Direct observation of counseling on colorectal cancer in rural primary care practices

To better understand colorectal cancer (CRC) screening practices in primary care, medical students directly observed physician-patient encounters in 38 physician offices. CRC was discussed with 14% of patients >or=50 years of age; 87% of discussions were initiated by the physician. The rate of discussions varied among the practices from 0% to 41% of office visits. Discussions were more common for new patient visits, with younger patients, and in the 24% of offices that utilized flow sheets. The frequency of CRC discussions in physician offices varies widely. More widespread implementation of simple office systems, such as flow sheets, is needed to improve CRC screening rates.     

Health care utilization and the proportion of primary care physicians

Background

The impact of primary care physicians on health care utilization remains controversial. Some have hypothesized that primary care physicians decrease health care utilization through enhanced coordination of care and a preventive care focus.

Methods

Using data from the Area Resource File (a Health Resources and Services Administration US county-level database) for the years 1990, 1995, and 1999, we performed a retrospective cross-sectional analysis with generalized estimating equations to determine if measures of health care utilization (inpatient admissions, outpatient visits, emergency department visits, and surgeries) were associated with the proportion of primary care physicians to total physicians within metropolitan statistical areas.

Results

The average proportion of primary care physicians in each metropolitan statistical area was 0.34 (SD 0.46, range 0.20-0.54). Higher proportions of primary care physicians were associated with significantly decreased utilization, with each 1% increase in proportion of primary care physicians associated with decreased yearly utilization for an average-sized metropolitan statistical area of 503 admissions, 2968 emergency department visits, and 512 surgeries (all P <.03). These relationships were consistent each year studied.

Conclusions

Increased proportions of primary care physicians appear to be associated with significant decreases in measures of health care utilization across the 1990s. National efforts aimed at limiting health care utilization may benefit from focusing on the proportion of primary care physicians relative to specialists in this country.     

Screening and treatment of diabetic nephropathy by primary care physicians

OBJECTIVE: To describe the practices of Indiana primary care physicians related to diabetic nephropathy screening and management. DESIGN: Cross-sectional, observational. SETTING: The state of Indiana. PARTICIPANTS: Active primary care physicians (defined as general internists, family practitioners, and general practitioners) in Indiana who provided care for diabetic patients at the time of the survey (n = 1,018) MEASUREMENTS AND MAIN RESULTS: Practice patterns relevant to microalbuminuria and overt albuminuria screening and management were assessed along two dimensions: the percentage of patients to whom the practices were applied and the frequency with which the practices were performed. Of 1,141 physicians who responded to the survey, 1,018 were eligible for analysis. Eighty-six percent of physicians reported screening more than half of their patients with type 1 diabetes for overt albuminuria, as did 82% of physicians for their patients with type 2 diabetes. Only 17% of physicians indicated performing microalbuminuria testing on more than half of their type 1 patients. Angiotensin-converting enzyme inhibitor agents were used frequently to treat abnormal urinary albumin excretion when hypertension was present, but less often when hypertension was absent. Physician specialty, year of graduation from medical school, practice location, and familiarity with the results of the Diabetes Control and Complications Trial were significant predictors of screening and treatment practice patterns. CONCLUSIONS: Primary care physicians report practices that allow them to detect overt albuminuria but not microalbuminuria. Angiotensin-converting enzyme inhibitors are frequently used by physicians who test for microalbuminuria, but efforts to increase the detection of early renal damage are needed so that these agents and other therapeutic strategies may be employed at the earliest opportunity.     

Ability of primary care physicians to diagnose and managePneumocystis carinii pneumonia

This study assesses the ability of primary care physicians to diagnose and managePneumocystis carinii pneumonia (PCP) in a standardized patient (SP) with unidentified HIV infection. One hundred thirty-four primary care physicians from five Northwest states saw an SP with unidentified HIV infection who presented with symptoms, chest radiograph, and arterial blood gas results classic for PCP. Seventy-seven percent of the physicians included PCP in their differential diagnoses and 71% identified the SP’s HIV risk. However, only a minority of the physicians indicated that they would initiate an appropriate diagnostic evaluation or appropriate therapy: 47% ordered a diagnostic test for PCP, 31% initiated an antibiotic appropriate for PCP, and 12% initiated an adequate dose of trimethoprim— sulfamethoxazole. Only 6% of the physicians initiated adjunctive prednisone therapy, even though prednisone was indicated because of the blood gas result. These findings suggest significant delay in diagnosis and treatment had these physicians been treating an actual patient with PCP. Presented at the International Conference on AIDS, Berlin, Germany, June 6 –11, 1993. Supported by grant number HS 06454-03 from the Agency for Health Care Policy and Research. Dr. Curtis is funded by the Robert Wood Johnson Clinical Scholars Program. The views expressed herein are those of the authors and are not necessarily the views of the Agency for Health Care Policy and Research or the Robert Wood Johnson Foundation.     

