An approach for integrating complementary-alternative medicine into primary care

BACKGROUND: Despite family practitioners frequently being requested to assist their patients with advice on or referrals to complementary-alternative medicine (CAM), there is an absence both of evidence about the efficacy of nearly all specific treatments or modalities and of guidelines to assist with the integration of conventional and CAM therapies. OBJECTIVE: The aim of this article is to suggest a comprehensive and rational, best-evidence strategy for integrating CAM by primary care practitioners into primary care, within the context of the limitations of the current knowledge base and the local milieu. METHODS: The suggested approach was developed by a combination of literature review, key informant interviews, focus groups, educational presentations for family practice residents and practitioners, and field testing. An iterative model was utilized whereby more refined drafts of the suggested approach were subjected to later discussants and groups, as well as further field testing. Drafts of the strategy were utilized in consultations of patients requesting advice on alternative medicine in a primary care setting and in a CAM clinic. RESULTS: Both family physicians and CAM practitioners provided useful comments and recommendations throughout the process. These can be categorized in terms of knowledge, attitudes and skills. Our strategy suggests that patients requesting advice on the use and integration of CAM modalities as part of their health care should be evaluated initially by their primary care physician. The physician's responsibilities are to evaluate the appropriateness of that use, and to maintain contact, monitoring outcomes. Advice on referrals should be based on the safety of the method in question, current knowledge on indications and contraindications of that modality, and familiarity and an open dialogue with the specific therapist. CONCLUSIONS: Given patients' demands and utilization of CAM therapies, despite the lack of evidence, there is an increasing need to address how CAM therapies can be integrated into conventional medical systems. These suggestions should respond to patient's expectations and needs, but at the same time maintain accepted standards of medical and scientific principles of practice.     

我国社区遗传学的发展现状及展望

本文介绍了"社区遗传学"在医学领域的定义及其发展简史,总结了社区遗传学在我国的发展现状,并针对目前我国存在的不足(如:缺乏对常见遗传病全面、系统的调查分析,缺乏面向社区居民的遗传咨询、遗传学筛查与诊断服务,缺乏相应的评估监测体系及社区卫生服务尚存在显著的地域不平衡等),提出了我国这一学科领域的总体发展战略目标、对策及应注意的问题,从而发挥社区遗传学在我国全民健康促进与疾病预防中应有的作用。     

Six month outcomes after emergency admission of elderly patients to a community or a district general hospital

BACKGROUND: Emergency admissions account for 40% of National Health Service bed usage. Recent policy is to increase the role of intermediate care, which includes the use of community hospitals (CHs). However, the proposed expansion presumes that CH care is as effective as acute hospital care. No direct comparison of outcomes between CHs and district general hospitals (DGHs) has been undertaken. OBJECTIVES: The aim of this study was to compare patient-based outcomes at 6 months following emergency admission to a DGH or CH. METHODS: We designed a prospective cohort study, with strict eligibility criteria. The study was set in one DGH and five CHs in Devon, UK. Study participants were people aged >70 years with an acute illness requiring hospital admission, but whose condition could have been treated in either hospital setting. A cohort of people admitted to each setting was identified and followed-up for 6 months. The primary outcome measure was change in quality of life 6 months after admission, as measured by SF-36 and EuroQol. Secondary outcome measures were death, readmission and place of residence at 6 months. The use of drugs and investigations during the hospital stay were also measured. RESULTS: A total of 376 patients were recruited and completed baseline measures, 254 of whom were followed-up at the 6-month stage (136 CH, 118 DGH). There were no differences in outcome between settings, with a small increase in quality of life scores at 6 months in both cohorts: the mean change in EuroQol 5D in CH was 6.6 points (95% confidence interval, 2.8-10.4) and in DGH was 6.5 (2.4-10.7); P = 0.97. Mortality and place of residence at 6 months were similar in the two groups. The numbers of investigations (median CH four investigations, DGH 22; P < 0.001) and of prescribed medications during the hospital stay (median CH eight drugs, DGH 11; P < 0.001) were significantly higher in the DGH. CONCLUSIONS: The quality of life and mortality in the CH cohort was similar to those in the DGH cohort. CH care can be used as an alternative to DGH care for a wide range of conditions requiring emergency admission.     

