caregivers, recruited by screening or GP's suspicion and subsequent cognitive testing among all persons aged 75 or older in 33 primary care practices in the Netherlands. Usual care was compared to intervention pairs who received case management by specialized district nurses over 12 months. Outcomes were the caregiver's quality of life, sense of competence to care, psychological wellbeing, and care burden, and the patient's quality of life, days of temporary institutionalization, days until permanent institutionalization, and days until death.

Results: Seventy-eight of 99 persons with dementia symptoms (mean MMSE score of 22) were previously unknown to their GP. Caregivers were mostly a spouse (41%) or child (54%) and provided a median of 9 hours per week informal care during a median of 28 months. Participants reported relatively good quality of life and little care burden at baseline functioning. Clinically relevant differences were absent on all outcomes.

Conclusions: A high number of previously unknown persons with dementia were detected. However, case management may have been provided too early regarding relatively little distress and good sense of competence to care in caregivers, and few behavioural problems in patients.

Points for discussion: Was the intervention not relevant for this target group? Was the follow-up time too short for this preventive intervention to demonstrate effects?

Presentation 20: Theme paper

Saturday, 29 September 2007, 10.00–10.30

Cost prediction for mental health-related morbidity in general practice–-a prospective cohort study

Marco Zoller, Michael Peltenburg

Einheit für Hausarztmedizin, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland. Tel: [phone]; Fax: [phone]. E-mail: [email protected]

Background: Quantifying the impact of psychiatric diagnosis and morbidity on future cost in ambulatory medicine is challenging, but mandatory. Particularly in remuneration systems based on capitation fees, a fair compensation including the degree of morbidity is essential.

Research question: To compare the power of DUSOI/WONCA Score, TMI (a Swiss tool called Thurgauer Morbiditäts Index), and a classification using 51 diagnostic categories of ICPC-2 in predicting cost related to psychiatric morbidity in patients of GPs.

Method: Thirty urban GPs participated in the prospective study. During 8 months, all patients of the largest Swiss insurance company were included; they filled in a patients’ questionnaire containing SF-12 and items from the Interheart questionnaire. After specific training, physicians coded in their own 51 diagnostic categories of ICPC-2, biaxial TMI, a set of social items, and DUSOI-WONCA Score. Statistical analysis used non-parametric methods, logarithms, and dummy coding; analyses were done in SAS or SPSS.

Results: We analysed complete data sets from 1903 patients (mean age 52.6±20.4 years, 58% female). The most frequently coded diseases were hypertension (25.6%), back pain (13.4%), and depressive disorders (11.9%). The frequency of other neuropsychiatric diagnoses ranged from 8.7 to 2.6% for chronic substance abuse, anxiety disorders, fear of illness, other psychological disorders, and dementia. Compared to the reference model, the best of six multivariable mathematic models reached 94% predictive value. Only a few diagnostic categories such as depressive disorders and chronic substance abuse contributed to the explanation of cost variance with more than 2%. Correlation between DUSOI and TMI reached r=0.75.

Conclusions: Depressive disorders and chronic substance abuse showed a relevant influence on future cost. Results allow us to make propositions for improving the TMI tool.

Points for discussion: 1) What is the practicability of the different tools? 2) Pros and cons compared to the ACG case-mix system? 3) What are the possible benefits for daily practice?

Presentation 21: Poster

Saturday, 29 September 2007, 11.30–13.00

The prevalence of psychiatric disorder with the Patient Health Questionnaire (PHQ) in a primary care population

Gintautas Daubaras, Jurgita Peleckiene

Department of Family Medicine, Clinic of Internal Diseases, Family Medicine, and Oncology, Saltiniu 1-54, LT 03218 Vilnius, Lithuania. Tel: [phone]. E-mail: [email protected]

Background: Psychiatric disorder is common in primary care, but it often goes unrecognized as most patients present only with somatic problems.

Research question: To determine the prevalence of psychiatric disorder with the Patient Health Questionnaire (PHQ) in a primary care population, and to evaluate its connection with severity of somatic symptoms

Method: Data from a cross-sectional survey (two family medicine centres in Vilnius, Lithuania, n=447) were analysed. Patients aged 18 to 65 years (mean age 35), waiting for admission to their family doctor, completed the PHQ by themselves. Severity of somatic symptoms was evaluated according physical symptoms marked in the questionnaire. The chi-square test and logistic regression methods were used to investigate the associations.

Results: Psychiatric disorder was detected in 92 patients (20.6%). Sixty-nine patients had only one psychiatric disorder; 23 of them presented with comorbid cases. Major depressive disorder was detected in 38 patients (8.5%), panic disorder in 55 (12.3%), generalized anxiety disorder in 26 (5.8%), and bulimia in eight patients (1.8%). Seventy patients presented with probable alcohol abuse (15.6%). Thirty patients (6.7%) presented with high somatic symptom severity, and 20 of them (67%) had psychiatric disorder. A statistically significant link between severity of somatic symptoms and psychiatric diagnosis was detected.

Conclusions: The study confirms the high prevalence of psychiatric disorder in primary care settings and demonstrates the utility of the PHQ as a screening tool. Mood or anxiety disorders can be suspected according the severity of somatic symptoms.

Presentation 22: Poster

Saturday, 29 September 2007, 11.30–13.00

Psychological support for patients with chronic diseases in general practice

Radost Asenova, Gergana Foreva

Department of General Practice, Medical University, Plovdiv, 15 A Vasil Aprilov str, 4000 Plovdiv, Bulgaria. Tel: [phone]; Fax: [phone]. E-mail: [email protected]

Background: The National Framework Contract obligates GPs to meet monthly patients on their lists with chronic diseases. These contacts can be used as an opportunity for psychological support and health education.

Research question: To explore patients’ views on how their GPs persuade them to follow treatment regimen

Method: Design: Posted structured questionnaire. Setting: Individual general practice–-2080 patients on the list. Participants: 153 patients with chronic diseases were identified in the electronic database of the practice; 65 questionnaires were sent and 47 were received back. Main variables measured: patients’ evaluation on key GP communication skills related to patients’ compliance, satisfaction, and psychological support. Analysis: alternative analysis; SPSS version 15.0.

Results: Sixty-six per cent of the investigated group has had chronic disease for more than 5 years. In more than two-thirds, GPs always listened to and encouraged patients. In 51.1%, patients felt comfortable enough to ask the GP questions, and in 42.6% the physician always bore in mind the patient's opinion. In 44.7%, patients reported that they received enough information about their health condition. Of those responding to the questionnaire, 40.4% evaluated GPs’ communication skills as very good, and 38.3% as excellent. As a result, half of the patients strictly followed GPs’ recommendations. Satisfaction was 53.2% excellent, 29.8% very good, 14.9% good, and only 2.1% of patients were dissatisfied.

Conclusions: Psychological support and appropriate education for self-management is one of the strategies for improving both GP services and outcomes concerning chronic conditions.

Presentation 23: Poster

Saturday, 29 September 2007, 11.30–13.00

Patients’ perception of and help-seeking from general practitioners about psychological problems

Gergana Foreva, Radost Asenova

Department of General Practice, Medical University, Plovdiv, 15 A Vasil Aprilov str, 4000 Plovdiv, Bulgaria. Tel: [phone]; Fax: [phone]. E-mail: [email protected]

Background: Family physicians are described by definition as doctors who are committed to the person rather than to a particular group of diseases or to special technique. For a long time, general practice services did not exist in the Bulgarian healthcare system. Traditionally, both physicians and patients often ignore psychological issues.

Research question: To explore patients’ perceptions regarding GPs’ role in the treatment of psychological problems

Method: Design: Cross-sectional study. Structured questionnaire incorporating GAD-7 (Generalized Anxiety Disorders scale). Setting: one working day in waiting rooms in two (individual and group practices [four GPs]) in the city of Plovdiv, Bulgaria. Participants: 97 patients attending appointments. Main variables measured: patients’ psychological condition value; trust, and intention to share and discuss problems with GP; GAD-7 scale for diagnosing anxiety disorders; patients’ psychological management by GP. Analysis: alternative analysis; SPSS version 15.0

Results: Of the patients, 30.9% were determined to have anxiety disorders by the GAD-7 scale. Of all patients, 69.4% evaluate their psychological condition as the most important and very important, in comparison to 83.3% of patients with high GAD-7 score. Only 14.3% of the whole investigated group and 36.7% in the GAD-7 group revealed an intention to share and discuss problems with their GP. Psychological support, limited to listening and discussion by the GP, was received by 67.3% of all respondents, and 18.4% were referred to specialists. Patients with anxiety were supported in 80% and were referred in 20% of cases.