Frequency and impact of housestaff contact with primary care physicians

To determine how often housestaff notified primary care providers (PCPs) of admissions, whether notification prompted a visit, and whether PCP input impacted care, 210 medical inpatients were asked about their PCPs, and at discharge, housestaff completed a questionnaire on the patient’s PCP, and whether he or she was contacted, came to the hospital, and influenced care. Of 105 patients with a PCP, 74 were contacted and 26 visited their patients. The PCPs spoken with personally more often made hospital visits than those contacted only by message (p<0.0001). PCP input frequently contributed to patient care by providing continuity, clarifying history/diagnosis, managing chronic problems, and elucidating psychosocial/cultural factors. Having a PCP did not influence length of stay or readmission rates. Received from the Department of Medicine, University of Washington, Seattle, Washington.     

Rectal cancer: An evidence-based update for primary care providers

Rectal adenocarcinoma is an important cause of cancer-related deaths worldwide, and key anatomic differences between the rectum and the colon have significant implications for management of rectal cancer. Many advances have been made in the diagnosis and management of rectal cancer. These include clinical staging with imaging studies such as endorectal ultrasound and pelvic magnetic resonance imaging, operative approaches such as transanal endoscopic microsurgery and laparoscopic and robotic assisted proctectomy, as well as refined neoadjuvant and adjuvant therapies. For stage Ⅱ and Ⅲ rectal cancers, combined chemoradiotherapy offers the lowest rates of local and distant relapse, and is delivered neoadjuvantly to improve tolerability and optimize surgical outcomes, particularly when sphincter-sparing surgery is an endpoint. The goal in rectal cancer treatment is to optimize diseasefree and overall survival while minimizing the risk of local recurrence and toxicity from both radiation and systemic therapy. Optimal patient outcomes depend on multidisciplinary involvement for tailored therapy. The successful management of rectal cancer requires a multidisciplinary approach, with the involvement of enterostomal nurses, gastroenterologists, medical and radiation oncologists, radiologists, pathologists and surgeons. The identification of patients who are candidates for combined modality treatment is particularly useful to optimize outcomes. This article provides an overview of the diagnosis, staging and multimodal therapy of patients with rectal cancer for primary care providers.     

Issues related to colorectal cancer and colorectal cancer screening practices in women

Studies have shown that colorectal cancer (CRC) incidence is equal between men and women. However, several studies have demonstrated lower adenoma detection rates in women than in men. Many questions arise about differences in adenomas, CRC, and screening practices between men and women: should screening be the same for both sexes, are there differences in risk factors in the formation of colon cancer, should special groups of women be screened differently from the general population, are colonoscopies tolerated differently in women and why, and what determines if a woman will undergo colonoscopy? This article reviews these issues.     

Screening and follow-up of pregestational diabetes and gestational diabetes mellitus: A survey of primary care physicians in Belgium

AimsConsensus regarding the best screening and follow-up strategy for gestational diabetes mellitus (GDM) is lacking, resulting in heterogeneity in clinical practice. We aimed to evaluate screening and follow-up practices for pregestational type 2 diabetes (T2DM) and GDM in primary care in Belgium.MethodsWe performed an online survey among primary care physicians (PCPs) in the northern part of Belgium, Flanders.ResultsResponses were obtained from 379 PCPs. Approximately two thirds of participants estimated the prevalence of pregestational T2DM and GDM in Flanders at 5% and <10%, respectively. The risk of developing T2DM within 10 years after a history of GDM was estimated at <30% by nearly half of all participants. The majority of interviewed PCPs screen for pre-existing T2DM and GDM. For T2DM, fasting glycaemia was used by 92.2% whereas for GDM, 75.2% used the 50 g glucose challenge test (GCT). Fasting glycaemia was the preferred test for postpartum follow-up.ConclusionsWhile overall guideline adherence appears favourable, the prevalence of GDM is underestimated. Increased awareness on the long-term risk for women with a history of GDM is needed. The overall preference for the two-step strategy with GCT indicates that the 2019 Flemish guidelines on GDM screening are attainable in primary care.     

