Low-budget method for lifestyle improvement in primary care. Experiences from the Göteborg Health Profile Project

OBJECTIVE: To describe a self-administered preventive tool dealing with risk factors for cardiovascular disease and its effect with special reference to the question: did the project involve persons most in need of lifestyle changes? DESIGN: Screening questions offered to consecutive patients and followed by a self-administered health profile, intervention, and follow-up. Setting. Primary healthcare area of Askim, Sweden. SUBJECTS: Men and women between 18 and 65 years of age visiting GPs for acute disorders or planned visits during a three-month period were offered screening questions and, if wanted, a health profile. MAIN OUTCOME MEASURES: Participation rates, effects on lifestyle factors. RESULTS: There was an overrepresentation of subjects with a less favourable lifestyle among those who asked for the health profile. There was good agreement for all variables between self-estimation in screening questions and grading in the basal health profile. Lifestyle improvement was observed for dietary habits, physical activity, and mental stress at the one year follow-up. CONCLUSIONS: The results indicate that a relevant selection of persons with a "risk profile" can be made by means of simple screening questions. The pedagogic model using self-administered health profile in combination with own responsibility seems to be a tool for low-budget preventive work in primary healthcare.     

Can quality improvement programs for depression in primary care address patient preferences for treatment?

BACKGROUND: Depression is common in primary care, but rates of adequate care are low. Little is known about the role of patient treatment preferences in encouraging entry into care. OBJECTIVES: To examine whether a primary care based depression quality improvement (QI) intervention designed to accommodate patient and provider treatment choice increases the likelihood that patients enter depression treatment and receive preferred treatment. METHODS: In 46 primary care clinics, patients with current depressive symptoms and either lifetime or current depressive disorder were identified through screening. Treatment preferences, patient characteristics, and use of depression treatments were assessed at baseline and 6 months by patient self-report. Matched clinics were randomized to usual care (UC) or 1 of 2 QI interventions. Data were analyzed using logistic regression models. RESULTS: For patients not in care at baseline, the QI interventions increased rates of entry into depression treatment compared with usual care (adjusted percentage: 50.0% +/- 5.3 and 33.0% +/- 4.9 for interventions vs. 15.9% +/- 3.6 for usual care; F = 12.973, P <0.0001). Patients in intervention clinics were more likely to get treatments they preferred compared with those in usual care (adjusted percentage: 54.2% +/- 3.3 and 50.7% +/- 3.1 for interventions vs. 40.5% +/- 3.1 for usual care; F = 6.034, P <0.003); however, in all clinics less than half of patients preferring counseling reported receiving it. CONCLUSIONS: QI interventions that support patient choice can improve the likelihood of patients receiving preferred treatments. Patient treatment preference appears to be related to likelihood of entering depression treatment, and patients preferring counseling may require additional interventions to enhance entry into treatment.     

A primary care lifestyle programme suitable for socioeconomically vulnerable groups – an observational study

Objective: To explore whether a primary health care (PHC) health promotion programme reaches and engages socioeconomically vulnerable groups in a community to the same extent as higher socioeconomic groups.

Design: Comparison of level of engagement and lifestyle improvements stratified by socioeconomic vulnerability level.

Setting: Hisingen PHC catchment area (130,000 inhabitants) Gothenburg, Sweden.

Participants: Men and women aged 18–79, visiting any of the eight public PHC centres during an eight-month period 2007–2008, were presented with a short intervention health questionnaire and offered a health dialogue with a nurse, including a health profile, p-glucose and blood pressure check. Participants were classified according to four socioeconomic vulnerability factors: education, employment, ethnicity and living situation.

Results: Out of 3691 participants, 27% had low education (Hisingen community level 23%), 18% were unemployed (community level 22%), and 16% were born outside Scandinavia (community level 22%). At the one-year follow-up, 2121 (57%) attended. At baseline, 3% of the individuals in the sample had three out of four socioeconomic vulnerability factors, 17% had two vulnerability factors, 43% had one vulnerability factor, and 37% had no vulnerability factors. Improved biological markers were seen in all vulnerability groups (1–3) and odds ratios for improvement were significantly higher in the most socioeconomically vulnerable group for smoking and stress compared to the group with no vulnerability factors.

Conclusion: Socioeconomically vulnerable groups were reached and lifestyle changes were accomplished to the same extent as in the higher socioeconomic groups in a PHC lifestyle intervention programme.

• KEY POINTS

• Primary care plays a major part in prevention of chronic diseases. However, non-pharmacological primary and secondary prevention is often less successful, especially concerning socioeconomically vulnerable groups.

• The health promoting intervention programme “Pro-Health” reached and engaged socioeconomically vulnerable groups.

• Participants from the socioeconomically vulnerable groups had comparable odds for lifestyle improvements after one year, compared to participants without vulnerability factors.

     

Population-focused care: a new rubric in the role definition for geriatric nurse practitioners in primary care practice?