Conclusions: The GP role in providing a safe place where patients feel they are listened to and understood should not be underestimated. Further research is required in the present healthcare system.

Presentation 24: Poster, Ongoing study with preliminary results

Saturday, 29 September 2007, 11.30–13.00

Frequency and related factors of mood disorders of women in Turkey, Eskisehir: A field study

Ahmet Keskin, Ilhami Unluoglu, Cinar Yenilmez, Veysel Yilmaz, Fatih Yuksel, Ugur Bilge

Department of Family Medicine, Eskisehir Osmangazi University, Medical Faculty, 26480 Eskisehir, Turkey. Tel: [phone]; Fax: [phone]. E-mail: [email protected]/[email protected]

Background: Frequent mood disorders in women have been the topic of several studies. In most of these studies, the frequency of mood disorders in women was two times that of males and was related to socio-demographic variables such as age, education, socioeconomic status, and marital status.

Research questions: What is the frequency of mood disorders in women, and what socio-demographic variables affect this frequency?

Method: In our study, the frequency of mood disorders was investigated in 543 women in Eskisehir city using the PRIME MD scale. PRIME MD is an exactly configured interview scale used to accurately diagnose common psychological disorders such as mood disorders, anxiety disorders, somatoform disorders, and possible alcohol abuse in a short time. The scale was improved by Spitzer et al., and a validity-reliability study in Turkey has been carried out by Abay et al., where it was found to be beneficial and commonly used in research. Additionally, mood disorders and related factors were interpreted with statistical techniques using a socio-demographic data form. To evaluate the obtained data, the chi-square and concordance analysis tests were used.

Results: According to the obtained results, 245 (45.1%) of 543 women had at least one mood disorder, while 298 (54.9%) of them did not have any mood disorder. The most frequently observed diagnosis was major depressive disorder (178, 32.8%). Also found were minor depressive disorder (38, 7.0%), dysthymia (15, 2.8%), and bipolar affective disorder (11, 2.0%). Mood disorders were significantly related to marriage (p=0.0004), education (p = 0.0083), and age (p=0.0039), according to chi-square analysis. Furthermore, we determined by concordance analysis that mood disorders are more common between the ages of 20 and 29 years, and among those with primary school or less education and with low income.

Conclusions: Our study demonstrated that less educated and married women have high risk for mood disorders. Further studies with high numbers would help to confirm these findings, and would contribute new interventions for at-risk groups.

Points for discussion: 1) What are the alternative explanations for the high frequency of mood disorders in women? 2) Is it possible to have differences between countries in this topic? What could the reasons be?

Presentation 25: Poster, Ongoing study, no results yet

Saturday, 29 September 2007, 11.30–13.00

Evaluation of the “Laennext” electronic stethoscope in measuring blood pressure in general practice

C. Brandt, R. Gass, M. S. Reichert, T. Vogel, E. Andres, Dominique Gras

Department of General Practice, University Louis Pasteur, 4 rue Kirschleger, 67085 Strasbourg, France. Tel: [phone]; Fax: [phone]. E-mail: [email protected]

Background: Blood pressure (BP) measured by classical stethoscope (CS) is poor compared to that measured by a 24-hour or a self blood pressure monitoring system (SBPMS). Fifteen to 26% of well-equilibrated patients measured with CS are actually hypertensive patients. In contrast, 20% of patients present a false hypertension with CS. Laennext has conceived a new digitalized stethoscope, screening, analysing, archiving, and showing the sound on a scope. We hypothesize that the Korotkoff sounds can be modified by the quality of the arterial walls, linked to age or some pathologies.

Research questions: 1) To compare BP measured by the Laennext stethoscope (LS) with that measured by a validated SBPMS; 2) to describe and analyse the five Korotkoff sounds with the LS in general practice among a population with or without any pathology

Method: The LS will be used at the same time and on the same arm as a validated SBPMS. The population will be stratified into three age categories: 18–40 years, 41–75 years, and more than 76 years. We will compare the patients without any pathology with those presenting with hypertension and/or valvulopathy and/or arteriopathy and/or cardiovascular risk factors such as diabetes, hyperlipidaemia, or tobacco. Pregnant women and children will be excluded. We intend to include at least 100 patients of each group at the beginning. After, we will revalue the sample according to the variation of the initial results.

Results: 1) The precision of this device in measuring BP will be assessed in comparison with the SBPMS. 2) We hope to find graphic differences between the population without and with pathologies, analysing the Korotkoff sounds archived by the LS.

Conclusions: Further study could show new graphic symptoms of false hyper- or normotension.

Points for discussion: We could discuss the first records of the five Korotkoff sounds, if available.

Presentation 26: Poster

Saturday, 29 September 2007, 11.30–13.00

Primary care health professionals’ knowledge, attitude, and behaviour regarding influenza immunization and 2006–2007 season adverse effect profile

Selcuk Mistik, Elcin Balci, Ferhan Elmali

Family Medicine Department, Erciyes University Medical Faculty, 38039 Kayseri, Turkey. Tel: [phone]; Fax: [phone]. E-mail: [email protected]

Background: Influenza causes a lot of morbidity and mortality throughout the world, and health professionals are a target group for influenza vaccination.

Research questions: Are primary care health professionals getting their influenza vaccine regularly, and what kind of adverse effect profile was observed for the 2006–2007 influenza vaccines?

Method: Of the 672 primary care health professionals in Kayseri, 552 (82%) completed a questionnaire comprised of 19 questions. The study was performed in March 2007 following a campaign by the Ministry of Health of Turkey for the influenza vaccination of primary healthcare workers.

Results: Of the health professionals, 67% (370) were women and 33% (182) were men. Overall, 420 (76.1%, 95% confidence interval [CI] 72.3–79.5) health professionals reported that they had influenza vaccine during the 2006–2007 influenza season. Adverse effects were reported by 157 (28.4%) health professionals. The adverse effects reported were fever (n=57, 13.5%), muscle pain (n=60, 14.2%), joint pain (n=40, 9.5%), loss of appetite (n=16, 3.8%), headache (n=41, 9.7%), cough (n=29, 6.9%), malaise (n=76, 18.0%), tiredness (n=41, 9.7%), blocked nose (n=49, 11.6%), sneezing (n=54, 12.8%), sore throat (n=33, 7.8%), and others (erythema, oedema and abscess at the vaccination site, and lymphadenopathy [n=14, 3.3%]).

Conclusions: Our study demonstrated that primary care health professionals in our study group have been vaccinated with influenza vaccine with a reasonable percent. There were no severe or serious adverse effects of the vaccine, which may be used to encourage both health professionals and the patients of primary care.

Points for discussion: 1) Are primary care health professionals getting their influenza vaccination regularly? 2) Are adverse effects of influenza vaccine observed more than expected? 3) Are vaccination campaigns for influenza vaccine effective?

Presentation 27: Poster

Saturday, 29 September 2007, 11.30–13.00

Metabolic syndrome: Different prevalence using different definitions

Nicola Buono, Filippo D'Addio, Ferdinando Petrazzuoli, Carmine Farinaro, Mirra Baldassarre

Family Medicine, SNAMID, Via Tartari 5, 81010 Prata Sannita, Italy. Tel: [phone]; Fax: [phone]. E-mail: [email protected]

Background: Since the initial description of the metabolic syndrome (MetS), several expert groups have produced different definitions, leading to confusion and the absence of comparability between studies. The MetS-associated increase in cardiovascular disease (CVD) risk may depend on the definition used. CVD prevalence is increased in the presence of MetS irrespective of the definition used, and MetS prevalence is different using different definitions.

Research question: To investigate whether the three recently proposed definitions of MetS (National Cholesterol Education Program – Adult Treatment Panel-III, International Diabetes Federation, and American Heart Association) are related to different numbers of subjects with MetS

Method: In a cross-sectional study of a representative sample of adults (38 341), 651 were selected using a search key for hypercholesterolaemia in the electronic clinical patient records of 20 GPs. MetS prevalence was calculated using a cluster of diagnostic criteria included in all three MetS definitions.

Results: Ninety subjects (13.8%) out of 651 had MetS. MetS prevalence was 7.1%, 13.8%, and 11.1%, respectively, with a positive relationship with BMI, waist circumference, sex, and triglycerides.

