How do clinical nurse specialists influence primary care management of asthma? A qualitative study.

METHODS: We carried out a qualitative interview study alongside a randomised controlled trial which tested the effectiveness of asthma nurse specialists in east London. We carried out face-to-face interviews with five asthma nurse specialists, eight general practitioners (GPs) and six practice nurses, and also held a focus group session with six people who had attended hospital with acute asthma. RESULTS: Four factors were associated with effective specialist nurse liaison: (1) primary care practices which prioritised asthma care; (2) GPs who trusted practice nurses to manage chronic disease autonomously; (3) GPs who recognised specialist nurse expertise and acted on their advice; and (4) practices which had simple systems in place to deal with recommendations. Patients found nurse specialists approachable and informative. CONCLUSIONS: Asthma specialist nurse influence was greatest in practices that prioritised asthma care and where practice nurses had clinical autonomy. Patients valued specialist nurses but found advice from a multiplicity of clinicians confusing. Ensuring that practices prioritise chronic disease care, and improving the credibility of nurse specialists amongst GPs, may improve the effectiveness of asthma nurse specialists.     

Part II. General practitioner-specialist referral process

This is the second of two articles that explore the general practitioner (GP)-specialist relationship. In this article, we explore the nature of the referral process, beginning with referrals frequently made by GPs in Australia and reasons for referral to specialists. In Australia, GPs commonly refer patients to specialists, particularly orthopaedic surgeons, ophthalmologists, surgeons and gynaecologists for a variety of reasons, including diagnosis or investigation, treatment and reassurance (reassurance for themselves as well as reassurance for the patient). GPs will choose a specialist after considering a variety of factors, such as the specialist's medical skill, their previous experience with the specialist, the quality of communication between them, office location and patient preferences. The referral is generally made by telephone or by letter, the latter of which is known to vary significantly in content and quality. The specialist, GP and patient expectations of the referral and the consultation process are also described. Specialists expect the GP to provide information about the problem to be addressed and adequate patient history, GPs expect a clear response regarding diagnosis and management as well as justification for the course of action, and patients expect clear communication and explanation of the diagnosis, treatment and follow-up requirements. When these expectations remain unmet, GPs, specialists and patients end up dissatisfied with the referral process.     

On attitudes about colorectal cancer screening among gastrointestinal specialists and general practitioners in the Netherlands

AIM: To find out whether there are differences in attitudes about colorectal cancer (CRC) screening among gastrointestinal (GI) specialists and general practitioners (GPs) and which method is preferred in a national screening program METHODS: Four hundred and twenty Dutch GI specialists in the Netherlands and 400 GPs in Amsterdam were questioned in 2004. Questions included demographics, affiliation, attitude towards screening both for the general population and themselves, methods of screening, family history and individual risk. RESULTS: Eighty-four percent of the GI specialists returned the questionnaire in comparison to 32% of the GPs (P<0.001). Among the GI specialists, 92% favoured population screening whereas 51% of GPs supported population screening (P<0.001). Of the GI specialists 95% planned to be screened themselves, while 30% of GPs intended to do so (P<0.001). Regarding the general population, 72% of the GI specialists preferred colonoscopy as the screening method compared to 27% of the GPs (P<0.001). The method preferred for personal screening was colonoscopy in 97% of the GI specialists, while 29% of the GPs favoured colonoscopy (P<0.001). CONCLUSION: Screening for CRC is strongly supported by Dutch GI specialists and less by GPs. The major health issue is possibly misjudged by GPs. Since GPs play a crucial role in a successful national screening program, CRC awareness should be realized by increasing knowledge about the incidence and mortality, thus increasing awareness of the need for screening among GPs.     