社区医疗与国际旅行卫生保健

社区医疗是医疗卫生事业发展的一个方向，社区医疗这一新兴模式在我国医疗保健事业的发展中正在显示出越来越强大的生命力，为了使它科学、合理、快速成长并有效发挥作用，更好地为全社会服务，我们对社区医疗保健机构的设立、人员构成及要求、必备设施与条件、服务对象、工作机制、财务运作、发展目标等方面作了一些探讨。同时发现国际旅行卫生保健部I_]是做好社区医疗保健服务的一支重要力量。首先它具有得天独厚的优越条件，不管是人员素质、规模设施及设备，还是较为齐全的服务功能与灵敏的保健信息咨询体系、广泛的联络协作机制都能满足社区居民医疗保健的基本需要。国际旅行卫生保健部门也能够在从事社区医疗的实践中发展自己。     

Developing clinically relevant and reproducible symptom-defined populations for cancer diagnostic research in general practice using a community survey

BACKGROUND: In developing cancer diagnostic studies, there is a particular need for the population of patients with symptoms of possible oncological significance who consult the GP in 'real life' to be comparable with the group of individuals with symptoms constructed as part of a research project. OBJECTIVES: The objective of this study was to seek to assess whether a community-based symptom survey can be harnessed in order to produce clinically relevant and reproducible populations within which studies of more detailed indicants could be undertaken. METHOD: A total of 3629 patients registered with a general practice at Winterton, UK, were sent a questionnaire enquiring about 10 symptoms of possible oncological significance together with their consultation intention in relation to these symptoms. Up to 1 month later, an identical questionnaire was applied to all patients reporting at least one symptom, and more detailed information was obtained by research nurses on each symptom. RESULTS: The overall response rate was 64.4%, and 850 patients reported one or more symptoms. For the majority of symptom reports, there was moderate to substantial agreement between the two applications of the questionnaire. The question on blood in the motions/toilet pan or on the toilet paper demonstrated almost perfect agreement. Slight agreement was found for abdominal pain for longer than 4 weeks and for black/tarry motions. In relation to the reliability of the patient consultation intention, there was substantial/moderate agreement for actions related to the majority of symptoms. For all symptoms, there was also a greater level of agreement for past activity than future intent. CONCLUSION: The results of the study provide some support for a community survey as a mechanism to develop 'clinically relevant' populations for the iatrotropic symptoms rectal bleeding or indigestion/heartburn within which studies of more detailed indicants could be undertaken. There is also consistency with the work of others in relation to the numbers and characteristics of patients within the 'clinically relevant' population.     

Community engagement with genetics: public perceptions and expectations about genetics research

Background

Knowledge of molecular biology and genomics continues to expand rapidly, promising numerous opportunities for improving health. However, a key aspect of the success of genomic medicine is related to public understanding and acceptance.

Design

Using community consultations and an online survey, we explored public attitudes and expectations about genomics research.

Results

Thirty‐three members of the general public in Newfoundland, Canada, took part in the community sessions, while 1024 Atlantic Canadians completed the online survey. Overall, many participants noted they lacked knowledge about genetics and associated research and took the opportunity to ask numerous questions throughout sessions. Participants were largely hopeful about genomics research in its capacity to improve health, not only for current residents, but also for future generations. However, they did not accept such research uncritically, and a variety of complex issues and questions arose during the community consultations and were reflected in survey responses.

Discussion

With the proliferation of biobanks and the rapid pace of discoveries in genomics research, public support will be crucial to realize health improvements. If researchers can engage the public in regular, transparent dialogue, this two‐way communication could allow greater understanding of the research process and the design of efficient and effective genetic health services, informed by the public that will use them.     

The needs of patients dying of chronic obstructive pulmonary disease in the community

