Suchergebnisse

Background Continuity of care with a general practitioner (GP) is vital for management of chronic conditions including diabetes as it provides proactive care facilitating opportunities to prevent or delay progression of disease.
Aim To capture the proportion of time people with diabetes are under the protective effect of contact with a GP using the Cover Index and its effect on potentially preventable hospitalisation (PPH) and length of stay (LOS).
Methods The linked self-report and administrative health service data of 267,153 participants in the 45 and Up study in New South Wales (NSW) in 2006-2009, obtained from the NSW Centre for Health Record Linkage and the Australian Government Department of Human Services, were used. A cohort of 21,965 people aged 45+ years identified with diabetes before July 2009 and followed up to 2015 were included in the analysis. Time duration protective effect of GP contact was estimated according to severity of diabetes using threshold effect models and then used to calculate the Cover Index. The effect of levels of GP cover on PPH and unplanned PPH and related LOS were estimated using negative binomial models weighted for the inverse probability of treatment to control for observed pre-treatment covariate imbalance.
Results Perfect GP cover was observed among 56% of people in the study cohort. Compared with low GP cover, having perfect GP cover was significantly associated with lower PPH (IRR 0.21, 95%CI 0.13-0.35), LOS for PPH (IRR 0.12, 95%CI 0.06-0.24), unplanned PPH (IRR 0.36, 95%CI 0.19-0.68) and LOS for unplanned PPH (IRR 0.39, 95%CI 0.17-0.85) after controlling for the observed pre-treatment covariate imbalance.
Conclusion This study suggests that longitudinal continuity of care measured by incorporating a time protective effect of a GP (cover) may be an important factor associated with reduction in PPHs and length of stay independent of other measures of longitudinal continuity.

Approximately 50% of the people with COPD are not aware of having the disease. However, the prevalence of COPD is increasing. COPD threatens to become the third leading cause of death in Europe by 2020. This dissertation focusses on a short questionnaire with the ability to detect COPD aimed at people over forty. That is important, as the reduction in lung capacity in patients diagnosed with COPD can be limited and health care costs will eventually be lower, as previously conducted research has shown. When the general practitioner offers active assistance, twice as many patients fill in this questionnaire. This also goes for disadvantaged areas. It was found that the percentage of patients who smoked was very high, and so was their motivation to stop smoking. Politicians and policymakers should be asked to financially support the infrastructure, allowing COPD patients to be detected earlier.

Background and rationale We have previously reported decreased rates and costs of diabetes-related hospitalisations with increasing regularity of general practitioner (GP) contact. However previous work has not adjusted for continuity of provider. Thus, despite the relevance for policy development, whether increased regularity is actually a proxy for, or a consequence of, increasing continuity of provider, or is a discrete facet of continuity of care is unknown.
Main Aim To assess the association between continuity of provider-adjusted regularity of GP contact and unplanned diabetes-related hospitalisation or emergency department (ED) presentation.
Methods/Approach This retrospective, cross-sectional study used linked administrative (from the Centre for Health Record Linkage & the Department of Human Services) and survey data from the baseline 45 and Up Study (2006-09 n=267,153) with a history of diabetes and at least two GP contacts (n=27,409). Multivariable zero-inflated negative binomial and two part generalised linear models were used to asses unplanned diabetes-related hospitalisations or ED presentations, associated costs and cumulative bed days.
Results Highest regularity of GP contact was associated with a lower probability (-0.28) of diabetes-related hospitalisation or ED presentations. For those with a previous hospitalisation or ED presentation, higher regularity was associated with a reduction in the number of hospitalisations or ED presentations (6 to 8%); bed days (30 to 44%); and average cost (23 to 41%). Importantly, continuity of provider did not significantly modify the effect of GP regularity for any outcome.
Conclusion Higher regularity of GP contact – that is more evenly dispersed, not necessarily more frequent care – has the potential to reduce health care costs and, for those with a previous hospitalisation, the time spent in hospital, irrespective of continuity of provider. These findings argue for the advocacy of regular care, as distinct from solely continuity of provider, when designing policy and financial incentives for GP-led primary care.