Self-perception of theoretical knowledges and practical skills by primary health care physicians in life-threatening emergencies according to their gender: A cross-sectional study

To assess the training received in Emergency Medicine (EM) by the Primary Health Care physicians of Asturias, as well as their perception of their own theoretical knowledge and practical skills in a series of procedures employed in life-threatening emergencies, and also to analyze the differences according to gender. The degree of preparation of Primary Health Care physicians for handling emergencies, according to the gender of the professionals, has never been studied before.Cross-sectional study of a sample of 213 Primary Health Care physicians from the Primary Health Care Service of Asturias, Spain, from among the total of 851 physicians on the staff of the Primary Health Care Service of Asturias. The survey was design ad hoc using the Body of Doctrine of Emergency Medicine proposed by the Spanish Society of Emergency Medicine, which indicates the theoretical and practical procedures that must be mastered by the Primary Health Care physicians.There are nonsignificant differences in the mean of theoretical knowledge and practical skills in many procedures or techniques studied depending on the gender.Female and male Asturian Primary Health Care physicians are generally well prepared to handle life-threatening emergencies. The degree of self-perception and acquisition of general theoretical knowledge and general practical skills for handling life-threatening emergencies is heterogeneous, and differences according to gender are not statistically significant.     

Epidemiological approaches to primary and secondary prevention of cancer

Summary Primary prevention of cancer requires control of both involuntary and voluntary exposures. Involuntary exposures include carcinogens in air and water, and various forms of radiation. Often these exposures are difficult to characterise individually and difficult to study epidemiologically. Although it is unlikely that they account for more than a small proportion of cancers, it is important that we refine our techniques of study to facilitate their control. Voluntary (lifestyle) exposures are responsible for the majority of cancers. In many developed countries, tobacco accounts for approximately 30% of cancer deaths, and major public health endeavours are justified to reduce this toll. Dietary factors may be as important, with dietary fat the most important risk factor, vegetables and fruits being protective. In several studies, including a cohort study in Canada, dietary fat increases breast cancer risk, though other studies have been negative. The evidence for fat increasing the risk of colorectal is more consistent. Epidemiology has shown that secondary prevention of cancer is applicable by screening for breast cancer with mammography with or without physical examination in women age 50–69, and screening for cervix cancer in women age 25–60 with cervical cytology. Organised screening programmes are essential to ensure that a high proportion of women are screened, and that the tests are high quality with adequate quality control. Under these circumstances screening every 2 years for breast cancer and every 3 years for cervix cancer is cost-effective. Screening for other cancers cannot be recommended currently. There is a time to effect that must be recognised in planning primary or secondary prevention. Full effect of most primary activities will not be achieved for decades, screening may require a decade. Available knowledge must be applied now, however, to ensure the effect will eventually be seen, as is now occurring in some countries with the downturn in lung cancer mortality following smoking reduction in men.The Journal of Cancer Research and Clinical Oncology publishes in loose succession Editorials and Guest editorials on current and/or controversial problems in experimental and clinical oncology. These contributions represent exclusively the personal opinion of the author The EditorsBased on a Plenary Lecture presented at the 15^th International Cancer Congress, Hamburg, 18 August 1990.     

The effects of two continuing medical education programs on communication skills of practicing primary care physicians

Purpose: To evaluate and compare the effects of two types of continuing medical education (CME) programs on the communication skills of practicing primary care physicians. Participants: Fifty-three community-based general internists and family practitioners practicing in the Portland, Oregon, metropolitan area and 473 of their patients. Method: For the short program (a 4 1/2-hour workshop), 31 physicians were randomized to either the intervention or the control group. In the long program (a 2 1/2-day course), 20 physicians participated with no randomization. A research assistant visited all physicians’ offices both one month before and one month after the CME program and audiotaped five sequential visits each time. Data were based on analysis of the content and the affect of the interviews, using the Roter Interactional Analysis Scheme. Results: Based on both t-test analysis and analysis of covariance, no effect on communication was evident from the short program. The physicians enrolled in the long program asked more open-ended questions, more frequently asked patients’ opinions, and gave more biomedical information than did the physicians in the short program. Patients of the physicians who attended the long program tended to disclose more biomedical and psychosocial information to their physicians. In addition, there was a decrease in negative affect for both patient and physician, and patients tended to demonstrate fewer signs of outward distress during the visit. Conclusion: This study demonstrates some potentially important changes in physicians’ and patients’ communication after a 2 1/2-day CME program. The changes demonstrated in both content and affect may have important influences on both biologic outcome and physician and patient satisfaction.     