Conclusions: The MetS definitions identify different numbers of subjects with the same cluster of cardiovascular risk. Current metabolic syndrome criteria should not be used as an alternative to established charts for risk prediction for vascular disease. Measurements of BMI provide as much clinical insight as determinations of WC in identifying multiple CVD risk factors, and the use of both indices would provide the most information

Points for discussion: Experience in other countries

Presentation 30: Poster, Ongoing study with preliminary results

Saturday, 29 September 2007, 11.30–13.00

Attitudes of primary care providers towards vocational retraining

Mustafa Kemal Alimoglu, Erol Gurpinar, Sumer Mamakli, Mehmet Aktekin

Department of Medical Education, Akdeniz University Faculty of Medicine, 07059 Antalya, Turkey. Tel: [phone]; Fax: [phone]. E-mail: [email protected]

Background: Regarding the rapid change of facts, knowledge, and practice in medicine, vocational retraining (VR) is a must for healthcare providers. However, there is not enough published material in the literature reporting the factors effective on the thoughts of health professionals on VR activities.

Research question: What affects the attitudes of primary care providers towards VR activities?

Method: A total of 585 primary care professionals (129 physicians, 115 nurses, 290 midwives, and 51 health officers) working in the primary care centres of Antalya were asked to complete a personal form (20 items) and Training Attitudes Inventory (TAI). The TAI was translated into Turkish by the researchers. The inventory consists of two parts: part I, general attitude towards education and motivation to learn (20 items); part II, training benefits and motivation to transfer (21 items). Each item has five-point Likert scale choice scored 1 (the worst) to 5 (the best).

Results: The participation rate was 76.3%, and the female/male ratio was 4.27. Reliability (alpha) scores for the whole inventory, part I, and part II were 0.88, 0.78, and 0.86, respectively. Overall mean score in the whole study group was 139.5±17.1. Mean total scores among physicians, nurses, midwives, and health officers were 145.1±18.0, 138.4±17.2, 136.8±15.9, and 143.5±17.3, respectively. Occupation, income, job satisfaction, willingness for and satisfaction with prior VR experiences, currently receiving career training, sparing time for education, and probability of receiving future job assignments requiring more responsibility were found to be effective on the attitudes of primary care health workers towards VR activities.

Conclusions: Our study group obtained a moderate score from the TAI. Their attitudes towards VR activities might be improved by increasing their motivation regarding the factors mentioned above in the results section.

Points for discussion: What can be done for health professionals to improve their motivation on training activities?

Presentation 31: Poster

Saturday, 29 September 2007, 11.30–13.00

Job satisfaction in non-physician staff of Akdeniz University Hospital

Erol Gurpinar, Mustafa Kemal Alimoglu, Sumer Mamakli, Mehmet Aktekin

Department of Medical Education, Akdeniz University, 07059 Antalya, Turkey. Tel: [phone]; Fax: [phone]. E-mail: [email protected]

Background: Job satisfaction (JS) is known to be protective against physical and psychological effects of long-term stress. Therefore, designing effective methods of intervention, research into both stress and job satisfaction is needed especially in service-based occupations. Although previous studies on JS of medical staff including physicians, dentists, pharmacists, nurses, and midwives are available in the literature, there is little data to compare the JS of medical staff with that of the other members of health service teams such as secretaries, administrative staff, officers, and other workers.

Research question: Is there any difference between the job satisfaction levels of medical and non-medical hospital staff?

Method: A total of 832 participants (322 medical, 510 non-medical staff) working at Akdeniz University Hospital completed a demographic form and the Work Satisfaction Questionnaire (WSQ). WSQ includes 14 items, and each item has a half-finished statement that can be completed by selecting one of five following choices ranging from ‘‘never satisfies me’’ (=1 point) to ‘‘highly satisfies me’’ (=5 points). Medical staff includes dentists, nurses, pharmacists, psychologists, physiotherapists, and dieticians, and non-medical staff includes personnel working in general, administrative, technical, and auxiliary services.

Results: Participation rate was 79.1%. Reliability (alpha) score for the WSQ was 0.90. Overall mean JS score in the whole study group was 38.2±11.7. Mean scores in medical and non-medical staff were 37.2±10.8 and 38.7±12.0, respectively. Although JS levels were found lower in medical staff, there was no statistically significant difference (p=0.064).

Conclusions: JS levels in medical and non-medical staff in a hospital did not differ significantly from each other.

Points for discussion: What can be done to increase the job satisfaction of medical and non-medical hospital staff?

Presentation 32: Poster

Saturday, 29 September 2007, 11.30–13.00

Evaluation of postgraduate education status of family physicians in Turkey

Murat Unalacak, Ilhami Unluoglu, Ayse Caylan

Department of Family Medicine, Zonguldak Karaelmas Üniversitesi Tip Fakültesi Aile Hekimlii AD Kozlu, 67600 Zonguldak, Turkey. Tel: [phone]; Fax: [phone]. E-mail: [email protected]

Research questions: How do family physicians receive postgraduate education in Turkey? What are the factors that facilitate or make it difficult to get postgraduate education? What do family physicians and residents think about problems of postgraduate education, and what are their suggestions?

Method: An inquiry form containing 19 questions was prepared and sent to an e-mail group of family physicians, and to all known addresses.

Results: A total of 421 family medicine physicians (49.6%) and residents (50.4%) (53.2% females, mean age 34.5±6 years) participated in the study. The physicians had been performing their jobs for a mean of 11.1±6 years. All of the participants knew at least one foreign language. Of the participants, 56.5% attended congresses and 61.3% attended symposiums at least once a year. The cost of the congresses or symposiums of 7.4% of participants was sponsored by their institutions; 75.3% of participants received no financial or any other kind of support; 52.5% could easily use the Internet as a source of postgraduate education, and 42.0% had a chance of limited use; 75.5% were positive about having an e-mail group in which medical subjects and problems were discussed and ideas were shared; and 41.1% thought that this e-mail group was used for education purposes. The mean number of journal subscriptions per family physician was 0.27±0.75 for international journals, and 0.6±0.98 for national journals.

Conclusions: Most family physicians are aware of the need for continuous medical education. Family physicians were found to be reinforced for education. Local educational programmes could be a solution to physicians’ financial and permission problems. Postgraduate education via the Internet, followed by certification exams, can be a solution to many obstacles against education.

Presentation 33: Poster

Saturday, 29 September 2007, 11.30–13.00

Differences in referral rates to speciality care from four primary care health systems in Klaipeda, Lithuania

Andrzej Zielinski, Anders Halling, Arnoldas Jugurtis, Ingvar Ovhed

Blekinge County Council, Blekinge Institute for Research and Development Wämö Centre, 37181 Karlskrona, Sweden. Tel: [phone]; Fax: [phone]. E-mail: [email protected]

Background: There are currently four different systems working in parallel in Lithuanian primary healthcare (PHC), which offers the possibility to study their effect on referral rates for specialist consultation. Earlier studies in Lithuania have shown that the population listed to former polyclinics has the highest consumption of secondary healthcare. No studies in Eastern Europe have been performed after taking comorbidity into account.

Research question: To study if there are differences in referral rates from different Lithuanian PHC systems in Klaipeda after adjustment for comorbidity

Method: The population is listed to 18 PHC institutions, serving 250 070 inhabitants in Klaipeda city and the surrounding region. There are four PHC institutions systems: rural family doctor practice, urban privately owned family doctors practice, state-owned polyclinics, and privately owned polyclinics. Information on listed patients and referrals during the year 2005 from each PHC institution in Klaipeda was obtained from the Lithuanian Sick Fund database. The database records included information on age, sex, PHC institution, referrals, and ICD 10 diagnoses. The John Hopkins Case-Mix system was used to study comorbidity. The referral rates from different PHC systems where studied using Poisson regression models.

Results: The referral rate from PHC doctors was shown to increase in parallel with comorbidity in contrast to the number of self-referrals, which were more common in individuals with lower comorbidity. Patients listed to state-owned rural family doctor practices had a significantly lower referral rate to speciality care than the other three PHC systems. There were no significant differences in referral rates between the other PHC systems.

Conclusions: Small rural family doctor practices show the lowest referral rate to speciality care. There were no significant differences among the other PHC systems. Comorbidity was the most important factor in explaining differences in referral rates, but PHC localization and doctor training were also important.

Points for discussion: It remains unclear whether it is new family doctor training that influences referrals to consultants or other factors such as closeness to specialists, communication among doctors, or earlier habits.