<i>Introduction:</i> Buprenorphine has already been registered in 27 European countries for maintenance therapy in opioid-dependent patients. In our office-based prescription study we applied sublingual buprenorphine, initiating the treatment at the addiction clinic with subsequent treatment at the offices of general practitioners (GPs) to evaluate its efficacy and feasibility in two different treatment settings. <i>Methods:</i> Sixty opioid-dependent patients were studied for a period of 15 weeks. The first 3 weeks of treatment initiation took place at the addiction clinic, followed by 12 weeks of treatment by GPs. Mean outcome measures were retention rate and additional consumption of illicit substances in addition to the evaluation of whether buprenorphine can be prescribed successfully by GPs. <i>Results:</i> The retention rate was 57% (n = 34). No significant differences occurred between the treatment phases at the specialized addiction unit and the GPs' offices. During the 15-week period a significant improvement in well-being and a significant reduction in craving for heroin (p < 0.001) and cocaine (p < 0.001) could be calculated for patients stabilized on a mean dose of 16 mg buprenorphine. Furthermore a significant reduction in additional consumption of opioids (p < 0.001) was found. <i>Discussion:</i> Our results show the involvement of office-based prescription, which should further encourage colleagues to treat opioid-dependent subjects with buprenorphine to make more treatment options for this target group available.

Aim: This study investigated the career preferences of medical graduates in Germany with regard to discipline, place and position after the completion of postgraduate training. We also investigated differences in career options according to gender and region of study (former German Federal Republic vs. former German Democratic Republic). Method: The study is based on a standardised postal survey among all last year medical students in the medical faculties of Erlangen, Giessen, Hamburg, Heidelberg, Cologne, Leipzig and Magdeburg in 2009. 2 107 persons were contacted and 1 012 (48%) participated in the survey. Results: 96% of participants stated their intention to pursue a postgraduate training in a medical discipline, and only 0.4% denied such an objective. 7% of the graduates preferred a career towards general practice, and a similar percentage preferred general internal medicine which usually also leads to a primary care activity. 84% aimed at becoming a medical specialist. In total, 28% intended to work in a specialist practice, and 10% in a general practice. Only one-fifth of the latter aimed at working in a countryside setting. 7% aimed at starting postgraduate training outside of Germany, and 8% preferred to work outside Germany after completion of the postgraduate training. In both cases, Switzerland was by far the most preferred country. Conclusions: The results contradict the thesis that young graduates are reluctant to enter clinical medicine. Working abroad is within the scope of less than 10% of the graduates. A dramatic difference between the demand for general practitioners and the career intentions of medical graduates is observed. Measures to increase the attractiveness of primary care, especially in the countryside, are urgently needed.

ObjectivesMore than one in four 11-year-old children in England are living with obesity. The implications for future musculoskeletal health remain unclear. We assessed whether general practitioner consultations for knee pain were more likely among children with obesity, and how this varied by sex, ethnic background, and area-level deprivation.
ApproachOf 61,478 11-year-old NCMP participants (2013-19), we linked 60,723 (98.8%) to their primary care records. 58,761 children (50.9% male) had no recorded knee pain consultation (including arthralgia and Osgood-Schlatter's disease) prior to the NCMP measurement date. We calculated the proportion with a consultation for knee pain by ethnic-adjusted weight status (underweight<2nd; overweight≥91st; obese≥98th centile), sex, ethnic background and Index of Multiple Deprivation quintile. We studied time to first general practitioner consultation for knee pain after the NCMP date by fitting Cox proportional hazards models, estimating mutually-adjusted hazard ratios (aHRs) and 95% confidence intervals (CI) for boys and girls separately.
ResultsWe identified 2503 (4.3%) children with at least one consultation for knee pain after the NCMP date. Boys were more likely to consult than girls (mean difference 1.5%; 95% CI: 1.2,1.9). Median time to first knee pain consultation was 1.88 years (IQR: 0.94,2.93). In adjusted analyses, boys with underweight (aHR 0.16; 95% CI: 0.05,0.51), from South Asian ethnic backgrounds (0.80; 0.69,0.92) and living in less deprived areas (Wald test statistic: 11.41; p-value=0.0223) were less likely, and those from Black ethnic backgrounds (1.31; 1.13,1.51) more likely, to consult with knee pain. Girls from South Asian ethnic backgrounds (0.70; 0.59,0.84) and those living in less deprived areas (15.44; p-value=0.0039) were less likely, and those with a BMI considered obese (1.30; 1.10,1.54) more likely to do so.
ConclusionAdolescent girls, but not boys, living with obesity are more likely to consult their general practitioner with knee pain. Ethnic differences in knee pain consultations merit further study. Linkage of primary care and NCMP records enables greater understanding of health service utilisation by children by weight status and demographic characteristics.