BACKGROUND: Ninety percent of the last year of life of a terminally ill patient is spent at home, but possible drawbacks to domicillary terminal care have been suggested. Most previous studies have taken place in secondary care settings, and have often obtained relatives' views of patients' needs rather than those of the patient. OBJECTIVES: Our aim was to determine the needs of patients dying in primary care from chronic obstructive pulmonary disease (COPD). METHODS: Semi-structured interviews were undertaken with 16 patients who were having maximal therapy for COPD, who were thought likely to die in the year following the commencement of the study. RESULTS: Five themes were identified. (i) Patients' information needs and the future course of their illnesses. Information needs were often variable and patients were sometimes unwilling to contemplate the future. (ii) The impact of symptoms on patients' lives. Dyspnoea was a particular problem. (iii) Attitudes towards and opinions on smoking, which many acknowledged as being causal. (iv) Attitudes to help received. Many patients relied on their family; most patients felt their doctors were helpful although some expressed reservations. (v) Patients' expressed needs. These usually focused on mobility, and many patients would not express needs even when prompted. CONCLUSION: Poor symptom control remains an important cause of distress. The low number of expressed needs may reflect patients' unwillingness to appear ungrateful, but the variability of information needs emphasizes the importance of an individual approach to patients with an apparently homogenous disease     

GPs' opinions of their role in prenatal genetic services: a cross-sectional survey

BACKGROUND: In the UK about 4.5% of the population carry cystic fibrosis, whilst in the inner city areas an even higher proportion carry one of the haemoglobin disorders such as thalassaemia. Couples who both carry the same recessive disorder have a 1 in 4 risk of an affected child in every pregnancy. OBJECTIVES: To assess GPs' confidence in their ability to provide initial prenatal advice for couples carrying common autosomal recessive disorders (either the cystic fibrosis or thalassaemia gene), and their opinions of different approaches for referral to prenatal diagnostic services for such at-risk couples. METHODS: A cross-sectional postal survey of all 644 GPs in 388 general practices in Nottinghamshire. Practices were randomly allocated to receive either the cystic fibrosis or the thalassaemia scenario survey. The survey questions predominantly used six-point Likert scales to assess confidence and opinions of prenatal services. RESULTS: The questionnaire was returned by 62% (397) of GPs. Only 23% (91) were confident in providing prenatal advice to the at-risk carrier couples. GPs were more confident about advising cystic fibrosis carriers than thalassaemia carriers (P = 0.01). The least popular approach to prenatal service provision was direct referral to prenatal services after counselling with 52% (194) scoring this as useful, whilst 60.5% (233) of GPs scored referral to the obstetric services with the prenatal diagnosis organised by the obstetrician as useful. CONCLUSIONS: GPs perceive that they lack the confidence to provide basic prenatal genetic advice to women at risk of the commonest recessive disorders, with particularly low confidence where the couple both carry thalassaemia. A significant knowledge gap was demonstrated by the poor awareness of the importance of rapid referral to prenatal diagnostic services.     

Community needs and preferences for community pharmacy immunization services

This study explored the Saudi community’s needs and preferences related to community immunization services. Community member’s expectations about the services were assessed, and their concerns, attitudes, and beliefs around the pharmacist’s role in providing immunization were examined.MethodQualitative in-depth, semi-structured interviews were conducted with a convenience sample that comprised Saudi community members who visited Saudi community pharmacies. Interviews were audio-recorded, transcribed verbatim, and then translated. Data obtained were then thematically organized and analyzed using NVivo (QSR International) Software.ResultA total of 20 interviews were conducted for this study. Seven themes emerged from the interviews and were grouped into three major categories relating to the community pharmacy immunization service: (1) community needs for the service; (2) community expectations of the service; and (3) community concerns, and beliefs around the service. Participants expressed their need for such services and acceptance of immunization performed by community pharmacists, with the expectation that it would improve their immunization uptake and community health in general. However, some participants expressed concerns about community pharmacists current level of ability and skill in providing immunization, the lack of a private area for conducting the service, the lack of female community pharmacists, and the cost of the immunization service. Some participants advocated for supervision of such services by the Ministry of Health (MOH) and Saudization of community pharmacy staff.ConclusionThe research results clearly demonstrated the Saudi community’s need for community pharmacy immunization services, described their expectations, and highlighted their concerns relating to community pharmacy infrastructure and an appropriate level of training for community pharmacist-administered immunization.     