Presentation 34: Poster, Ongoing study with preliminary results

Saturday, 29 September 2007, 11.30–13.00

Education and perception of menstruation among university students

Aysegul Kul Uludag, Fatih Yuksel, Ilhami Unluoglu, Sinan Ozalp

Department of Family Medicine, Eskisehir Osmangazi University Medical Faculty, 26480 Eskisehir, Turkey. Tel: [phone]. E-mail: [email protected]/[email protected]

Background: Previous investigations have shown that education for women concerning menstruation helps them to have a better perception of themselves. Management of menstrual problems and changes makes teenagers conscious, and avoids stress. Resources and content of sexuality have to be ameliorated to reach a sexually healthy community.

Research questions: What do “educated” university students think about menstruation, and what are the sources of sexual education in their life? What are the differences in knowledge between males and females? How does it affect their lives?

Method: This is a cross-sectional study using undergraduate students at two universities in Eskisehir, in mid-western Anatolia. Students were selected from the Faculty of Medicine, the Faculty of Education, the Faculty of Pharmacy, the Faculty of Engineering, and the Medical Services Vocational School. In our study, we used a special questionnaire. Knowledge about menstruation, source of knowledge, satisfaction of education, and ideas about necessity of education were collected. Furthermore, certain personal information such as school, phase, city, and age were collected. Incomplete questionnaires were excluded. Results were evaluated with the chi-square and other tests.

Results: There were 599 accepted questionnaires (57.3% females). According to significant preliminary results, girls received knowledge more from mothers, and boys from fathers, the Internet, and other sources (p<0.05); students who selected adequate knowledge were informed more by teachers or health institutions (p<0.05). Girls suggested the need for more information about menstruation regularity and family planning (p<0.05). Being aware of menstruation symptoms was more important for girls. Menstruation period evoked more “femininity” for boys and “health” for girls (p<0.05). Paleness, fatigue, sensitive breasts, and sleep tendency changes were realized more by girls as signs of menstruation (p<0.05).

Conclusions: Our preliminary comparison results determined that education concerning menstruation is necessary in the community. Reliable sources should be determined, and the poorer awareness of boys regarding girls’ menstrual complaints should be improved. Wide investigations and satisfactory education should be introduced.

Points for discussion: 1) What should be done to improve people's education about sexual topics, especially menstruation? 2) Which education method is most reliable? 3) How does menstruation affect the mood of women every month, and also the mood of their boyfriends/husbands?

Presentation 35: Poster

Saturday, 29 September 2007, 11.30–13.00

Relationship between perceived health and social class

Mehmet Rifki Aktekin, Erol Gurpinar, Sumer Mamakli, Mehtap Turkay

Akdeniz University, Faculty of Medicine, Department of Public Health, 07059 Antalya, Turkey. Tel: [phone]; Fax: [phone]. E-mail: [email protected]

Background: Perceived health is based on an individual's perception of his/her health condition and is affected by different variables. Socioeconomic conditions might affect individuals’ perceptions of wellbeing.

Research question: Is there any relationship between perceived health and social class?

Method: Eight hundred and fifty outpatients over 30 years of age who presented to a primary care centre for a variety of reasons were recruited to the study. Blood pressure, fasting blood glucose, and serum cholesterol level were measured, and body-mass index (BMI) was calculated for each participant to determine physical health status. The participants were divided into eight social classes according to their income level, educational level, self-employment and having labourers, etc.: blue collars, white collars, qualified and unqualified workers, high and petty bourgeois, self-employed, and unemployed. Perceived health was measured by the question “which of the following is appropriate to describe your health status in the last 2 weeks?” There were five choices ranging from “excellent” to “poor”.

Results: Perceived health among unemployed, unqualified workers, and blue collars was found to be lower than that of people from other social classes. When variables other than social classes were evaluated in the logistic regression, poor education levels, poor home conditions, and low income were found to be more effective than the other factors.

Conclusions: Perceived health in low social classes is worse than that of other social classes.

Presentation 36: Poster

Saturday, 29 September 2007, 11.30–13.00

Assessment of diagnostic probability estimates of certain common diagnoses among Hungarian family doctors

Peter Vajer, Agnes Szelvári, Peter Torzsa, Krisztian Voros, Ferenc Tamas, Laszlo Kalabay

Department of Family Medicine, Semmelweis University, Kutvolgyi ut 4, H-1125 Budapest, Hungary. Tel: [phone]; Fax: [phone]. E-mail: [email protected]

Background: Patients expect doctors to estimate diagnoses at the same probability when seen by different doctors. One study has demonstrated that the probability of certain diagnoses based on a given standardized clinical setting shows extreme variation among 183 family doctors in Switzerland.

Research questions: 1) Is there a difference between the probabilities of the same diagnoses given by Hungarian doctors, too? 2) If so, what are the factors responsible for the high variation?

Method: Three hundred and forty-eight Hungarian doctors (age 51±11 years) specialized in family medicine filled out the questionnaire that had been used in Switzerland. This questionnaire asked for assessment of the diagnostic variability of six common diseases (pulmonary embolism, myocardial infarction, COPD, giant cell arteritis, influenza, and congestive heart failure). In addition, we registered the doctors’ age, the length of time spent in family practice, and the existence of other specializations, especially internal medicine. The Mann-Whitney test and Spearman rank correlation were used for statistical analysis.

Results: The medians and 10–90% interquartile ranges of probabilities of all the six diagnoses were almost the same in both countries. The physicians’ age strongly correlated with time spent in practice (r=0.855, p<0.001). The presence or lack of broad specialization in internal medicine had no effect on the estimates. Physicians in practice for ≥30 years estimated the probability of myocardial infarction higher (73±27% vs 60±27%, p=0.001) but were less alert to COPD (41±27% vs 54±27%, p=0.002) than younger colleagues.

Conclusions: There is a high variance of diagnostic estimates among Hungarian doctors. Alertness to myocardial infarction increases with experience. Older doctors pay less attention to COPD, probably because their training is not up to date in this field. These differences draw attention to issues on which postgraduate medical education should be focused.

Points for discussion: 1) Have such studies been carried out in other countries? 2) Are family doctors also less alert to COPD in other countries?

Presentation 37: Poster, Ongoing study with preliminary results

Saturday, 29 September 2007, 11.30–13.00

Gender and the instant aging system

Christophe Attencourt, Pinar Topsever, Eva Hummers-Pradier, Jean-Yves Le Reste

Médecine Générale de Brest, Université de Bretagne Occidentale, Rue Camille Desmoulins, 29200 Brest, France. Tel: [phone]. E-mail: [email protected]

Background: Instant aging was developed by Leon Patalan in 1974. It was designed to develop empathy for nurse training. A preliminary study has found that there is a difference between males and females in the success of this training for medical students.

Research question: Is there a gender difference in the effects of the instant aging system?

Method: Five European universities would like to conduct this interventional study, with undergraduate and postgraduate medical students, 15–20 in each group with two facilitators, using Spielberger's state plus trait anxiety scale. Preintervention assessment (quantitative): fill in the Spielberger's scale (with a nickname); short brainstorming (what is empathy, is empathy important in medicine, if yes why?). Intervention: students in pairs will switch roles (first role disabled person walking, climbing, reading a drug description, putting on and taking off shoes, listening radio; second role helper). Then, in postintervention assessment (quantitative), fill in the Spielberger's scale with the same nickname, and in postintervention qualitative assessment answer the following questions: did this experience make a difference for you? If yes, please describe it in one sentence. The first intervention with postgraduate students has been conducted with 16 females and six males (difficulties to recruit half males and females), and a control group with 19 students (five males, 14 females). The universities of Brest (France), Göttingen (Germany), Hamburg (Germany), Marmara (Turkey), and Koceali (Turkey) are involved in this project.

Results: This experience seems to make a difference for postgraduate students. They think the workshop helps them to have a better understanding for handicapped people (qualitative assessment). Data analysis is ongoing. No definitive results as yet.

Conclusions: Ongoing study in Brest: conclusions of the French team of the collaborative study will be given in Vilnius.

Points for discussion: Are these types of intervention usable and formable in medical education?

Presentation 38: Poster

Saturday, 29 September 2007, 11.30–13.00

Assessment of how successfully reform in primary healthcare is implemented, according to patient satisfaction with medical treatment efficiency

Violeta Vasic, Radmila Mihajlovic

Department of General Practice, Health Centre, Zeleznicka bb, 14000 Valjevo, Serbia. Tel: [phone]. E-mail: [email protected]

Research questions: The introduction of the Project of Selected GP, within the reform in primary healthcare currently in progress in Serbia, has raised numerous questions both among patients and GPs alike. Is it possible to bring about changes in a complex system that has been in operation for a long time for the benefit of all? Is the new method going to give better results for medical treatment, help establish a better relationship between patients and GPs, and increase patient satisfaction?