OBJECTIVE: To evaluate the effectiveness of a government-regulated rehabilitation guideline compared with education and activation by general practitioners, and to a preferred-provider insurance-based rehabilitation programme on self-reported global recovery from acute whiplash-associated disorders (WAD) grade I-II. DESIGN: Pragmatic randomised clinical trial with blinded outcome assessment. SETTING: Multidisciplinary rehabilitation clinics and general practitioners in Ontario, Canada. PARTICIPANTS: 340 participants with acute WAD grade I and II. Potential participants were sampled from a large automobile insurer when reporting a traffic injury. INTERVENTIONS: Participants were randomised to receive one of three protocols: government-regulated rehabilitation guideline, education and activation by general practitioners or a preferred-provider insurance-based rehabilitation. PRIMARY AND SECONDARY OUTCOME MEASURES: Our primary outcome was time to self-reported global recovery. Secondary outcomes included time on insurance benefits, neck pain intensity, whiplash-related disability, health-related quality of life and depressive symptomatology at 6 weeks and 3, 6, 9 and 12 months postinjury. RESULTS: The median time to self-reported global recovery was 59 days (95% CI 55 to 68) for the government-regulated guideline group, 105 days (95% CI 61 to 126) for the preferred-provider group and 108 days (95% CI 93 to 206) for the general practitioner group; the difference was not statistically significant (Χ2=3.96; 2 df: p=0.138). We found no clinically important differences between groups in secondary outcomes. Post hoc analysis suggests that the general practitioner (hazard rate ratio (HRR)=0.51, 95% CI 0.34 to 0.77) and preferred-provider groups (HRR=0.67, 95% CI 0.46 to 0.96) had slower recovery than the government-regulated guideline group during the first 80 days postinjury. No major adverse events were reported. CONCLUSIONS: Time-to-recovery did not significantly differ across intervention groups. We found no differences between groups with regard to neck-specific outcomes, depression and health-related quality of life. TRIAL REGISTRATION NUMBER: NCT00546806.

Objective To evaluate the effectiveness of a government-regulated rehabilitation guideline compared with education and activation by general practitioners, and to a preferred-provider insurance-based rehabilitation programme on self-reported global recovery from acute whiplash-associated disorders (WAD) grade I-II. Design Pragmatic randomised clinical trial with blinded outcome assessment. Setting Multidisciplinary rehabilitation clinics and general practitioners in Ontario, Canada. Participants 340 participants with acute WAD grade I and II. Potential participants were sampled from a large automobile insurer when reporting a traffic injury. Interventions Participants were randomised to receive one of three protocols: Government-regulated rehabilitation guideline, education and activation by general practitioners or a preferred-provider insurance-based rehabilitation. Primary and secondary outcome measures Our primary outcome was time to self-reported global recovery. Secondary outcomes included time on insurance benefits, neck pain intensity, whiplash-related disability, health-related quality of life and depressive symptomatology at 6 weeks and 3, 6, 9 and 12 months postinjury. Results The median time to self-reported global recovery was 59 days (95% CI 55 to 68) for the government-regulated guideline group, 105 days (95% CI 61 to 126) for the preferred-provider group and 108 days (95% CI 93 to 206) for the general practitioner group; the difference was not statistically significant (X 2 =3.96; 2 df: P=0.138). We found no clinically important differences between groups in secondary outcomes. Post hoc analysis suggests that the general practitioner (hazard rate ratio (HRR)=0.51, 95% CI 0.34 to 0.77) and preferred-provider groups (HRR=0.67, 95% CI 0.46 to 0.96) had slower recovery than the government-regulated guideline group during the first 80 days postinjury. No major adverse events were reported. Conclusions Time-to-recovery did not significantly differ across intervention groups. We found no differences between groups with regard to neck-specific outcomes, depression and health-related quality of life.

