Management of patients with angina pectoris by GPs: a study with standardized (simulated) patients in actual practice

BACKGROUND: Little is known about the management of patients with angina pectoris by GPs. OBJECTIVE: The purpose of this study was to assess how a group of GPs managed a patient with angina pectoris complaints in a real-life practice setting during unbiased consultations with standardized patients. METHODS: GPs were consulted during normal surgery hours by a standardized patient portraying a patient with angina pectoris. The setting was Trondheim, Norway. All 87 GPs in the city of Trondheim (Norway) were informed by letter about a study with standardized patients and invited to take part. They were asked to give consent to be visited during actual surgery hours by standardized patients. The date, number and content of the visits planned were not mentioned. They were not told that the study focused on angina pectoris. For budgetary reasons it was decided to ask 24 physicians to participate. The GPs were consulted during normal surgery hours by a standardized patient portraying a patient with angina pectoris. The patients reported on the consultations using a checklist based on guidelines for management of angina pectoris. Outcome measures were the content and number of actions undertaken from the guidelines. RESULTS: Twenty-eight GPs (32%) agreed to participate. Of these, 24 were selected and visited. One doctor detected the standardized patient. The results showed that the participating physicians met 76% of the guidelines used. However, the GPs ordered 31 different types of laboratory test (mean = 7.9, range = 1-18 per physician). In addition, the 23 consultations resulted in seven referrals (two for chest X-rays, four for an exercise test and one referral to a specialist in cardiology). Twenty-two of the 23 doctors made the correct diagnosis and informed the patient accordingly. CONCLUSIONS: When assessed in an unbiased situation in real practice, GPs performed well against a pre- set standard for management of angina pectoris patients. Much variation was found in the request for laboratory tests. These real-life practice data suggest that there is a need for discussing guidelines for effective ordering of laboratory tests in general practice.      

Why do GPs perform investigations?: The medical and social agendas in arranging back X-rays

OBJECTIVE: We aimed to determine the most important medical and psychosocial reasons GPs report for requesting back X-rays. METHODS: All GPs in a single health district were mailed a questionnaire and asked to document their reasons for requesting back X-rays. RESULTS: A total of 166/236 (70%) of GPs responded. There were 445 comments (mean 2.7 per doctor): 319 (72%) were medical indications (mean 1.9 per doctor) and 126 (28%) psychosocial reasons (mean 0.8 per doctor). GPs' medical criteria for requesting back X-rays were mainly in line with current guidelines. The most common psychosocial reasons were patient satisfaction (17%), work related (14%) and reassurance (8%). CONCLUSION: GPs' reported medical criteria for arranging back X-rays are mainly 'appropriate', but psychosocial reasons-especially patient satisfaction and reassurance-are also likely to be important factors. If psycho-social agendas are important in ordering investigations, then clinical guidelines which discuss only medical criteria may not be effective in reducing 'inappropriate' investigations.      

Sciatica and other low-back disorders in private practice: extent of the problem and therapeutic approaches

Using data collected by INSERM in a 1975 survey among French general practitioners and specialists in private practice, the reporting of sciatica and low back pain (LBP) was studied, as well as doctors' diagnoses and therapeutic approaches. Only 0.7% of patients were reported as having sciatica, while 2.8% were reported with LBP. These percentages suggest, respectively, 1.5 and 6.5 million consultations with private practitioners. The prevalence of sciatica was estimated at 8%. There was no urban-rural difference in the consultation rate; three-quarters of the patients were seen by GPs. The frequency of LBP was higher among the employed, particularly among manual workers. Referrals for additional examinations were nearly twice as high for sciatica as for LBP. GPs prescribed more medicines, and more sick leave, than specialists, but made fewer referrals for additional examination, probably because the patients seen were different, or were at a different stage of disease. It is concluded that the formulation of standards of care specific to each level of care might be useful.     

Combined training of GPs and practice-assistants on peripheral arterial disease: positive effects after six months

OBJECTIVES: To improve the use of the ankle-brachial index (ABI) measurement, and management of patients with peripheral arterial disease (PAD) a combined training, targeting GPs and practice assistants (PAs) was developed. To measure the effect of the combined training on the management of patients with PAD, a cross-sectional study was performed. METHODS: Fifty consecutive patients referred by GPs to a vascular surgery out-patient clinic were analysed. Six months after the training an additional fifty patients were included. In all patients the ABI measurement, risk factor management, and treatment as performed by the GP, prior to referral, were analysed. RESULTS: The measurement of the ABI significantly increased from 10% before the training to 53% after the training (GPs with training: 83%, GPs without training: 35%; P: 0.001). The referral of patients with actual PAD significantly increased from 32% before the training to 70% after the training (GPs with training: 83%, GPs without training: 59%; P: 0.05). The presence and treatment of risk factors did not differ between the groups. CONCLUSIONS: Within the limitations of a before and after study the combined training of GPs and PAs appears to be an effective method to increase ABI measurements and significantly improve adequate diagnostics.     