Frequency and diagnostic utility of cognitive test instrument use by GPs prior to memory clinic referral

BACKGROUND: Previous studies have indicated not only that cases of dementia are missed in primary care but also that many non-demented patients are referred for evaluation to secondary care. OBJECTIVES: To measure frequency of cognitive test instrument use in primary care prior to patient referral to secondary care and to assess the relationship between instrument use and ultimate diagnosis. METHODS: This was a prospective study conducted in a Cognitive Function Clinic, Regional Neuroscience Centre setting. The referral letters for all patients seen in the clinic over a 2-year period (n = 231) were examined for mention of cognitive test instrument use. Patients were evaluated by standard clinical, neuropsychological and neuroimaging methods and diagnoses were made according to widely accepted diagnostic criteria for dementia and dementia subtype. Primary care cognitive test use and final diagnosis were then compared. RESULTS: Evidence of cognitive test use in primary care was found in 20% of referrals. Patients evaluated with cognitive test instruments in primary care were more likely to receive a diagnosis of dementia, whereas those not tested were more likely to receive a diagnosis of 'not demented'. CONCLUSIONS: Use of simple cognitive test instruments in primary care may improve dementia diagnosis and reduce the rate of referral of non-demented patients.     

The prevalence of ear, nose and throat problems in the community: results from a national cross-sectional postal survey in Scotland

OBJECTIVE: To assess the prevalence of ear, nose and throat (ENT) symptoms experienced by individuals living in Scotland, and their use of GP or hospital services for these problems. METHODS: A cross-sectional postal self-completed questionnaire was sent to a random sample of 12,100 households throughout Scotland. 15,788 individuals aged 14+ years living in the 7244 households who returned the questionnaire (adjusted response rate 64.2%) participated in the study. RESULTS: Roughly a fifth of respondents reported currently having hearing difficulties, including difficulty following conversations when there is background noise and hearing problems causing worry or upset; few wore a hearing aid regularly. A fifth reported noises in head or ears (tinnitus) lasting more than five minutes. In the previous year, between 13 and 18% of respondents reported persistent nasal symptoms or hayfever, 7% sneezing or voice problems and 31% had at least one episode of severe sore throat or tonsillitis. Nearly 21% of all respondents reported ever having had dizziness in which things seemed to spin around the individual; 29% unsteadiness, light-headedness or feeling faint; 13% dizziness in which the respondent seemed to move. Important gender, age, occupation and deprivation differences existed in the occurrence of these ENT symptoms. There was considerable variation in the proportion of individuals consulting their GP or being referred to hospital for different problems. CONCLUSIONS: ENT problems occur frequently in the community, and most are managed without consulting medical services. Whilst reasonable for many problems, there are likely to be important groups in the community with ENT problems that might benefit from modern interventions.     

Eugenic utopias/dystopias, reprogenetics, and community genetics

The impetus for this review is the intriguing realisation that eugenics, viewed as dystopian and authoritarian in most of the 20^th century, is in the process of being reinterpreted today – in the context of reproductive genetics – as utopian and liberal. This review offers an analytical framework for mapping the growing literature on this subject in order to provide a summary for both teaching and research in medical sociology. Recent works are subsumed and explored in three areas: historical criticism of the 'old eugenics'; the continuation of this stream in the form of criticism of reprogenetics as a new, 'backdoor' eugenic regime of bio-governmentality – an area which also includes the application of Foucauldian and feminist perspectives; and the recent enthusiasm regarding 'liberal eugenics,' claiming that reprogenetic decisions should be left to individual consumers thus enhancing their options in the health market. The review concludes by discussing and illustrating potential research directions in this field, with a focus on the social and ethical aspects of 'community genetics' and its emerging networks of individuals genetically at risk.     

江宁路街道老年人慢性非传染性疾病社区诊断

目的分析本社区慢性非传染性疾病问题及特点，为制定本社区慢病防治对策、改善社区整体健康水平提供依据。方法收集警署人口结构资料；收集区疾病控制中心（CDC）居民病伤死亡原因报表；建立≥60岁居民健康档案。结果近2年来前10位疾病谱显示，本社区糖尿病由第4位上升至第3位；前3位死因顺位为肿瘤、脑血管病、心脏病。结论本社区应优先解决的问题是糖尿病，应加强以健康教育为主的综合管理干预，并以此带动健康教育和其他卫生服务工作。     

香港社区护理的发展(综述)

香港社区护理发展于六十年代中期,经过三、四十年的发展,现今社区护理颇具规模.在2000年,香港医院管理局辖下有三十个社区护理中心及三百二十五名社康护士,每年提供家访共554269次,其中18637次是产科个案,454697次采访者是高于六十五岁.香港社区护理的发展是经过不少人各方的努力而达至今天的境地.概略来说,服务发展可分四个阶段,包括开垦期(1967-1973),探索期(1973-1978),演进期(1979-1991)及增进期(1992-现今).以下讨论这几个时期的发展,香港社康护士的职能及角色.     