Costs of ambulant care for patients with inflammatory bowel disease in general practice

BACKGROUND: Outpatient care managed by general practitioners plays an important role in diagnostic and treatment of inflammatory bowel diseases (IBD). The chronic recurrent course often requires intensive and costly medical care. OBJECTIVE: To measure the costs of outpatient care for patients with IBD provided by general practitioners (GPs). MATERIAL AND METHODS: The analysis is based on an electronic data base implemented in 100 general practices in different parts of Germany. 191 patients with altogether 705 consultations over a period of one year were included in the analysis. Costs of care were measured using German fee schedules for health care delivery and market prices for drugs. RESULTS: In a 12-months-period the mean number GP-contacts was 3.6. Mean costs were 23.61 euro; per visit and annual costs were 87.15 euro; per patient. Pharmacotherapy was used by 147 patients (77%) and caused costs of 613.40 euro; per year, with 64% due to the use of salicylates. 66 patients (35%) also had diagnostic services provided from specialists, 7 patients (4%) required psychotherapeutic care. CONCLUSION: The presented study is the first to analyse in detail the costs for medical care of IBD in general practices in Germany. Results can be used in economic assessment of the disease and in cost-effectiveness-analyses of intervention strategies. They may support treatment guidelines and treatment decisions from an economic point of view.     

French general practitioners' attitudes toward therapeutic advances in HIV care: results of a national survey

We aimed to assess attitudes to French primary care providers towards recent advances in HIV care. Telephone surveys in a random sample of French general practitioners (GPs) were carried out in April 1996 (response rate=70.3%; n=1186). Only 40.5% of the sample had participated in the regular medical follow-up of HIV-infected patients during the previous year. Among these 480 respondents, only a few (13.3%) declared that they would take care of an asymptomatic patient with a high (>500 cells/mm3) CD4 count as the unique provider. A majority (66.2%) had referred at least one HIV-infected patient to a hospital specialist in the previous year. A total of 31.4% declared that they considered it appropriate for an antiretroviral treatment to be initiated to an asymptomatic patient with 300 CD4 cells/mm3, and only 23.5% were already in favour of combination therapies rather than zidovudine monotherapy as treatment of choice. GPs with the most experience with HIV care tended to be the most reluctant to modify their attitude in favour of earlier initiation of antiretroviral therapies and of the switch from monotherapy to combination therapies. The survey suggests there is a gap between attitudes of GPs and those of AIDS specialists toward preliminary reports of therapeutic advances in HIV care. Whether or not such a gap may create problems for an appropriate diffusion of new antiretroviral therapies should be carefully monitored, in the context of current reforms emphasizing the key role of primary providers in most health-care systems.     

Treatment preferences,return visit planning and factors affecting hypertension practice amongst general practitioners and internal medicine specialists (The General Practitioner Hypertension Practice Study)

Abstract. Objectives. To study clinical practice and attitudes in hypertension care amongst general practitioners (GPs) and hospital internal medicine specialists. Design. Mailed case report questionnaires. Subjects. Ninety GPs and 69 internal medicine specialists at randomly selected primary health care centres and hospital outpatient departments. Main outcome measures. Case-bound treatment preferences, treatment goals and return visit planning, and views on factors influencing practice. Results. The participation rate was 84% and 70%, for GPs and internal medicine specialists, respectively. GPs more often proposed nonpharmacological therapy (P < 0.05), solely and as a complementary treatment, and prescribed more calcium antagonists (P < 0.001), whilst internal medicine specialists prescribed more ACE inhibitors (P < 0.001). Personal experience guides practice more than national consensus and economy, more so with increasing time since specialization. Conclusions. GPs and internal medicine specialists in Sweden report a hypertension practice closely related to each others' and to the intentions of national guidelines.     

Cost-effectiveness of introducing licensed GP practices to manage diabetes patients in Hungary

AimTo investigate the cost-effectiveness of the endowment of the same authority and responsibility in diabetes management to licensed GPs as licensed outpatient specialists in Hungary.MethodsThe Syreon Diabetes Control Model (SDM) was used to evaluate life expectancy, quality-adjusted life expectancy (QALY) and direct medical costs over patient lifetimes. Cohort characteristics were derived from national database, clinical history data of 476,211 persons with diabetes were used, treatment effects and costs were derived from literature, national databases and expert opinions.ResultsThe purchase of one additional quality adjusted life year with the use of licensed general practitioners was EUR 51,420 compared to making the service available only through universal GPs. The purchase of one additional quality adjusted life year through the service of licensed GPs is EUR 459,950 compared to outpatient care provision.ConclusionsThe management of diabetes care with licensed GPs has the potential to improve patients health gains compared to the current patterns of care in Hungary in a cost-effective way if licensed GPs are reimbursed below the average current cost of outpatient diabetes services. Increase of the capitation for diabetic patients would be a practical way to reimburse the GP’s additional service.     