Assessment of GP management of symptoms of dying patients in an Australian community hospice by chart audit

BACKGROUND: With specialist palliative care services becoming widespread, and the place of the GP in palliative care being examined, audit of patient care delivered by GPs is required in order to ensure adequate standards of care. OBJECTIVE: We aimed to evaluate symptomatic care delivered to palliative care patients by GPs in an Australian community hospice with a developed quality assurance programme. METHODS: The study was set in a newly established community-based, GP- run hospice in a provincial city in Queensland, Australia. A chart audit was carried out of the first 20 patients admitted to a community- based hospice, in order to establish (i) whether attempts were made by the treating doctor to find the direct cause of symptoms before initiating management; and (ii) whether management accorded with developed consensus-based guidelines. RESULTS: Twenty patients were treated by 14 GPs; 135 new symptoms were identified in the records of these patients. Of the 125 symptoms for which guidelines could be identified in the literature, in 87 (70%) an attempt by the treating GP to find a direct cause could be demonstrated. Of the 114 symptoms with treatments defined in the guidelines, 107 (90%) treatments conformed to the guidelines. Constipation, nausea/vomiting, anorexia and back pain were the conditions for which there were the fewest attempts at establishing a direct cause before treatment. In most cases these conditions were treated in accordance with the guidelines. CONCLUSION: Quality assurance mechanisms present in an in-patient palliative care setting appear to be associated with high-quality care by GPs.      

User satisfaction with a real-time automated feedback system for general practitioners: a quantitative and qualitative study.

OBJECTIVE: The GRIF automated feedback system produces real-time comments on the appropriateness of diagnostic tests ordered by general practitioners (GPs) based on recommendations from accepted national and regional practice guidelines. We investigated the experiences of GPs with this system and, more specifically, with the recommendations produced by the system as well as their views on using this system in daily practice. SETTING: We tested the GRIF system in an experiment in a laboratory setting and in a daily practice trial. STUDY PARTICIPANTS: General practitioners. INTERVENTION: In the laboratory experiment, GPs used the GRIF system to assess the appropriateness of 30 request forms. Each of the GPs was confronted with requests they had submitted to the diagnostic unit of the hospital in the past. In the field trial, the GRIF system was applied during patient consultations for 1 year. MAIN OUTCOME MEASURES: We measured GPs' satisfaction with the system using a questionnaire, and also conducted group discussions (in the laboratory experiment) and in-depth interviews (in the field trial) to elicit GPs' opinions of and experiences with the system. In addition, we explored GPs' reasons for not accepting the comments offered by the GRIF system. RESULTS: The results show that the GPs in the laboratory experiment had more positive attitudes towards the system compared with participants in the field trial. All discussion groups and most of the GPs in the field trial regarded receiving the immediate feedback during the test ordering process as an important advantage. The most frequently mentioned reason to reject the recommendation was disagreement with the content and/or the recommendations in the practice guidelines. CONCLUSION: Apart from securing agreement on guideline content, a prerequisite for using GRIF in daily practice on a large scale is that more attention is paid to promotion of the guidelines and their adoption, and stimulation of a positive attitude towards the practice guidelines among the users.     

Continuity of care through medical records--an explorative study on GPs' management considerations

BACKGROUND: The growing complexity of care with more professionals involved is a threat to the delivery of coherent and consistent care. Excellent exchange of information between professionals may be a way to maintain continuity of care. Relevant information to be passed over includes thoughts about future management for individual patients. AIM: To explore the nature of GPs' thoughts about future management, and to determine the extent to which such thoughts are actually recorded in medical records. DESIGN OF STUDY: Cross-sectional study of 5741 consultations. SETTING: Thirty GPs from 17 practices in a region in the eastern part of The Netherlands. METHODS: The GPs responded to an electronic questionnaire, directly after 200 successive consultations. The questionnaire included items on management considerations, consultation characteristics and personal continuity. We compared the data from the questionnaire to the actual recording of management considerations in the patient records. RESULTS: The GPs had management considerations in 66.4% of the consultations, involving mainly considerations about additional testing (15.5%), adjustment of medication (22.5%), alternative treatment plans (18.6%), possible referral (11.8%) and coping behaviour (18.0%). These considerations were seldom recorded in the electronic patient record; additional testing (3.0%) adjustment of medication (2.9%) and alternative treatment plans (4.1%). Surprisingly however, GPs rarely found that management considerations from earlier consultations were lacking in the medical record. CONCLUSION: GPs often have thoughts on how to deal with this patient, but hardly ever record such considerations. We recommend the development of tools that facilitate the recording of management considerations in electronic patient records.     