Naeem Mubarak,1 Sarwat Ali Raja,1 Asma Sarwar Khan,1,2 Sabba Kanwal,1 Nasira Saif-ur-Rehman,1 Muhammad Majid Aziz,1 Irshad Hussain,3 Ernieda Hatah,4 Che Suraya Zin5 1Department of Pharmacy Practice, Lahore Medical & Dental College, University of Health Sciences, Lahore, Punjab, Pakistan; 2Department of Pharmacy Practice, University of Health Sciences, Lahore, Punjab, Pakistan; 3Department of Pharmacy, Shaheed Mohtarma Benazir Bhutto Medical University, Larkana, Sindh, Pakistan; 4Department of Pharmacy, The National University of Malaysia, Bangi, Malaysia; 5Kulliyyah of Pharmacy, International Islamic University, Kuantan, MalaysiaCorrespondence: Naeem MubarakLahore Medical & Dental College, University of Health Sciences, Tulspura, North Canal Bank, Lahore, 53400, PakistanTel +92 42-37392208Email naeem.mubarak@lmdc.edu.pkChe Suraya ZinUniversiti Islam Antarabangsa, Malaysia Kampus Kuantan, Pahang Darul Makmur, Jalan Sultan Ahmad Shah, Bandar Indera Mahkota, Kuantan, Pahang, 25200, MalaysiaTel +60 11-14881605Email chesuraya@iium.edu.myBackground: There is a growing global interest in formulating such policies and strategic plans that help devise collaborative working models for community pharmacists (CPs) and general practitioners (GPs) in primary care settings.Objective: To conceptualize a stakeholder-driven framework to improve collaboration between CPs and GPs in Malaysian primary care to effectively manage medicines in chronic diseases.Design and Setting: A qualitative study that involved individual semi-structured interviews of the leadership of various associations, guilds, and societies representing CPs, GPs, and Nurses in Malaysia.Methods: This study collected and reported data in accordance with the guidelines of the Consolidated Criteria for Reporting of Qualitative Studies. Key informants were recruited based on purposive (expert) sampling. Interviews were transcribed verbatim and data were coded based on the principles of thematic analysis in NVivo.Results: A total of 12 interviews (5 CPs, 5 GPs, and 2 nurses) were conducted. Five themes emerged: Theme 1 highlighted a comparison of community pharmacy practice in Malaysia and developed countries; Theme 2 involved current practices in Malaysian primary care; Theme 3 encompassed the advantages of CP–GP collaboration in chronic diseases; Theme 4 highlighted the barriers which impede collaboration in Malaysian primary care; and Theme 5 delineated the way forward for CP–GP collaboration in Malaysia.Conclusion: The actionable insights obtained from the Malaysian stakeholders offered an outline of a framework to enhance collaboration between CPs and GPs in primary care. Generally, stakeholders were interested in CP–GP collaboration in primary care and identified many positive roles performed by CPs, including prescription review, adherence support, and patient education. The framework of the way forward includes: separation of CP and GP roles through a holistic revision of relevant legislation to grant an active role to CPs in chronic care; definition of protocols for collaborative practices; incentivization of both stakeholders (CPs and GPs); and design and implementation of an effective regulatory mechanism whereby the Malaysian Ministry of Health may take a leading role.Keywords: community pharmacist, general practitioner, chronic disease, collaborative care, Malaysia, qualitative research medicine management