Effect of training on adoption of cancer prevention nutrition-related activities by primary care practices: Results of a randomized, controlled study

OBJECTIVE: The National Cancer Institute (NCI) developed a manual to guide primary care practices in structuring their office environment and routine visits so as to enhance nutrition screening, advice/referral, and follow-up for cancer prevention. The adoption of the manual’s recommendations by primary care practices was evaluated by examining two strategies: physician training on how to implement the manual’s recommendations versus simple mailing of the manual. This article reports on the results of a randomized controlled trial to evaluate the effectiveness of these two strategies. DESIGN: A three-arm, randomized, controlled study. SETTING: Free-standing primary care physician practices in Pennsylvania and New Jersey. INTERVENTION: Each study practice was randomly assigned to one of three groups. The training group practices were invited to send one member from their practice of their choosing to a 3-hour “train-a-trainer” workshop, the manual-only-group practices were mailed the nutrition manual, and the control group practices received no intervention. For training group practices, training was provided in the four major components of the nutrition manual: how to organize the office environment to support cancer prevention nutrition-related activities; how to screen patient adherence to the NCI dietary guidelines; how to provide dietary advice/referral; and how to implement a patient follow-up system to support patients in making changes in their nutrition-related behaviors. MEASUREMENTS: The primary outcomes of the study were derived from two evaluation instruments. The observation instrument documented the tools and procedures recommended by the nutrition manual and adopted in patient charts and the office environment. The in-person structured interview evaluated the physician and staff’s self-reported nutrition-related activities reflecting the nutrition manual’s recommendations. Data from these two instruments were used to construct four adherence scores corresponding to the areas: office organization, nutrition screening, nutrition advice/referral, and patient follow-up. MAIN RESULTS: The adoption of the manual’s recommendations was highest among the practices in the training group as reflected by their higher adherence scores. They organized their office (P=.005) and screened their patients regarding their eating habits (P=.046) significantly more closely to the recommendations of the nutrition manual than practices in the manual-only group. However, despite being the highest in compliance, the training group practices were only 54.9% adherent to the manual’s recommendations regarding nutrition advice/referral, and 28.5% adherent to its recommendations on office organization, 23.5% adherent to its recommendations on nutrition screening, and 14.6% adherent to its patient follow-up recommendations. CONCLUSIONS: Primary care practices exposed to the nutrition manual in a training session adopted more of the manual’s recommendations. Specifically, practices invited to training were more likely to perform nutrition screening and to structure their office environment to be conducive to providing nutrition-related services for cancer prevention. The impact of the training was moderate and not statistically significant for nutrition advice/referral or patient follow-up, which are important in achieving long-term dietary changes in patients. The overall low adherence scores to nutrition-related activities demonstrates that there is plenty of room for improvement among the practices in the training group.     

palliative care and end-stage colorectal cancer management:The surgeon meets the oncologist

Colorectal cancer(CRC)is a common neoplasia in the Western countries,with considerable morbidity and mortality.Every fifth patient with CRC presents with metastatic disease,which is not curable with radical intent in roughly 80%of cases.Traditionally approached surgically,by resection of the primitive tumor or stoma,the management to incurable stageⅣCRC patients has significantly changed over the last three decades and is nowadays multidisciplinary,with a pivotal role played by chemotherapy(CHT).This latter have allowed for a dramatic increase in survival,whereas the role of colonic and liver surgery is nowadays matter of debate.Although any generalization is difficult,two main situations are considered,asymptomatic(or minimally symptomatic)and severely symptomatic patients needing aggressive management,including emergency cases.In asymptomatic patients,new CHT regimens allow today long survival in selected patients,also exceeding two years.The role of colonic resection in this group has been challenged in recent years,as it is not clear whether the resection of primary CRC may imply a further increase in survival,thus justifying surgeryrelated morbidity/mortality in such a class of shortliving patients.Secondary surgery of liver metastasis is gaining acceptance since,under new generation CHT regimens,an increasing amount of patients with distant metastasis initially considered non resectable become resectable,with a significant increase in long term survival.The management of CRC emergency patients still represents a major issue in Western countries,and is associated to high morbidity/mortality.Obstruction is traditionally approached surgically by colonic resection,stoma or internal by-pass,although nowadays CRC stenting is a feasible option.Nevertheless,CRC stent has peculiar contraindications and complications,and its long-term cost-effectiveness is questionable,especially in the light of recently increased survival.Perforation is associated with the highest mortality and remains mostly matter for surgeons,by abdominal lavage/drainage,colonic resection and/or stoma.Bleeding and other CRC-related symptoms(pain,tenesmus,etc.)may be managed by several mini-invasive approaches,including radiotherapy,laser therapy and other transanal procedures.     