EGPRW European General Practice Research Workshop Developing research skills throughout Europe

Objectives: To analyse the frequencies of, and the clinical risk factors for, full-time sick leave (100% sick leave) in the past month after cognitive-behavioural treatment of young persons at risk of permanent disability.

Patients and methods: Persons aged 16-45 years on more than six weeks of sick leave for benign disorders were asked to participate in a four-week treatment programme in primary care. It included weekly patient-doctor dialogues on worries about pain, and daily training. Mental and somatic health and psychosocial stressors were assessed. Locations of muscular insertion lesions (enthesopathies) were counted. Pain behaviour was defined as ≥1.5 points on the University of Alabama scale. Self-reported inability to work, pain anxiety, pain behaviour and depression were evaluated before and after the treatment.

All variables were categorised. Non-parametric tests were used to detect group differences and changes in related dichotomous variables. The variables that were significantly related to 100% sick leave at the three-month, one-year and three-year follow-ups were used as independent variables in multinomial logistic regression calculations of odds ratios (ORs) with 95% confidence intervals (95% CI) for 100% sick leave in the past month. Also, three or more enthesopathy locations and previous 100% sick leave of more than three months were chosen as independent variables. The ORs were adjusted for age and sex.

Results: Two Swedes and 149 immigrants participated; nearly all were working in the service sector. Long periods of sick leave were common, on average 47 weeks. All reported pain as their major problem, mostly in the back and shoulders, and 27.8% had three or more locations of enthesopathies. Pain anxiety (76% to 50%), self-reported inability to work (75% to 60%) and pain behaviour (68% to 54%) were common but diminished after treatment (p<0.001). The frequency of 100% sick leave in the past month decreased at the follow-ups, from 76% at the start to 48%, 44% and 51%, respectively (p<0.001). Persons with self-reported inability to work had ORs of 3.04 (95% CI 1.22-7.56) at the three-month follow-up, and 3.13 after one year (95% CI 1.26-7.80) for being on 100% sick leave, while persons with three or more enthesopathy locations had an OR of 2.98 (95% CI 1.19-7.44) after three years. Previous durations of 100% sick leave of more than three months had significant ORs varying from 5.19 to 2.89.

Conclusion: The number of persons on 100% sick leave declined significantly after this treatment. The risk factors for future 100% sick leave were, in the short term, self-reported inability to work and, in the long term, multiple enthesopathies.     

Hypertension management in general practice.

The views of 542 general practitioners (GPs) and 64 consultant physicians about the management of patients with hypertension in general practice were sought by postal questionnaire. 325 (60%) of the GPs and 45 (70%) of the consultant physicians completed the questionnaire. For a 40-year-old man with no other cardiovascular risk factors most general practitioners would intervene with drugs at blood pressure levels specified in published guidelines, whereas many local consultants and older GPs would consider drug treatment at lower levels. About 75% of GPs, compared with 87% of consultants, would suggest drug treatment in a woman of 70 years with a BP of 180/100 mmHg. Although consultants tended to expect GPs to order more tests when investigating a patient with hypertension than the GPs actually did, both GPs and consultants would order similar types of investigations apart from imaging. Consultants had different expectations about the frequency with which general practitioners should record patients' blood pressure and the GPs' ability to prevent cardiovascular events in hypertensive patients. Many older GPs and consultants seem to have unrealistic expectations of the value of treating patients with hypertension.     

Long-term prognosis of acute low back pain in patients seen in general practice: a 1-year prospective follow-up study.