Demenzkranke in der Hausarztpraxis – Ergebnisse einer Befragung

In line with the current demographic trends, the number of elderly suffering from dementia is increasing. GPs have a key position in dealing with these patients at the primary care level. Different aspects of care for patients suffering from dementia provided in general practice in Germany were assessed by means of a questionnaire (n = 563). The results highlight the role of GPs in the delivery of medical and psychosocial care. However, diagnosing dementia seems challenging and co-operation could be improved. Three fourths of the GPs diagnose vascular dementia more often than Alzheimer's disease, which is contrary to what is known from epidemiological findings. One third refers patients to a specialist on a regular basis for establishing the diagnosis. Only 4% of the German GPs entertain co-operative relationships with the "Alzheimer society" and the "Brain league". Consequences for improving these for patients with dementia and their families are discussed.     

Factors influencing the decision to start drug treatment in hypertension. A questionnaire study comparing general practitioners and hypertension specialists in Denmark

Objective. To determine the factors influencing treatment decisions in patients with hypertension. Methods. A postal questionnaire based on five constructed cases with hypertension was sent to 122 general practitioners (GPs) in the area around Herlev University Hospital and to 46 Danish hypertension specialists. The cases varied in gender, age, blood pressure, cholesterol, diabetes and smoking status and absolute risk for cardiovascular events. Results. Response rate was 46% for GPs and 59% for specialists. There were no significant differences in treatment decisions nor in drug choices for first-line monotherapy, which were diuretics, angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor antagonists in both groups of physicians. Blood pressure alone was the most important factor for instituting drug therapy according to 59% of the GPs and 56% of the specialists. There was no association between pre-treatment risk assessment and instituting treatment in either group in four out of five cases. Conclusions. We found agreement with respect to all treatment decisions between GPs and hypertension specialists. The results from this study suggest that, in both GPs and specialists, a blood pressure threshold approach to treating hypertension is still dominating.     

Doctors' estimation of cardiovascular risk and willingness to give drug treatment in hypertension: fair risk assessment but defensive treatment policy

OBJECTIVE: We studied the differences between recommendations given in the 1999 World Health Organization-International Society of Hypertension (WHO/ISH) Guidelines and doctors' risk estimation and willingness to give antihypertensive drugs. METHODS: A population-based sample, the WHO Multinational Monitoring of Trends and Determinants in Cardiovascular Disease (WHO MONICA) (n = 5997), was classified according to the 1999 WHO/ISH Hypertension Guidelines risk stratification scheme. A total of 54 subjects were randomly drawn from the 12 different risk categories. Written case stories were constructed based on risk-factor levels for each selected subject. SETTING AND PARTICIPANTS: Doctors (n = 139), comprising general practitioners (GPs, n = 110) and specialists in internal medicine or cardiology (specialists, n = 29), in northern Sweden assessed 12 cases each. MAIN OUTCOME MEASURES: Factors used in risk assessment, estimation of cardiovascular risk, and willingness to give antihypertensive drugs. RESULTS: In a multivariate logistic regression model including all doctors, most major risk factors were significantly associated with a higher estimated risk and willingness to give drug treatment. Estimated risk was lower than the risk classified by 1999 WHO/ISH Hypertension Guidelines, and there was no difference between GPs and specialists in this respect. The use of antihypertensive drugs was much lower than advocated by the guidelines, but specialists were more inclined to give antihypertensive drug treatment than GPs. CONCLUSIONS: Doctors estimated the cardiovascular risk as being less severe than the recommendation given in the 1999 WHO/ISH Hypertension Guidelines. Moreover, their willingness to prescribe antihypertensive drugs was also lower than that advocated by the guidelines. The control of hypertension is poor in the community today, and this seems to be the way the profession wants to have it.     