Abstract Background In a General Practitioner (GP) setting, preventative medicine is reported as the predominant source of health care for the well-child. However, the role of the GP in well-child health care is not well understood in Australia. The aim of this study was to describe the role of the GP in providing services for well-children and families in Australia. Methods This was a qualitative descriptive study. Face-to-face interviews were held with 23 GPs to identify their role in the provision of well-child health care. Participants worked in a variety of general practice settings and 21 of the 23 GPs worked in the Greater Western Sydney area. Results Five main themes were identified in the analysis: 'prevention is better than cure', 'health promotion: the key messages', 'working with families', 'working with other health professionals', and 'barriers to the delivery of well-child health services'. Conclusions Participating GPs had a predominantly preventative focus, but in the main well-child care was opportunistic rather than proactive. The capacity to take a primary preventative approach to the health of children and families by GPs is limited by the increasing demands to manage chronic disease. Serious consideration should be given to developing collaborative models of care where GPs are joined up with services funded by State and Territory governments in Australia, such as the universal maternal child and family health nursing services that have well children and families as their prime focus.

Background with rationalePseudonymised UPRNs based on patient addresses can be used to link environmental information to electronic health records (EHRs), however the representativeness and potential demographic or health-related biases in linkage using existing address-matching algorithms have not been evaluated using patient addresses.
Main AimTo evaluate representativeness and bias in assigning UPRNs using an address-matching algorithm based on general practitioner (GP)-recorded patient addresses for a geographically-defined multi-ethnic inner city population.
MethodsWe evaluated the Discovery Programme deterministic address-matching algorithm, comprising 213 rules applied, in rank order of minimising false positives, to the GP-recorded address of 879,286 (48% female) patients currently registered with all GP practices in four boroughs in inner east London.
We used logistic regression to estimate the adjusted odds (aOR) of an address not being linked to a UPRN by: age band (reference group: <1 year), sex (female), ethnic group (White British), Index of Multiple Deprivation (IMD) quintile (most deprived), number of long-term conditions (none); and timing of GP registration (most recent quartile). We evaluated the linkage and algorithm error rates in an independent validated NHS address dataset using best practice linkage reporting standards.
Results99% of patients had a UPRN assigned. Men (aOR;95%CI:0.87;0.8,0.91), and patients aged 15-19 (0.51;0.39,0.68), 20-24 (0.67;0.51,0.89), or ≥90 years (0.35;0.83,0.91), of Chinese ethnic background (95% CI; 0.50; 0.45,0.56), or living in the least deprived IMD quintile (0.24; 0.20,0.30) were less likely, and those with a GP-registration preceding mid-2016 (p-value0.00) more likely, to have a UPRN assigned. The sensitivity, specificity, positive and negative predictive-values and F-measure of the algorithm were, respectively: 0.993, 0.019, 0.914, 0.204, and 0.9516.
ConclusionWe have demonstrated, for the first time, a high GP-address UPRN match rate and quantified error rates and biases for users. Further work is needed to investigate addresses in patients with more complex address histories.

BACKGROUND: There is a growing global interest in formulating such policies and strategic plans that help devise collaborative working models for community pharmacists (CPs) and general practitioners (GPs) in primary care settings. OBJECTIVE: To conceptualize a stakeholder-driven framework to improve collaboration between CPs and GPs in Malaysian primary care to effectively manage medicines in chronic diseases. DESIGN AND SETTING: A qualitative study that involved individual semi-structured interviews of the leadership of various associations, guilds, and societies representing CPs, GPs, and Nurses in Malaysia. METHODS: This study collected and reported data in accordance with the guidelines of the Consolidated Criteria for Reporting of Qualitative Studies. Key informants were recruited based on purposive (expert) sampling. Interviews were transcribed verbatim and data were coded based on the principles of thematic analysis in NVivo. RESULTS: A total of 12 interviews (5 CPs, 5 GPs, and 2 nurses) were conducted. Five themes emerged: Theme 1 highlighted a comparison of community pharmacy practice in Malaysia and developed countries; Theme 2 involved current practices in Malaysian primary care; Theme 3 encompassed the advantages of CP–GP collaboration in chronic diseases; Theme 4 highlighted the barriers which impede collaboration in Malaysian primary care; and Theme 5 delineated the way forward for CP–GP collaboration in Malaysia. CONCLUSION: The actionable insights obtained from the Malaysian stakeholders offered an outline of a framework to enhance collaboration between CPs and GPs in primary care. Generally, stakeholders were interested in CP–GP collaboration in primary care and identified many positive roles performed by CPs, including prescription review, adherence support, and patient education. The framework of the way forward includes: separation of CP and GP roles through a holistic revision of relevant legislation to grant an active role to CPs in chronic care; definition of protocols for collaborative ...