OBJECTIVES: We aimed to examine the prognosis of acute low back pain (LBP) in patients in general practice and to identify prognostic factors associated with the long-term prognosis based on information immediately available to the GP. METHOD: We conducted a prospective cohort study in general practice in Denmark. The patients were those aged 18-60 years consulting their GP due to an episode of LBP lasting less than 2 weeks. The GPs collected data regarding 34 exposure variables, including their global assessment of the likelihood of chronic LBP. Outcome variables were collected from the patients after 1, 6 and 12 months. The outcome measures were days on sick leave, and functional or complete recovery from LBP. RESULTS: In total, 503 (96%) patients were followed during the whole study period. Fifty per cent of the patients on sick leave returned to work within 8 days; after 1 year, only 2% remained on sick leave. At the 1-year follow-up, 45% of the patients continued to complain of LBP. Logistic regression analyses showed that the factors most significantly associated with poor long-term LBP outcome were (i) severity of LBP at inclusion, (ii) assessments by the GP of susceptibility to develop chronic LBP and (iii) a history of LBP having caused previous sick leave. CONCLUSIONS: LBP in general practice has a good prognosis with regard to sick leave, but a high proportion of patients continue to complain of LBP. We were not able to identify objective measures that strongly predict the prognosis of the individual LBP patient. The overall assessment by the GPs seems to be the most important predictor associated with the long-term outcome.     

Correspondence in Stakeholder Assessment of Health,Work Capacity and Sick Leave in Workers with Comorbid Subjective Health Complaints? A Video Vignette Study

Purpose The purpose of this study is to test if there is correspondence in stakeholders’ assessments of health, work capacity and sickness certification in four workers with comorbid subjective health complaints based on video vignettes. Methods A cross sectional survey among stakeholders (N = 514) in Norway in 2009/2010. Logistic regression and multinomial logistic regression was used to obtain the estimated probability of stakeholders choosing 100 % sick leave, partial sick leave or work and the estimation of odds ratio of stakeholder assessment compared to the other stakeholders for the individual worker. Results The supervisors were less likely to assess poor health and reduced work capacity, and more likely to suggest partial sick leave and full time work compared to the GPs for worker 1. The public was less likely to assess comorbidity and reduced work capacity, and 6 and 12 times more likely to suggest partial sick leave and full time work compared to the GPs for worker 1. Stakeholders generally agreed in their assessments of workers 2 and 3. The public was more likely to assess poor health, comorbidity and reduced work capacity, and the supervisors more likely to assess comorbidity and reduced work capacity, compared to the GPs for worker 4. Compared to the GPs, all other stakeholders were less likely to suggest full time work for this worker. Conclusions Our results seem to suggest that stakeholders have divergent assessments of complaints, health, work capacity, and sickness certification in workers with comorbid subjective health complaints.     

Meeting and treating cultural difference in primary care: a qualitative interview study

BACKGROUND: Primary care doctors see patients from diverse cultural backgrounds and communication plays an important role in diagnosis and treatment. Communication problems can arise when patient and doctor do not share the same cultural background. OBJECTIVE: The aim of this study was to examine how consultations with immigrant patients are understood by GPs and how GPs manage these consultations. METHODS: Semi-structured interviews with GPs about their experiences with immigrant patients were recorded on audio-tape, transcribed and analysed using a qualitative thematic analysis methodology. A constructivist approach was taken to analysis and interpretation. RESULTS: Culture is not in focus when GPs meet immigrant patients. The consultation is seen as a meeting between individuals, where cultural difference is just one of many individual factors that influence how well doctor and patient understand each other. However, when mutual understanding is poor and the consultation not successful, cultural differences are central. The GPs try to conduct their consultations with immigrant patients in the same way that they conduct all their consultations. There is no specific focus on culture, instead, GPs tend to avoid addressing even pronounced cultural differences. CONCLUSION: This study indicates that cultural difference is not treated in GPs consultation with immigrant patients. Learning about cultural difference's effect on mutual understanding between doctor and patient could improve GPs cross-cultural communication. Increased awareness of the culture the doctor brings to the consultation could facilitate management of cross-cultural consultations.     

Improving motivation and goal setting for return to work in a population on sick leave: a controlled study

AIM: Limited knowledge precludes evidence-based interventions targeting return to work among employees on sick leave. The objective of this study was to examine the vocational effect of an intervention focused on motivation, goal setting, and planning of return to work. DESIGN AND METHODS: A total of 2,795 people, across 6 municipalities, on sick leave for at least 21 days received a questionnaire; 1,256 with a self-assessed poor prognosis for fast return to work were eligible for the study. An examination by a specialist in social medicine, followed by additional counselling by a social worker, was offered to 510 residents in two municipalities and accepted by 264 (52%). The goal was to enhance motivation, goal setting, and planning of return to work. Residents in the remaining municipalities (n=746) received the standard case management offered by the municipalities; 845 (67%) persons completed a follow-up questionnaire gathering data on general health and employment status. The duration of the sick leave was analysed by Cox regression, and the chance of being gainfully employed was analysed by logistic regression analysis, both adjusted for several covariates. RESULTS: The intervention neither shortened sick leave periods nor increased the likelihood of gainful employment after one year (OR 0.76; 95% CI 0.45-1.28). CONCLUSIONS: A low-cost counselling programme addressing motivation, goal setting, and planning of return to work did not improve vocational outcomes or reduce the duration of sick leave.     