Method: The research was conducted using the questionnaire produced by the General Medicine Section of the Serbian Medical Association. It is comprised of two parts: the survey, and the record of medical conditions of patients with arterial hypertension and diabetes mellitus over a period of 12 months, in 2006.

Results: The study comprised 178 patients, 71 males and 107 females, most of whom were aged 65–74 years (100, 56.2%). Most patients (148, 83.1%) had visited their GP in the last 2 months due to a chronic health condition. One hundred and twenty (60.6%) patients had an appointment. According to their medical records for the year 2006, 114 (64%) had a glucose level of 5.5 or lower. One hundred and eight (60.7%) patients had systole blood pressure < 130 mmHg, and 138 (77.5%) patients had diastole blood pressure < 85 mmHg.

Conclusions: The findings show that most patients were fully satisfied with their selected GP, both in terms of the GP's expertise and organizational aspects. This is an indicator of the successful implementation of the reform which is currently in progress in primary healthcare. The large number of satisfied patients proves successful practice and is strong encouragement for further improvements and the introduction of new methods.

Presentation 39: Poster

Saturday, 29 September 2007, 11.30–13.00

Gender-related knowledge among male final-year medical students

Tamer Edirne, Siddik Keskin

Department of Family Medicine, University of Yuzuncu Yil, YYU Tip Fakultesi Arastirma Hastanesi, 65300 Van, Turkey. Tel: [phone]. E-mail: [email protected]

Background: It is claimed that disregard for women's health in the medical curriculum exists, and that the male is considered as the norm or reference point for all courses and women are regarded as exceptions to the male. The teaching of basic clinical skills such as the physical examination of women is thought to be neglected, especially in countries with strong religious communities, resulting in gender-insensitive physicians.

Research questions: Are there gender inequalities in medical education, and can investigating the knowledge of final-year students show this?

Method: A questionnaire investigating satisfaction concerning undergraduate medical education and including a five-point Likert scale ranging from 1 (very high) to 5 (very low) was designed to investigate the self-perception of knowledge of final-year medical students. Topics were selected on a gender basis equally distributed between the two sexes. Additional questions about male and female health regarding well-known topics were asked. Data analysis was performed to determine significant mean differences using the Wilcoxon test.

Results: A total of 24 male interns with a mean age of 25.4 years (23–30 years) completed the questionnaire. Satisfaction concerning undergraduate medical education was given a “no” by 32% of students, and 32% noted not being sure. Theoretical knowledge about female health topics was statistically higher compared with knowledge about male health topics (p=0.050). Knowledge compared with practice showed that male students think they have fewer skills in both male- and female-specific physical examinations and interventions (p=0.000).

Conclusions: Male students could have difficulties in obtaining skills for female body examination at our medical school. Although they have more knowledge about female health problems, the skills needed to evaluate them seem to be lacking. The same deficit exists in male-related evaluating methods.

Points for discussion: Which gender is more neglected? Is gender-related medical education possible?

Presentation 40: Poster

Saturday, 29 September 2007, 11.30–13.00

Are blood pressure and cholesterol monitored as closely in people with serious mental illness (SMI) as in the general population?

David Khavia, Karena Hanley, John Sheeran

General Practice Training Scheme, Education Centre, General Hospital, 000 Letterkenny, Donegal, Ireland. Tel: [phone]; Fax: [phone]. E-mail: [email protected]

Background: Patients with a history of psychosis have been shown to be particularly health compromised, with a higher risk of developing many physical illnesses and a higher risk of developing complications from these illnesses compared to the general population. Evidence suggests they receive poorer reactive healthcare. There has been little research into whether they receive poorer preventive healthcare.

Research question: In comparing the monitoring of two key cardiovascular risk factors, blood pressure (BP) and cholesterol levels, is there a difference in the frequency of measurement of these in people with serious mental illness compared with the general population?

Method: This is a retrospective cohort survey in a single large urban practice over a 3-year period. Twenty-six patients diagnosed with serious mental illness (SMI) were matched blindly for age, socioeconomic (SE) status, and comorbidities with 26 patients from the general population. Data were collected on the total number of visits, the number of BP measurements and the number of cholesterol measurements over this period. The Student's t test was used to test the significance of differences, and the chi-square test was used to test the degree of association.

Results: While those with SMI had more frequent visits (563 vs 458), a significantly smaller proportion of these visits resulted in either a BP measurement being recorded (38% vs 46%, t test, p<0.0001) or a cholesterol test recorded (16.5% vs 6.2%, t test, p<0.0017).

Conclusions: Primary care providers monitor the blood pressure and cholesterol of patients with serious mental illness significantly less frequently compared with the general population. This supports previous evidence that there is a deficiency in the care of physical health offered to the patient group with serious mental illness compared to the general population.

Points for discussion: Greater physical morbidity also exists in the population who suffer serious mental illness. As healthcare providers, we may need to increase awareness of the possibility of prejudice in the quality of healthcare provided for those with serious mental illeness.

Presentation 41: Poster

Saturday, 29 September 2007, 11.30–13.00

Alzheimer disease in general practice: Do GPs have all the diagnosis criteria at hand?

Sebastien Cadier, A. Gentric. P. Bail, Eva Hummers-Pradier, Jean-Yves Le Reste

Médecine Générale de Brest, Université de Bretagne Occidentale, Rue Camille Desmoulins, 29200 Brest, France. Tel: [phone]. E-mail: [email protected]

Background: Alzheimer disease affects around 18% of the population over the age of 75 in France. The French High Health Authority recommends explicit criteria for the diagnosis, and to use cholinesterase inhibitors and Memantine only in the case of probable Alzheimer disease. However, only one-third of patients are treated. The research hypothesis is that, given the frequency of unwanted effects and the controversial efficacy, therapy is stopped after hospital discharge, because a lack of transmission of the diagnostic's determinants to general practitioners leads to diagnostic uncertainty. We want to study this in the population of the Lanmeur nursing home, a well-established care facility in which medical services are provided by local GPs.

Research question: Do GPs have all the recommended diagnostic criteria of Alzheimer disease when patients with dementia are referred to Lanmeur's nursing home?

Methods: Lanmeur's nursing home has electronic patient records which contain ICD-coded diagnoses since 1989. From this database, we sampled all patients with a diagnosis of dementia or Alzheimer disease. Twenty-four diagnostic criteria were extracted from admission letters, and their presence was noted (without detailed results). These criteria are: cognitive function difficulties and their evolution, antecedents with Alzheimer disease, history of alcoholism in antecedents, Instrumental Activity of Daily Living, depression, neurological abnormalities, MMSE, simple and advanced cognitive test batteries, TSH, haemoglobin rate, natraemia, calcaemia, glycaemia, brain imagery, serology of syphilis and HIV, folate and cobalamin blood rates, prothrombin time, analysis of cerebrospinal fluid, electroencephalography, and specialized opinion. The data were captured and descriptive analyses done thanks to the software Epi Data. The results are compared to the French High Health Authority's guidelines.

Results: Two hundred and seventy-six patients were included. The analysis of the data is ongoing. Further results will be published at the Vilnius congress.

Conclusions: Ongoing study

Points for discussion: 1) GPs are sent away from the beginning of treatment in Alzheimer disease in France. Is this the same in other countries? 2) Would the EGPRN like to support studies on this subject to see whether the actual chemical treatments are useless or useful?

Presentation 42: Poster, Ongoing study with preliminary results

Saturday, 29 September 2007, 11.30–13.00

Use of sleep medications and benzodiazepines: Analysis of prescriptions filled in one district in Israel, 2006

Shlomo Vinker

Department of Family Medicine, Tel Aviv University, PO Box 14238, 77042 Ashdod, Israel. Tel: [phone]; Fax: [phone]. E-mail: [email protected]

Background: Insomnia is a very common complaint. It is more common in the elderly, and pharmacotherapy remains the main modality of treatment. Most family physicians prescribe chronic benzodiazepines and benzodiazepine-like agents (BBLA), although it is known whether chronic use causes habituation and dependence.

Research question: To describe patient characteristics and patterns of BBLA used in the adult population of our district

Methods: Study population: All members of the Clalit Health Services in the Central District aged 26–95 in 2006 (about 274 000 members). Data extraction: All community pharmacies in use by the HMO are computerized and report to a central repository. All prescriptions of BBLA, which were filled in 2006, were documented. We retrieved socio-demographics for all the district adult population. Main outcome measure: Socio-demographic characteristics of BBLA users.