Underdiagnosis of Nocturnal Symptoms in Asthma in General Practice

Objective. To evaluate the prevalence of nocturnal symptoms in a large sample of asthmatic patients, and to assess the agreement between patients' complaints and general practitioners' (GPs') reports in primary care. Design. Cross-sectional survey involved 3,526 GPs and 751 specialists (pulmonologists and allergists) and included 13,493 patients with persistent asthma. Symptoms, treatment, and social and medical data were collected in real time by the patients and their GPs. Setting. France. Results. Prevalence of nocturnal symptoms was 60%. A total of 7,989 patients with nocturnal symptoms had complete data for both patients and GPs; 3,849 (48.1%) had perfect agreement between GP and their complaints for nocturnal symptoms (agreement group; [kappa = 1]); 3,376(42.2%) declared having no symptoms during the night, but these were detected by the GP during the visit (underestimated by patients and detected by GPs); 773(9.6%) declared having nocturnal symptoms, but these were not detected by GPs. Patients with a good agreement with their GP's opinion were significantly more frequently followed-up by a specialist than other patients (p = 0.002). Conclusions. Nocturnal symptoms appear to be underdeclared by patients. GPs should therefore systematically ask their patients about nocturnal symptoms to increase control of asthma and to adequately manage its treatment.     

Structuring Payment to Medical Homes After the Affordable Care Act

The Patient-Centered Medical Home (PCMH) is a leading model of primary care reform, a critical element of which is payment reform for primary care services. With the passage of the Affordable Care Act, the Accountable Care Organization (ACO) has emerged as a model of delivery system reform, and while there is theoretical alignment between the PCMH and ACOs, the discussion of physician payment within each model has remained distinct. Here we compare payment for medical homes with that for accountable care organizations, consider opportunities for integration, and discuss implications for policy makers and payers considering ACO models. The PCMH and ACO are complementary approaches to reformed care delivery: the PCMH ultimately requires strong integration with specialists and hospitals as seen under ACOs, and ACOs likely will require a high functioning primary care system as embodied by the PCMH. Aligning payment incentives within the ACO will be critical to achieving this integration and enhancing the care coordination role of primary care in these settings.     

The department of general internal medicine--a model of synoptic internal medicine at a university with primary care responsibilities

It is reported on the department of general internal medicine of the Friedrich Schiller University Jena and its position in the complex of the internal medical basic care. It is particularly dealt with the cooperation with the specialists for general medicine and the subspecialists. At this example the role of the "general" internal specialists and his tasks in care, research and education in a university clinic are discussed and the necessity of a profile determination is made clear.     

Atención a las enfermedades músculo-esqueléticas: distintas visiones del mismo problema

ObjectiveTo identify the main problems affecting general practitioners (GPs) and specialists in the care of the main musculoskeletal problems in Catalonia.MethodCross-sectional, self-administered survey in a representative sample of GPs and all specialists in four areas (orthopedic surgery, rheumatology, physical medicine and rehabilitation and pain units). Variables evaluated in the survey were related to socio-demographic data, attention to musculoskeletal diseases, self-declared expertise, referral process, coordination mechanisms and major constraints to provide high quality care.ResultsGPs value well their expertise in the management of musculoskeletal diseases (6,7 ± 1,0 on a scale of 1 to 10). Less than 25% of GPs are coordinated with hospital specialists. For them, waiting lists are the main problem (8.2 ± 1,6/10) followed by lack of feedback (8 ± 1,9/10) and poor coordination (7.8 ± 1,9/10). Referenced specialties should change for some diseases (back pain and osteoarthritis). Specialists are critical for GPs. For specialists, the main problems are excessive workload (7,8 ± 2/10) and the inefficiency of healthcare information systems (7.4 ± 2/10).ConclusionsThe vision of the problems affecting the care of musculoskeletal diseases differs between GPs and hospital specialists. The limited accessibility and workload excess, deficiencies in the flow of information and poor coordination are the most important problems in the proper care for musculoskeletal diseases.     

Palliation by laser photoablation: a multidisciplinary quality assessment.

To evaluate the quality of life and degree of palliation by laser photoablation for gastrointestinal cancer, a questionnaire was sent to general practitioners (GPs) and referring specialists. The response was 85%. General practitioners considered palliation by laser to be effective in 74% compared with 50% for referring specialists (p less than 0.001). Specialists felt themselves unable to answer in 17% compared with no GPs (p less than 0.001). The differences in assessment between specialists and GPs were most pronounced in colorectal cancers. There was a striking consensus of opinion about the rate of failed palliation among endoscopist, referring specialist, and GP. On the other hand, the rating of success by specialists and GPs was significantly lower than the endoscopist's evaluation. The endoscopist and GP were more at variance than the endoscopist and specialist. Above all, the GPs seemed to outweigh the burden against the benefits of treatment. Disagreement of the specialists and the GPs with the endoscopist about the outcome appeared to be related to unrealistic expectations, to a shift in presenting symptoms or to complications, misinterpreted as being laser-induced but mainly due to progression of disease.     