Impact of support initiatives on retaining rural general practitioners

OBJECTIVE: This study aimed to evaluate the impact of the Dr DOC program, a rural doctor workforce support program, which consists of social and psychological support and practical interventions, on the well-being and retention of rural GPs. DESIGN: Rural GPs were assessed on different aspects of well-being and their intentions to leave rural general practice, and these were compared with similar data collected two years prior. SETTING: Rural general practices in South Australia. PARTICIPANTS: Two hundred and twenty-one rural GPs (55% of South Australian rural GP workforce). MAIN OUTCOME MEASURES: GPs completed a questionnaire assessing their levels of support, intention to leave rural practice, use of the dr doc program, and psychological health. RESULTS: Improvements were found in the support networks and in the physical and emotional health of rural GPs from time 1 to time 2. There was also a reduction in the number of GPs wanting to leave rural general practice in the short to medium term (from 30% to 25%). CONCLUSIONS: The initial study in this series suggested that improving psychological well-being might influence rural GPs' intentions to leave rural practice. The current study confirms these suggestions by demonstrating that programs targeted at psychological and physical well-being do indeed impact on rural GPs' intentions to leave. The results of this study highlight the role of psychological well-being in retaining rural GPs and emphasise the value of developing psychologically based programs to not only boost the physical and mental health of GPs, but also to reduce departure from rural areas.     

Acute bronchiolitis management in Tunisia: Impact of the national guidelines

Background:Acute bronchiolitis management involves all pediatricians and primary care physicians. The national guidelines for bronchiolitis diagnosis and treatment were published in Tunisia to reduce excessive use of diagnostic tests and unify bronchiolitis management. Objectives:We aimed to assess the real impact of the national guidelines on acute bronchiolitis management in Tunisia. Methods:We conducted an evaluative cross-sectional study. We randomly distributed anonymous questionnaires to physicians managing acute bronchiolitis during the period from 1st March 2014 to 30 November 2015. Results:We analyzed 140 questionnaires. Ninety-three interviewed physicians (66.4%) were advised of the latest national guidelines, half of them (33.6%) declared they didn’t follow these guidelines. Real and complete guidelines adherence was observed in only 1.4% of interviewed physicians. According to bronchiolitis diagnosis, appropriate Chest X-rays and blood tests were requested respectively by 57.8% and 59.3% of interviewed doctors. Regarding bronchiolitis therapeutic management, bronchodilators and epinephrine nebulization weren’t prescribed by respectively 45.7% and 38.6% of them. Antibiotics were prescribed by 92.9% of interviewed doctors and chest physiotherapy was well indicated by 47.8% of them. Conclusions:There is a disconnect between the bronchiolitis guidelines and clinical practice. National strategies have to be developed to reduce excessive use of diagnostic tests and unrecommanded therapies.     

Choosing to biopsy or refer suspicious Melanocytic lesions in general practice

ABSTRACT: BACKGROUND: General practitioners (GPs) are involved in the management of most melanocytic skin lesions in Australia. A high quality biopsy technique is a crucial first step in management, as it is recognized that poor techniques can mislead, delay, or miss a diagnosis of melanoma. There has been little published on the biopsy decisions and techniques of GPs. This study aims to describe the current management choices made by GPs for suspicious melanocytic skin lesions and to compare their choices with the best practice guidelines. METHODS: An anonymous survey of GPs presented with three clinical scenarios with increasing complexity of melanoma in which a referral or biopsy decision was specified. RESULTS: 391 mailed surveys with a 76.3% response rate. Mean biopsy experience was 4.14 biopsies per GP per month. The rates of choosing to refer among the three scenarios were 31%, 52% and 81% respectively, with referral to surgery being the most common choice (81%). Most biopsy techniques (55%) were chosen according to best practice guidelines, although non-guideline biopsy techniques chosen included shave (n = 10), punch biopsy (n = 57), wide excisions (n = 65), and flaps (n = 10). The few GPs (n = 5) who identified themselves as skin specialist GPs were no more likely to adhere to guidelines than their colleagues. CONCLUSION: A majority of referrals and biopsies were chosen by GPs according to best practice guidelines, but concern remains for the high proportion of GPs making non-guideline based choices. How GPs choose to biopsy or refer needs further training, audit, and research if Australia is to improve the outcome of melanoma management in general practice.