Why older community-dwelling adults do not discuss urinary incontinence with their primary care physicians

OBJECTIVES: This study explored reasons why older adults with urinary incontinence (UI) do not initiate discussions with or seek treatment for UI from their primary care provider. DESIGN: A randomized, prospective controlled trial involving 41 primary care sites. SETTING: Primary care practice sites. PARTICIPANTS: 49 older adults age 60 and older not previously screened for UI by their primary care doctor. MEASUREMENTS: Demographic data, self-reported bladder-control information using questionnaires, and health status. RESULTS: Adults who did not discuss UI were older, had less-frequent leaking accidents and fewer nighttime voids and were less bothered by UI than those who did. The two main reasons why patients did not seek help were the perceptions that UI was not a big problem (45%) and was a normal part of aging (19%). CONCLUSIONS: Embarrassment or lack of awareness of treatment options were not significant barriers to discussing UI. Adults with a fairly high frequency of UI (average of 1.7 episodes per day) did not view UI as abnormal or a serious medical condition.     

Geographical variation and factors associated with colorectal cancer mortality in a universal health care system

OBJECTIVE:

To investigate the geographical variation and small geographical area level factors associated with colorectal cancer (CRC) mortality.

METHODS:

Information regarding CRC mortality was obtained from the population-based Manitoba Cancer Registry, population counts were obtained from Manitoba’s universal health care plan Registry and characteristics of the area of residence were obtained from the 2001 Canadian census. Bayesian spatial Poisson mixed models were used to evaluate the geographical variation of CRC mortality and Poisson regression models for determining associations with CRC mortality. Time trends of CRC mortality according to income group were plotted using joinpoint regression.

RESULTS:

The southeast (mortality rate ratio [MRR] 1.31 [95% CI 1.12 to 1.54) and southcentral (MRR 1.62 [95% CI 1.35 to 1.92]) regions of Manitoba had higher CRC mortality rates than suburban Winnipeg (Manitoba’s capital city). Between 1985 and 1996, CRC mortality did not vary according to household income; however, between 1997 and 2009, individuals residing in the highest-income areas were less likely to die from CRC (MRR 0.77 [95% CI 0.65 to 0.89]). Divergence in CRC mortality among individuals residing in different income areas increased over time, with rising CRC mortality observed in the lowest income areas and declining CRC mortality observed in the higher income areas.

CONCLUSIONS:

Individuals residing in lower income neighbourhoods experienced rising CRC mortality despite residing in a jurisdiction with universal health care and should receive increased efforts to reduce CRC mortality. These findings should be of particular interest to the provincial CRC screening programs, which may be able to reduce the disparities in CRC mortality by reducing the disparities in CRC screening participation.     

Survey of primary care physicians and home care clinicians

CONTEXT: Providing home care in the United States is expensive, and significant geographic variation exists in the utilization of these services. However, few data exist on how well physicians and home care providers communicate and coordinate care for patients. OBJECTIVE: To assess communication and collaboration between primary care physicians (PCPs) and home care clinicians (HCCs) within 1 primary care network. DESIGN: Mail survey. SETTING: Boston. PARTICIPANTS: Sixty-seven PCPs from 1 academic medical center-affiliated primary care network and 820 HCCs from 8 regional home care agencies. MEASUREMENTS: Provider responses RESULTS: Ninety percent of PCPs and 63% of HCCs responded. The majority (54%) of PCPs reported that they only "rarely" or "occasionally" read carefully the home care order forms sent to them for signature. Further, when asked to rate their prospective involvement in the decision making about home care, only 24% of PCPs and 25% of HCCs rated this as "excellent" or "very good." Although more HCCs (79%) than PCPs (47%) reported overall satisfaction with communication and collaboration, 28% of HCCs felt they provided more services to patients than clinically necessary. CONCLUSIONS: PCPs from 1 provider network and the HCCs with whom they coordinate home care were both dissatisfied with many aspects of communication and collaboration regarding home care services. Moreover, neither group felt in control of home care decision making. These findings are of concern because poor coordination of home care may adversely affect quality and contribute to inappropriate utilization of these services.