Asthma Management Failure: A Flaw in Physicians' Behavior or in Patients' Knowledge?

Objectives. Patient–physician communication and patients' knowledge about asthma are relevant factors that influence health outcomes. The aim of this study was to explore general practitioners' (GPs) behaviors, asthma patients' knowledge requirements, and the relationship between physicians' communicative issues, and failures in patients' knowledge. Methods. GPs participating in a continuing medical education program on asthma completed an ad hoc survey on communicative style and recruited at least three adult asthma patients to indicate, among 10 options, three aspects of asthma about which they felt less informed. Results. The survey was completed by 2332 GPs (mean age 54.39 ± 5.93 years) and 7884 patients (mean age 49.59 ± 18.03 years). Several ineffective strategies emerged in the physicians' behaviors: 28.5% of GPs did not encourage patients to express doubts, expectations, or concerns; 39.4% tried to frighten patients concerning disease-related risks; only 25.7% used a written action plan. In addition, 18.6% of GPs were not averse to informing the patient about potential side effects; 16.3% did not try to simplify asthma treatment; approximately 30% considered ease of use when selecting drugs; 18% were not disposed to carry out a partnership with the patient; 36.9% were unlikely to involve the patient in asthma management; and 73% tried to retain control over their patients. Finally, 90.3% of GPs declared they want to be consulted before any treatment change. The three topics on which patients felt less informed were the meaning of asthma control (14% of patients); integration of asthma into daily life (13.3%); and periodic checkups (12.7%). There were significant associations between patients' choices and physicians' answers. Conclusion. These results demonstrate that in general medicine the recommendations of international guidelines on education, communication, and development of a doctor–patient partnership are still ignored and that patients' educational priorities may differ from those identified by medical specialists and by patients belonging to patients' associations.     

Cardiovascular risk profile and risk stratification of the hypertensive population attended by general practitioners and specialists in Spain. The CONTROLRISK study

The CONTROLRISK study was designed to determine the cardiovascular risk profile of the hypertensive population attended at primary care and specialist setting in Spain and to investigate whether physicians stratify the risk correctly, according to the 2003 European guidelines. A total of 8920 patients were recruited from primary care (n=4485) and specialist outpatient clinic (n=4435). The age criteria was 62.6+/-11.1 years; 51.6% were women. No differences were observed in the severity of hypertension. More than 85% presented other cardiovascular risk factors, similarly in both groups. Target organ damage (TOD) and associated clinical conditions (ACC) were more frequent in specialist setting (57.6 vs 34.3% and 39 vs 28.7%, both P<0.0001). The most common risk factor was age. The most frequently reported TOD was left ventricular hypertrophy (42.3 and 22.1%; P<0.0001). Ischemic heart disease was the most common ACC (21.5 vs 13.1%; P<0.0001). The risk profile was significantly higher in specialist population (75.1 vs 60.3% of patients belonged to high- or very high-risk groups). Specialists and primary care physicians stratified only 54.6 and 48% of their patients correctly, respectively (P<0.05). Both, specialists and general practitioners (GPs) strongly underestimated the risk. Very high-risk patients were adequately assessed only in 44.9% of cases by specialists and in 25.3% by GPs (P<0.001). More than half of the hypertensive patients attended by GPs in Spain belong to the high- or very high-risk groups. GPs and specialists tend to underestimate the cardiovascular risk in daily clinical practice, mainly in very high-risk patients.     

Management of asthma in patients supervised by primary care physicians or by specialists.