Results: In 2006, 11.7% of the population (33 075 patients) used BBLA; 91% used benzodiazepines. A total of 7 645 775 pills had been purchased (average of 231 pills per patient per year). In every age group, women used more BBLA than men. Among the age group 36–45, 3.7% of women and 3% of men used BBLA; the rate increased to 30.3% and 20% at the age of 66–75, and was 65.4% and 57.6% at the age of 86–95, respectively. Patients with low socioeconomic status used BBLA significantly more than the others (24.7% vs 9.2%). New immigrants and patients living in villages tended to use more BBLA.

Conclusion: Many patients use benzodiazepines and benzodiazepine-like agents, most of them on a chronic basis. The following question is raised: should we reduce the use of BBLA, especially among the elderly, and do we have the skills and time to do it?

Points for discussion: 1) Should we try to reduce the use of benzodiazepines and benzodiazepine-like agents? 2) Should we try to move patients from benzodiazepines to benzodiazepine-like agents?

Presentation 43: Poster, Ongoing study, no results yet

Saturday, 29 September 2007, 11.30–13.00

Presenting the Position Paper “Depression and Primary Care”

Diederik Aarendonk, Margaret Maxwell

European Forum for Primary Care, PO Box 8228, 3503 RE Utrecht, the Netherlands. Tel: [phone]; Fax: [phone]. E-mail: [email protected]

Background: An example of the methods used by the European Forum for Primary Care (EFPC) to collect and disseminate information. In 2006, the EFPC produced three Position Papers on the topics Self-Care, Diabetes, and Mental Health. This year, there are five new topics, among which depression is one.

Research question: What are the best practises in the primary care (PC) approach towards depression in Europe and beyond?

Methods: The aim of the Position Paper is to provide policymakers in the WHO, EU, and member states with evidence and arguments which allow them to support and promote mental health care in the PC setting. In addition, the aim of the Position Paper is to facilitate the exchange of evidence and experience for the benefits of supporting psychiatric patients from different countries. A draft will be presented and comments will be administered for a final version at the end of 2007.

Results: The knowledge, skills, positive attitudes, and change in clinical practice behaviour that those working in primary care across Europe need, as a contribution to the WHO and EU policy in supporting mental health care in PC across Europe. Strengthening PC is an important strategy to offer comprehensive community-based services: preventive, curative, and care, including social support. The performance and approaches of PC in addressing depression are promising. In view of the observed increase of depression, reliable information on effective interventions at the primary level will help to identify good practices.

Conclusion: Active sharing of information on PC sub-themes and between different professions is needed to prepare standpoints towards policymakers within the European healthcare services.

Points for discussion: Medicalization of mental health problems versus self-care. Depression treated at PC level: what are the organizational options? Prescribing of psychopharmaca at primary care level: who does what?

Presentation 44: Poster

Saturday, 29 September 2007, 11.30–13.00

Cooperation between general practitioners and mental health care specialists: A consensus regarding depression and suicide prevention

Leo Pas, Lutgart De Deken, Edward van Rossen

Research Department, Domus Medica, Sint-Hubertusstraat 58, 2600 Berchem, Belgium. Tel: [phone]; Fax: [phone]. E-mail: [email protected]

Background: That cooperation is needed between general practitioners and mental health care specialists (especially psychologists and psychiatrists) in order to tackle the challenge of treating depressive patients and preventing suicides is widely accepted. However, many hindering factors and differences in opinion remain to be overcome before this goal can be achieved to everyone's satisfaction, and scientific literature on the matter is very scarce.

Research question: 1) On what topics is there a consensus? 2) What are the most important hindering factors? 3) How can these be overcome?

Method: Delphi consensus method with a purposive sample of Flemish GPs, independent psychologists, and representatives (mostly psychologists and psychiatrists) of various specialized care units. Round 1: collection of answers to research questions 2 and 3. Round 2: consensus scores in terms of acceptability as well as suggestions for changes. Round 3: final consensus scores in terms of acceptability and feasibility. Statements were accepted as consensus if they were supported by at least 75% of GPs as well as 75% or more of the other professions.

Results: Respondents (136 in round 1, 88 in round 2, 79 in round 3) were evenly distributed between the different professions. The most important hindering factors referred to task descriptions, accessibility, and (too little) communication. Reported minimum tasks of GPs included specific attention for detection and diagnosis, context exploration, informing patients, and motivating them for non-medicinal therapy. Crucial factors for suicide risk assessment and essential communication topics for referrals were also defined. Agreement was reached on what information should be provided to patients, when to seek external advise, how to support the family, and what to communicate during and after specialized treatment. Finally, suggestions were made to stimulate regional cooperation.

Points for discussion: Similar studies? Similarities and differences in your country?

Presentation 45: Poster, Ongoing study with preliminary results

Saturday, 29 September 2007, 11.30–13.00

Complementary and alternative medicine (CAM) survey in eastern Turkey

Tamer Edirne, Dilek Kusaslan Avci, Mahir Baloglu

Department of Family Medicine, University of Yuzuncu Yil, YYU Tip Fakultesi, 65300 Van, Turkey. Tel: [phone]. E-mail: [email protected]

Background: The use of complementary and alternative medicine has grown in popularity among both patients and practitioners. The exploration of such a need to consume and practise non-proven modalities needs to be investigated as a whole including consumers, practitioners, and educators.

Research questions: What are the types of CAM modalities used most frequently in eastern Turkey? What are the perceptions of groups involved in CAM?

Method: This study is planned prospectively for 1 year to cover 1) all medical students and 2) all residents at the Research Hospital, 3) all cancer patients recorded at the Department of Oncology, and 4) all primary care physicians working in the city of Van in Turkey. A main questionnaire with key questions focused on 10 core modalities including prayer and folklore was developed based on existing prevalence studies.

Results: Preliminary: Sixty-four second-year students participated in the survey. Forty-nine students (76.6%) notified using any method of CAM at least once. Students believe that CAM use in the population has a high prevalence (frequent 68.8%, occasionally 26.6%, rare 4.7%). Of these, 71.9% believe that CAM is sometimes useful in alleviating illnesses, and 76.6% believed it sometimes useful in promoting good health. All of the students reported having insufficient knowledge of CAM, and 59.4% of them wanted CAM to become part of the curriculum. Herbal products, massage, and prayer (20.7%, 18.8%, and 16.9%, respectively) were the most common modalities used by students.

Conclusions: CAM use among second-year students is high in the east of Turkey. Prayer is more frequently used compared with the western world. Students believe that CAM is sometimes useful. Students are aware of their lack of knowledge of CAM but only a small majority (59.4%) find it necessary to become part of the curriculum.

Points for discussion: How much is CAM used and accepted by health personnel? Does culture have an effect on CAM use?

Presentation 46: One slide/five minutes

Saturday, 29 September 2007, 15.00–15.10

How to save the mental health of general practice?

Nevenka Radosavljevic, Dragica Nikolic

Department of General Practice “Stari Grad”, Simina No. 27, 11000 Belgrade, Serbia. Tel: [phone]. E-mail: [email protected]

Background: A GP represents the first point of contact, so besides examining the patient he/she needs to notice risk factors, damaging habits, mental framework, and family and workplace relationships. A GP also needs to keep detailed and meticulous medical records. The demands placed on the GP are great – to be omniscient, infallible, and self-assured.

Research question: Assess the burden on the GP in terms of medical examinations, as well as the administrative burden

Method: Numerical analysis of a 6-month period of work of four doctors in an ambulatory setting. Elements analysed: first examinations, control visits, prescribed medication receipts, diagnostic analyses, and time used for keeping medical records.

Results: The doctors, during a 6-month period, examined 13 811 patients – an average of 2302 a month. They wrote 26 225 prescriptions, or 1.9 prescriptions per patient. They took 917 ampoules and prescribed lab analyses for 1902 patients (13%). They also prescribed ultrasound for 553 patients (4%), and X-ray examinations for 582 patients (4.2%). Three hundred and nineteen patients (2.2%) were referred for hospital treatment. For every 10 of examination time, there were 3 to 6 min of administrative work (30–60%), 45–60 s for writing receipts, 15–25 s for filling forms, and 60–120 s for filling out medical documentation.

Conclusions: The time allotted to patients is not sufficient. A GP does not make enough use of his knowledge, and is tired and dissatisfied with his own work. We use unwarranted diagnostic procedures and consultative examinations, which raise the costs of health insurance. Reducing the administrative obligations for doctors and leaving more time per patient would bring about improvements in the quality and cost of treatment.

Points for discussion: How much time does a GP have to examine a patient in your country, and how great is the administrative burden?