Complementary and alternative medicine use in patients with chronic diseases in primary care is associated with perceived quality of care and cultural beliefs

OBJECTIVES: The purpose of our study was to determine the prevalence of complementary and alternative medicine (CAM) use and its clinical and psycho-social correlates, including perceived satisfaction with care and cultural health beliefs. METHODS: A cross-sectional study was carried out in public sector primary care clinics in Singapore using a random sample of 488 adult patients with chronic diseases. The measures were CAM use, satisfaction with care and traditional health beliefs. RESULTS: The 1 year prevalence of CAM use was 22.7%. In univariate analyses, factors associated with CAM use included: middle age, arthritis, musculoskeletal disorders and stroke, multiple conditions, poor perceived health, family use of CAM, recommendation by close social contacts, strong adherence to traditional health beliefs and perceived satisfaction with care. Patients who were dissatisfied/very dissatisfied with the cost of treatment [odds ratio (OR) = 1.79, 95% confidence interval (CI) 1.15-2.82] and waiting time (OR = 1.96, 95% CI 1.20-3.19) were more likely to use CAM. Patients who were very satisfied with the benefit from treatment were much less likely to use CAM (OR = 0.49, 95% CI 0.29-0.83). Satisfaction with doctor-patient interaction was not associated with CAM use. Being 'very satisfied' on overall care satisfaction was significantly associated with much less CAM use (OR = 0.30, 95% CI 0.14-0.68). Multivariate analyses confirmed that CAM use was significantly and independently predicted by the 'chronic disease triad' (arthritis/musculoskeletal disorders/stroke) (OR = 4.08, 95% CI 2.45-6.83), overall satisfaction with care (OR = 0.32, 95% CI 0.14-0.74) and strong adherence to traditional health beliefs (OR = 1.88, 95% CI 1.07-3.31). CONCLUSION: CAM use in Asian patients is prevalent and associated with the 'chronic disease triad' (of arthritis, musculoskeletal disorders and stroke), satisfaction with care and cultural beliefs. In particular, CAM use is not associated with the quality of doctor-patient interaction.     

Familiarity breeds neglect? Unanticipated benefits of discontinuous primary care

BACKGROUND: Continuity of medical care is generally considered to be beneficial to patients. OBJECTIVE: The aim of this study was to investigate the possibility that familiarity with patients may sometimes discourage case finding. METHODS: Extensive qualitative interviews were carried out with a sample of Australian adults with type 2 diabetes, focusing in particular on their experience of diagnosis. RESULTS: Interviews were conducted with 119 participants, 75% of whom supplied sufficient information to enable the coding of whether diagnosis occurred under circumstances of discontinuity. Half of all participants (two-thirds of the coded subsample) had a diagnosis that could be categorized as resulting from discontinuous primary care: hospital admission, change of doctor, patient initiative and/or diabetic emergency. CONCLUSION: The same circumstances that enhance the management of chronic disease can at times hinder its diagnosis. Primary care service providers may need to instigate more active methods of case finding in order to avoid this paradoxical effect of familiarity with the patient.     

Receiving care at home at end of life: characteristics of patients receiving Hospice at Home care

BACKGROUND: Specialist Hospice at Home (HAH) services play an important role in the provision of care for people who choose to die at home. METHODS: A pilot evaluation of a new HAH scheme in East Midlands, UK was carried out between January and December 2003, in which routine data were collected and analysed. RESULTS: In 2003, 155 people received the HAH service. Most patients (83%) were over the age of 60 and had a cancer diagnosis (92%). Almost one-third of patients waited for 2 days or longer to receive care from the HAH scheme. These patients were around three times as likely to be in an inpatient hospice (RR=3.27; 95% CI=1.19-8.95) or an acute hospital (RR=2.85; 95% CI=1.33-6.09) when they were referred. The median length of service use was 4 days. CONCLUSIONS: The HAH service enabled people to die at home in the last days of life. Given the aging population, we would expect the demand for such services to further increase. Shortcomings identified included delay in receiving care for people moving to home from hospices and acute hospitals.