Traditionally, geriatric nurse practitioners (GNPs) provide care to individual older adults and their families in a primary care practice. Although the goal is to provide high-quality, cost-effective care, GNPs may be providing ineffective care by narrowly focusing on individuals and their families. Given today's health care climate, it is essential that GNPs practice with a wider perspective. This is done by noting health issue trends among the specific older adult population that are targeted for care and planning that care with a population focus delineated by either health issues or characteristics of the older adult population.     

Guidelines for the management of headache in primary care: are they being used?

The uptake of guidelines for the management of headache in primary care was assessed using surrogate measures in patients with headache referred to secondary care (number of prior general practitioner attendances and medications prescribed). The results suggest that headache guidelines are seldom, if ever, applied in this geographical location.     

Emergency department care for low back pain: Should we adopt recommendations from primary care guidelines?

ED visits for low back pain are increasing, but the lack of specific guidance for emergency physicians impedes evidence‐based care, and adopting primary care recommendations may not be appropriate. The ED sees a different spectrum of low back pain presentations, where physicians are likely to encounter a larger proportion of patients with an underlying serious pathology or non‐spinal diseases than in primary care. Current low back pain guidelines do not adequately cover screening for these conditions, but making a differential diagnosis is crucial in emergency patients with low back pain. In this article, we also discuss the challenges in developing specific ED guidelines for low back pain, the limited evidence on the profile of these patients and the surprising dearth of randomised trials.     

Are preventable hospitalizations sensitive to changes in access to primary care? The case of the Oregon Health Plan

OBJECTIVE: To examine whether preventable hospitalization (PH) rates are sensitive to the impact of policies aimed at improving access, such as the Oregon Health Plan (OHP), which expanded Medicaid coverage to all adults with incomes under the federal poverty level. STUDY DESIGN: We conducted a retrospective, time series analysis of PH rates in Oregon from 1990 to 2000. We calculated hospitalization rates for ambulatory-care sensitive conditions for the Medicaid + uninsured population and compared average annual rates from 1990 to 1993 (pre-OHP implementation) to those from 1995 to 2000 (post-OHP implementation). We compared changes in PH rates over time in the Medicaid + uninsured group to changes in the non-Medicaid insured population. We standardized rates by age and sex and used logistic regression models to compare rates. RESULTS: Contrary to our hypothesis, annual PH rates in the Medicaid + uninsured population increased after the eligibility expansion, from an average of 46.1 to 54.9 per 10,000 persons. This rise was significant compared with the non-Medicaid insured population, who experienced a slight decline in annual PH rates, from 26.9 to 26.1 per 10,000 (P < 0.001, after adjusting for age, sex, and rates of unpreventable hospitalizations). The increase in overall PH rates for the Medicaid + uninsured population can be explained by an increase in PH rates for the newly insured group. CONCLUSIONS: Our results suggest that PH rates may vary not only with access to primary care (inversely) but also with access to hospital care (directly). The use of PH rates as a marker of health care access should take into account these dual influences. Limitations in available data may also contribute to perceived variation in PH rates unrelated to health care access.     

Dementia in primary care: why the low detection rate?

OBJECTIVE: The aim of the present study was to find reasons for the low detection rate of dementia in primary care. Another aim was to investigate the attitudes and knowledge on dementia among Swedish general practitioners (GPs). DESIGN: Two-hundred-and-twenty-eight postal questionnaires were distributed to GPs in the county of Osterg?tland. SETTING: Primary care in Sweden. MAIN OUTCOME MEASURES: The opinions of GPs on dementia management in primary care. RESULTS: The response rate was 67%. GPs showed a good knowledge of dementia diseases but underestimated the occurrence of dementia. They presented a positive attitude towards managing patients with dementia and considered that existing drug therapy justified an active search for patients with dementia in primary care, but they believed the efficacy of the drugs to be limited. Assessing the social environment of patients and organising social support were regarded as the most difficult tasks in the management of demented patients. CONCLUSION: The study indicates that the main obstacles are a lack of resources and a sceptical attitude to the benefits of drug treatment. Co-operation between the community services, specialist clinics and the primary care team should be improved.     

Dementia in primary care: why the low detection rate?

Objective - The aim of the present study was to find reasons for the low detection rate of dementia in primary care. Another aim was to investigate the attitudes and knowledge on dementia among Swedish general practitioners (GPs). Design - Two-hundred-and-twenty-eight postal questionnaires were distributed to GPs in the county of Östergötland. Setting - Primary care in Sweden. Main outcome measures - The opinions of GPs on dementia management in primary care. Results - The response rate was 67%. GPs showed a good knowledge of dementia diseases but underestimated the occurrence of dementia. They presented a positive attitude towards managing patients with dementia and considered that existing drug therapy justified an active search for patients with dementia in primary care, but they believed the efficacy of the drugs to be limited. Assessing the social environment of patients and organising social support were regarded as the most difficult tasks in the management of demented patients. Conclusion ? The study indicates that the main obstacles are a lack of resources and a sceptical attitude to the benefits of drug treatment. Co-operation between the community services, specialist clinics and the primary care team should be improved.