Presentation 47: One slide/five minutes, Study proposal/idea

Saturday, 29 September 2007, 15.10–15.20

Can family meetings prevent anxiety and depression in family caregivers of demented patients? Design of the study

Karlijn Joling, Hein van Hout, Harm van Marwijk, Philip Scheltens

Department of General Practice, Institute for Research in Extramural Medicine/VU University Medical Centre Amsterdam, Van der Boechorstraat 7, 1081 BT Amsterdam, The Netherlands. Tel: [phone]; Fax: [phone]. E-mail: [email protected]

Background: Dementia is a major public health problem with enormous costs to society and devastating consequences for both patients and their relatives. Family members of persons with dementia provide much of the care for older adults with dementia in the community. Caring for a demented relative is not easy, and is fraught with emotional strain, distress, and physical exhaustion. Family caregivers of dementia patients have an extremely high risk of developing affective disorders such as major depression and anxiety disorder. Family meetings appear to be among the most powerful psychosocial interventions to reduce affective disorders in caregivers.

Research question: Are structured family meetings more effective than usual care in preventing family caregivers from developing depression or anxiety disorders?

Method: This randomized controlled trial comparing usual care with and without family meetings is evaluated in dyads of patients and their primary caregiver over 2 years. Four family meetings will be organized with the family and close friends of the primary family caregiver of a community-dwelling patient with a clinical diagnosis of dementia. The main outcome measure is the incidence of anxiety and depressive disorders assessed with the Mini-International Neuropsychiatric Interview (MINI telephone version). The severity of anxiety and depressive symptoms is measured by validated self-report instruments: the Geriatric Depression Scale (GDS) and the Symptom Checklist (SCL-90, depression, agoraphobia, and anxiety subscales).

Points for discussion: 1) Should the patient be present at the family meetings? 2) How should we analyse the data?

Presentation 48: One slide/five minutes, Study proposal/idea

Saturday, 29 September 2007, 15.20–15.30

Anxiety–depression comorbidity: Prevalence and socioeconomic context

A. S. Albergaria, Maria Luisa Leite, C. Mendes, J. J. Soares

Medicina Geral e Familiar, CS Vagos, Av. Grão Vasco, N° 1, 5° Esq. Benfica, 1500-336 Lisboa, Portugal. Tel: [phone]. E-mail: [email protected]

Background: Evidence suggests that anxiety–depression comorbidity is common and related to a higher incapacity than each of the entities isolated. Existing studies indicate that socioeconomic context influences the prevalence of anxiety–depression comorbidity. The data concerning this theme are rare, although the health resources impact is apparently high. This study intends to answer some of the existing questions.

Research question: What is the prevalence, demographic distribution, and socioeconomic context of anxiety–depression comorbidity in attending patients of four Portuguese general practitioners?

Method: The study will be a descriptive, correlational, cross-sectional, observation-based study. The studied population will include the attending adult (>19 years old) patients of four general practitioners. Participant selection will be randomized and representative of the studied population. A questionnaire will be developed and applied by the general practitioners in order to characterize the demography and the socioeconomic context of each participant, and diagnose anxiety–depression comorbidity cases. The questionnaire will be based on the Graffard and HAD scales. The following variables will be studied: sex, age, socioeconomic context, and anxiety–depression comorbidity. Data will be registered and analysed using SPSS. Descriptive statistic and inferential statistic results will be determined. Chi-square test will be used to relate proportions. The level of significance will be 0.05.

Points for discussion: Background; relevance of study; validity of study

Presentation 49: One slide/five minutes, Ongoing study with preliminary results

Saturday, 29 September 2007, 15.30–15.40

Panic syndrome (PS) and other anxiety syndrome (OAS)

Janez Rifel, Igor Švab, Danica Rotar-Pavlic, M. King, F. Torres-Gonzales, H. I. Maaroos, J. Neeleman, M. Xavier, I. Nazareth

Department of Family Medicine, Medical Faculty Ljubljana, Poljanski Nasip 58, 1000 Ljubljana, Slovenia. Tel: [phone]; Fax: [phone]. E-mail: [email protected]

Background: Anxiety disorders and/or elevated anxiety symptoms are common among primary care patients, and they induce psychosocial impairment and disability comparable to chronic somatic diseases, but mostly they are under recognized and under treated. Previous research has shown that anxiety disorders have a chronic course and recovery is low. There is a lack of longitudinal cohort studies evaluating the broad spectrum of presumed risk factors for panic disorder and generalized anxiety disorder in the primary care setting.

Research question: A proposed longitudinal cohort study in primary care in Slovenia to assess prevalence and incidence of panic syndrome and other anxiety syndrome. The study will also determine associations of the broad spectrum of presumed risk factors with occurrence and maintenance of panic syndrome and other anxiety syndrome by multivariate logistic regression.

Method: One thousand, one hundred and nineteen randomly selected general practice attendees were recruited and re-interviewed after 6 and after 24 months for the presence of panic syndrome and other anxiety syndrome, as well as the presence of a large selection of presumed risk factors. Prevalence and incidence rates of panic syndrome and other anxiety syndrome are to be evaluated. Associations of presumed risk factors with the presence and maintenance of panic syndrome and other anxiety syndrome is to be evaluated by logistic regression.

Results: Results expect to show the chronic course of both panic syndrome and other anxiety syndrome in primary care settings in Slovenia, and that multiple factors are correlated with the occurrence and maintenance of panic syndrome and other anxiety syndrome.

Conclusions: As the general practitioner/family physician deals with health problems in the physical, psychological, social, cultural, and existential dimensions of a patient's life, the results of this thesis would help practitioners to use their knowledge of patients’ circumstances to diagnose present anxiety syndromes and prevent future episodes of anxiety.

Presentation 50: One slide/five minutes, Study proposal/idea

Saturday, 29 September 2007, 15.00–15.10

Use of psychotropic drugs in a coastal community of central Portugal

Tiago Villanueva, Rita Lopes, Haunara Caldas, Lidia Lupascu

Department of Family Medicine, USF Tornada, Estrada Nacional 8, 27, r/c 2500-315 Tornada, Caldas da Rainha, Portugal. Tel: [phone]. E-mail: [email protected]

Background: Prescription of psychotropic drugs is common in primary care. Previous studies have found higher levels of use among female and elderly patients. There are few studies in Portugal exploring the use of psychotropic drugs at national, regional, and local levels. Furthermore, there are no regional or local studies focusing on the area of influence of two primary healthcare centres located in a costal community of central Portugal.

Research question: What are the socio-demographic factors related to the use of psychotropic drugs in a coastal community of central Portugal?

Method: In this observational, cross-sectional study, the health records belonging to the patient lists of four family doctors (in total, n=6739) working in two Portuguese coastal primary healthcare centres in central Portugal were analysed for this purpose. In each list, 10% of the total number of patients aged 10 and over were selected using a stratified randomized sample, and the corresponding health records consulted for the following variables: current use of psychotropic drugs, type and number of psychotropic drugs used, sex, age, type of family, Graffard scale, Duvall life cycle, addictive behaviours, previous use of psychotropic drugs, current use of psychotropic drugs in another member of the family, chronic diseases, and chronic diseases in other family members. The chi-square test was used to investigate the association between the use of psychotropic drugs and the aforementioned socio-demographic factors.

Points for discussion: Socio-demographic factors related to the use of psychotropic drugs; importance of conducting national, regional, and local studies for the professional development of Portuguese GP trainees and the build-up of a national research capacity

Presentation 51: One slide/five minutes, Ongoing study, no results yet

Saturday, 29 September 2007, 15.10–15.20

Patient adherence to polypharmacy

Guido Schmiemann, Eva Hummers-Pradier

Dept. Allgemeinmedizin, Medizinische Hochschule Hannover, Carl Neuberg Str 1, 30625 Hannover, Germany. Tel: [phone]; Fax: [phone]. E-mail: [email protected]

Background: The number of patients treated with >5 drugs/day is increasing. Adherence and congruence are key aspects in the care of these patients. Congruence is the extent to which doctor and patient agree on the same medication scheme. The literature shows that a relevant discrepancy in congruence exists, especially in those receiving polypharmacotherapy. Despite the impact of poor congruence on individual therapy, few interventions aim to reduce the amount of incongruence in daily practice.

Research question: Is a multifaceted intervention at practice level successful in improving congruence among doctors and patients with polymedication?