Introduction: Post-traumatic stress disorder is a major concern of the French Army Health Service who made military GPs the pivot of care courses and field actions. Previous works have shown that despite a good theoretical understanding of pathologies, difficulties remain in the care. We wanted to understand the motivations and the practices of military GPs about TPPT disregarding local opportunities. Patients and methods: A questionnaire by clinical cases was sent electronically to a sample of 400 metropolitan GPs. Results: 151 physicians answered our study. 66.1% had already established an initial diagnosis of traumatic mental disorder. They were related mainly with a military psychiatrist (93%). A restriction of fitness searched mainly to protect the patient from further traumatic encounter (44.5% in 1st choice). The identification of trauma patients had to apply to all personnel returning from foreign countries (88.1%) and by a self-administered questionnaire like PCL-S (23.9% in 1st choice) or collective information (21.8% in 1st choice). Responders were taking care of the direct and indirect witness of a traumatic event risk (71.9%) mainly to diagnose acute stress disorders (54.4% in 1st choice) using a collective information on psychological trauma (25.7% in 1st choice). The information provided to the patient on the evolution of disturbances was mainly focused on the need to support (36.3% in 1st choice) to positively support the evolution of symptoms (46.8% in 1st choice). Discussion: Despite the diversity of experiences and local practices, many principles of action are shared by military GPs. Early identifying and treat is approved by a large proportion of responders. Our study also shows the high exposure of healthcare professionals to traumatic situations. ; Introduction : Les troubles psychiques post-traumatiques sont une préoccupation majeure du Service de Santé des Armées qui a fait du médecin des forces le pivot du parcours de soin et des actions de terrain. Les travaux précédents ont montré que, malgré une bonne connaissance théorique des pathologies, des difficultés persistent dans la prise en charge. Nous avons donc voulu connaître les motivations et les pratiques des médecins généralistes militaires concernant les TPPT en faisant abstraction des possibilités locales. Matériels et méthodes : Un questionnaire par cas cliniques a été adressé par voie électronique à un échantillon de 400 médecins des forces métropolitains. Résultats : 151 médecins ont répondu à notre étude. 66,1% avaient déjà établi un diagnostic initial de traumatisme psychique. Ils étaient en lien principalement avec un psychiatre des armées (93%). Une restriction d'aptitude visait surtout à protéger le patient d'une nouvelle rencontre traumatique (44,5% en 1re modalité). Le repérage des patients traumatisés devait s'adresser à tous les personnels revenant de mission (88,1%) et ce par un auto-questionnaire de type PCL-S (23,9% en 1re modalité) ou une information collective (21,8% en 1re modalité). Les répondeurs prenaient en charge les témoins directs et indirects d'un évènement à risque traumatique (71,9%) en majorité pour diagnostiquer les états de stress aigu (54,4% en 1re modalité) en utilisant une information collective sur les traumatismes psychiques (25,7% en 1re modalité). L'information apportée au patient sur l'évolution des troubles étaient principalement focalisée sur la nécessité de prise en charge (36,3% en 1re modalité) afin de soutenir positivement l'évolution des symptômes (46,8% en 1re modalité). Discussion : Malgré la diversité des expériences et des pratiques locales, de nombreux principes d'action sont partagés par les médecins des forces. Le repérage et la prise en charge précoces des troubles sont approuvés par une large majorité de répondants. Notre étude montre également l'exposition élevée des professionnels de santé aux situations traumatiques.