French asthma patients may be supervised by general practitioners (GPs) and/or specialists. Therefore, this study examined asthma management in patients exclusively supervised by specialists (SPE), GPs, (GP) and both (GP+SPE group), and compared the findings. Asthma patients were consecutively recruited in 348 pharmacies. Each patient completed a questionnaire providing data on personal characteristics, asthma management, perception of disease and asthma supervision. Asthma control was measured using the Asthma Control Test. Questionnaires were linked to computerised records of medications which had been dispensed before inclusion in the study. From the 1,256 patients (mean age = 36.1 yrs, 54.3% females), 11.4, 36.6, and 52.0% were placed in the SPE, GP, and GP+SPE groups, respectively. During the previous 4 weeks, most patients in the SPE group were properly controlled (52.2 versus 26.4 and 21.5% in GP and GP+SPE groups, respectively). The SPE group made more use of fixed combinations of long-acting beta agonist and inhaled corticosteroid, while receiving less short-acting beta agonists, antitussives and antibiotics. Striking differences in symptoms and asthma management were observed according to the type of asthma supervision. The current results strongly support the need to improve the management of asthma in primary care, and the coordination of care between general practitioners and specialists.     

Management of reflux disease in clinical praxis in hungary

BACKGROUND: Gastro-oesophageal reflux disease (GERD) is a chronic condition that affects a large proportion of the population. The majority of patients are treated in the primary care but effective management of the disease still remains a challenge for specialists as well. A recent survey - based on the case of a typical GERD patient - conducted in Germany indicated that mainly specialists adhered to the guidelines. AIM: The purpose of this study was to conduct a survey among specialists and primary care physician members of the Hungarian Society of Gastroenterology about the practical management of GERD using the same questionnaire as in the German study. METHODS: A questionnaire based on the case of a typical patient with GERD was sent out to a total of 1090 members of the society. The questions concerned general measures for avoiding reflux symptoms (dietary and life-style modifications), diagnosis of GERD and the type of treatment. Answers were compared with those in the German study. RESULTS: A total of 421 questionnaires were evaluated (38 %), which had been returned by 174 general practitioners (GP), 173 gastroenterologists (GE), 41 paediatricians, and 33 surgeons. Only 9 % (38/421) of the responders think that there is no necessity to carry out specific diagnostic approaches before starting any treatment. In 91 % of the cases (25 % always and 66 % only if symptoms persist) doctors carry out specific diagnostic tests (75 % endoscopy, 13 % 24 hours pH-metry, and 12 % X-ray). 47 % of responders start drug treatment at once while 35 % start medications only after getting the results of the requested examinations. 18 % of Hungarian doctors do start with a non-medical therapy. Almost all responders feel that it is important to advise a reduction of weight and a cessation of smoking for GERD patients. Altering specific dietary and life-style habits was considered useful by more than 85 % of our responders. Hungarian physicians were more concerned about different alcoholic drinks and spicy, fatty or bloating meals and less about sweets than their German counterparts. More than 85 % of GPs administer some kind of drug therapy as first choice. Over 65 % of GPs are using the step-down approach with proton pump inhibitors as the initial strategy and 78 %, 76 %, and 81 % of GEs, paediatricians, and surgeons, respectively, do the same. Almost one-third of GPs and paediatricians are willing to continue therapy and almost two-thirds of GPs will reduce the dose of current medical therapy if the GERD patient is responding well to the initial therapy. CONCLUSIONS: Irrespective of the country, specialists are adhering more strictly to the guidelines on the diagnosis and treatment of GERD than general practitioners. The majority of responders, however, ask for endoscopy prior to initiation of any medication and use the step-down approach. Despite the lack of scientific evidence, reduction of weight, cessation of smoking, dietary and life-style modifications are still part of the treatment of GERD in both Germany and Hungary.     

An evaluation of diabetes knowledge amongst general practitioners and senior medical students. Central Manchester Health Authority Working Party on Diabetes Care

Knowledge about diabetes, its management and its complications was assessed using a questionnaire sent to 80 Central Manchester general practitioners (GPs) and 192 senior medical students. Completed questionnaires were received from 57 GPs and all medical students. Eight GPs had already established mini-clinics and a further 10 expressed interest in starting such a clinic. GPs scored 60 (38-83) % in the test whereas students had a mean score of 50 (26-77) % (p less than 0.001). Deficiencies in knowledge were detected in the following areas: the management of insulin-treated patients during acute illness, indications for insulin therapy in Type 2 diabetes, and several aspects of dietary management. This survey has demonstrated a considerable interest in diabetes amongst GPs, with a response rate of 71%, and one in three of those who responded were interested in establishing clinics. Should these results be representative of GPs elsewhere, this would suggest the need for a postgraduate course on diabetes in general practice, and emphasizes the necessity of close cooperation between hospital and general practice in diabetes care.