Method: We are planning a randomized, controlled, practice-based intervention study. Participating GPs (n=20) will be randomized to an intervention or control group. Sixteen patients with a polymedication will be randomly chosen from each practice. In both groups, the actual medication will be assessed by standardized interviews (patients and doctors) before and after intervention. The control group will receive no further conditioning, while the intervention consists of 1) patient information (stressing the benefits of adherence, information on interaction of over-the-counter medication, comprehensive medication plan [including diagnosis, allergies]), 2) educational outreach visits (giving the GP feedback on some of his patients with polymedication), and 3) case management by empowerment of practice nurses (telephone follow-up for patients on polymedication/organization and control of refills).

Results: The degree of congruence before and after the intervention will be assessed using the Brief Medication Questionnaire. Furthermore, the data will allow us to appraise the medication with regard to the appropriateness according to predefined pharmacological criteria. In addition, the study will show the feasibility and effectiveness of a multifaceted intervention. Will the GPs accept individual feedback regarding their prescribing behaviour?

Points for discussion: What other interventions might be useful in enhancing congruence? How to choose patients (receiving polypharmacotherapy) randomly from a practice? What is the best way for giving general practitioners feedback on their prescriptions?

Presentation 52: One slide/five minutes, Study proposal/idea

Saturday, 29 September 2007, 15.20–15.30

Career planning of general practitioners in Europe

Lieve Peremans, Eva Hummers-Pradier, Amanda Howe, Martina Kelly, Yvonne Winants, Jean-Yves Le Reste

Department of General Practice, University of Antwerp, Universiteitsplein 1, 2610 Antwerp-Wilrijk, Belgium. Tel: [phone]; Fax: [phone]. E-mail: [email protected]

Background: WONCA and the World Health Organization emphasize the central role of general practice in European healthcare systems. However, many countries will be soon confronted with a shortage of GPs. Several intrinsic and extrinsic factors may limit the attractiveness of general practice. Also, often regarded in the context of the feminization of general practice, finding a work-life balance is an issue for all GPs. The aim of the study is to find a positive role model that can help GPs in their work-life balance and that can contribute to keep GPs in the profession and help students to make a positive choice for general practice.

Research questions: The aim of the study is to describe and compare female and male GPs’ concepts of a good work-life balance, and to identify characteristics associated with a high level of satisfaction and persistence in the profession. Which policies could be suggested to guarantee an efficient future allocation of the GP workforce? Which educating system could promote general practice at university?

Method: This study will be a collaborative project with different European countries, and this implicates first of all a comparison of relevant aspects of the healthcare and social system, which may influence the particular situation of general practice in each of the participating countries. Depending of the resources and manpower, we will conduct a qualitative study with interviews in each country to make an inventory of all factors contributing to professional wellbeing and a positively perceived work-life balance for GPs. Afterwards, we will send a survey to a random sample of GPs up to 10 years after graduating.

Results: We especially want to invite Mediterranean and East European countries to collaborate in this project.

Points for discussion: We want to discuss the research question, the feasibility, and the best research methodology in this short presentation.

Presentation 53: One slide/five minutes, Study proposal/idea

Saturday, 29 September 2007, 15.30–15.40

Weight reduction in obese patients: The use of the “motivational interviewing” technique

Ferdinando Petrazzuoli, Francesco Carelli, Nicola Buono, Filippo D'Addio, Jean Karl Soler

Snamid Caserta, Via Orientale 3, 81010 Ruviano (CE), Italy. Tel: [phone]; Fax: [phone]. E-mail: [email protected]

Background: Obesity is a widespread problem and is often related to unhealthy behaviours. A transient loss of weight in obese patients is not so difficult to obtain, yet much more difficult is keeping this reduction of weight over the years. Motivational interviewing (MI) is a style of patient-centred counselling developed to facilitate change in health-related behaviours. The core principle of the approach is negotiation rather than conflict.

Research question: Is the use of MI in general practice in Mediterranean countries more effective than traditional methods in terms of weight reduction and maintenance in obese patients?

Method: An educational approach will be adopted to teach 30 GPs in two Mediterranean countries, Italy and Malta, the motivational interviewing technique. After 3 months, each of these 30 GPs will randomly enrol 10 obese patients and apply the technique of MI. Thirty other motivated GPs (the control group) will deal with 10 obese patients randomly selected for each GP, with traditional methods. The following variables will be considered: age, sex, body-mass index, and cultural level. Data will be stored in an Excel file and analysed using SPSS 11. Bivariate distribution tables and odds ratios with confidence intervals will be used to assess the association between variables. Inferential statistics will include chi-square test to assess the significance of the difference in proportions. Unconditional logistic regress will be used to avoid confounders or effect modifiers (interaction).

Results: Data will be compared after 3 years to find out if this technique is effective or not.

Conclusion: Motivational interviewing has been regarded as an effective tool to deal with unhealthy behaviours. The use of this technique has never been tested in primary care to treat obesity in Italy and Malta.

Points for discussion: 1) Research methods; 2) relevance of this proposed study

Presentation 54: Theme paper, Ongoing study with preliminary results

Saturday, 29 September 2007, 16.10–16.40

Depression and comorbidity in family practice

Kadri Suija, Ruth Kalda, Heidi-Ingrid Maaroos

Department of Polyclinic and Family Medicine, Tartu University, Puusepa 1a, 50406 Tartu, Estonia. Tel: [phone]. E-mail: [email protected]

Background: Depression has become one of the most prevalent mental disorders in family practice (FP). Depression in FP is commonly comorbid with somatic diseases, and is associated with a high use of medical care and disability.

Research questions: How does depression influence a patient's consultation rate in FP? Which concomitant somatic diseases are associated with depression? What kind of impact does depression exert on a patient's ability to work?

Method: Current study is part of the PREDICT study carried out in 2003–2005 in 23 FPs across Estonia. The study group consisted of 1100 consecutive patients, aged 18–75 years, attending FP to consult the family doctor (FD). Occurrence of depression was estimated using the Composite International Diagnostic Interview (CIDI) at baseline, at 6 months, and at 12 months. The medical records of all patients were analysed concerning concomitant diseases, the number of visits to FDs, and disability, and the corresponding characteristics of depressed and non-depressed patients were compared.

Results: In 2003–2005, depressed patients visited FDs 14±11 times and non-depressed patients visited FDs 12±11 times (p=0.019). The mean number of different diagnoses per depressive patient was 3.7±2.6 and per non-depressive patient 3.1±2.5 (p=0.014). Depressed patients had significantly more other psychiatric problems (F00–F99) (p=0.000) and different symptoms, not classified elsewhere (R00–R99) (p = 0.028), compared with non-depressed patients. Depressed patients had 24±42 disability days, and patients without depression had 15±30 disability days (p<0.001).

Conclusions: Depressed patients have more concomitant diseases than non-depressed patients. They use more healthcare and have more disability days, and hence need more time and attention from FDs.

Points for discussion: 1) Depression and co-morbidity in family practice.

Presentation 55: Freestanding paper

Saturday, 29 September 2007, 16.40–17.10

Quality of life in unknown coronary heart disease patients

Sumer Mamakli, Mustafa Kemal Alimoglu, Erol Gurpinar, Mehmet Aktekin

Department of Medical Education, Akdeniz University Faculty of Medicine, 07059 Antalya, Turkey. Tel: [phone]; Fax: [phone]. E-mail: [email protected]

Background: Quality of life (QoL) is known to be reduced in patients with coronary heart disease (CHD). However, there is no study investigating QoL of CHD patients who have not been diagnosed and are therefore unaware of their disease.

Research question: Is quality of life reduced in unknown coronary heart disease patients who have not been diagnosed yet?

Method: Eight hundred and fifty outpatients over 30 years of age who applied to a primary care centre for several reasons except for cardiac complaints were recruited in the study. All participants were face-to-face interviewed to complete a personal demographic data form, SF-36 for measuring QoL, and Rose questionnaire to detect unknown CHD cases. In addition to medical history and physical examination, ECG was performed on all participants, and medical history was obtained by face-to-face interview. All suspected CHD cases were sent to regional hospital to confirm the diagnosis of CHD.

Results: CHD was determined in 126 (14.8%) of the participants who were unaware that they had such a health problem. Mean scores of CHD and non-CHD cases in eight main parts of SF-36 were as follows: physical functioning 74.7±20.2 vs 87.7±201, social functioning 64.5±22.7 vs 72.9±21.3, bodily pain 55.1±25.1 vs 70.7±25.9, vitality 49.5±17.3 vs 54.3±17.9, role emotional 51.0±46.3 vs 70.3±45.1, role physical 51.8±46.9 vs 78.1±39.1, mental health 50.6±16.1 vs 54.8±17.8, and general health 44.9±25.9 vs 57.2±28.8 (p<0.05, t test).

Conclusions: Quality of life is reduced in unknown CHD patients.