Patient priorities of care in rheumatology outpatient clinics: a qualitative study

Objective: To provide more understanding of what rheumatoid arthritis (RA) patients want and need from an outpatient visit. Methods: 25 patients who experienced care in a nurse practitioner clinic (n = 10), junior doctor clinic (n = 9) or consultant clinic (n = 6) in a large teaching hospital in West Yorkshire were interviewed about their perceptions and experiences of care. Interviews were approximately 1¹/₂ hours in duration and were carried out in a neutral environment by a research nurse. Interview data were subjected to atheoretical content analysis, which resulted in the identification of emergent themes. Results: Five main themes emerged from the analysis of interview data: 1) patients want to be communicated to clearly and effectively and value positive relationships with practitioners. These help to give patients confidence in the care they are receiving; 2) patients want to feel in control of their condition and tend to refuse interventions as a way of gaining control; 3) patients want to be given clear explanations during consultations, and want information in oral and written forms; 4) patients want to be able to access practitioners between scheduled appointments as a way of gaining reassurance; and 5) patients want to feel valued by society through having their difficulties appreciated and understood by others. Conclusion: This research adds to the body of evidence on what patients want from their rheumatology care, and each theme has clear implications for future practice. Copyright © 2007 John Wiley & Sons, Ltd.     

Patient ethnicity and the identification of anxiety in elderly primary care patients

OBJECTIVES: To examine the role of ethnicity and primary care physician (PCP) identification of anxiety in older adults. DESIGN: A cross‐sectional survey conducted between 2001 and 2003. SETTING: Primary care offices in the Baltimore, Maryland, area. PARTICIPANTS: A sample of 330 adults aged 65 and older from Maryland primary care practices with complete information on psychological status and physician assessments. MEASUREMENTS: PCPs were asked to rate anxiety on a Likert scale. Patient interviews included measures of psychological status and patient use of psychotropic medications. RESULTS: Older black patients were less likely than older white patients to be identified as anxious (unadjusted odds ratio (OR)=0.34, 95% confidence interval (CI)=0.18–0.64) and less likely to be taking psychotropic medications (unadjusted OR=0.40, 95% CI=0.20–0.81). In multivariate models that controlled for potentially influential characteristics including depression and anxiety symptoms, the association between identification (OR=0.30, 95% CI=0.15–0.61) with patient ethnicity remained significantly unchanged. CONCLUSION: PCPs were less likely to identify older black Americans as anxious than white patients. An understanding of the role of ethnicity in the identification of anxiety is important for the screening and management of anxiety in elderly people.     

Physical activity in health care professionals as a means of primary prevention of cardiovascular disease: A STROBE compliant cross-sectional study

The aim of this study was to assess the physical activity level of health care professionals, as well as the differences by sex, age, academic background, and among different health care professions.This is an cross-sectional study.Health care settings in the Valencian Community, Spain.A total of 647 health care professionals.Physical activity was assessed with the European Health Interview Survey-Physical Activity Questionnaire (EHIS-PAQ) that includes the assessment of work-related physical activity, transport-related physical activity, health-enhancing physical activity, muscle-strengthening physical activity, and total physical activity.93.51% of all health care professionals were physically active at work. Transport-related physical activity and health-enhancing physical activity were significantly lower in women (21.62% vs 41.86%, P < .001; and 50.19% vs 68.99%, P < .001, respectively). In addition, compliance with health-enhancing and muscle-strengthening physical activity guidelines were lower in older professionals (42.7% vs 61.84%, P < .001; and 47.57% vs 61.84%, P < .001, respectively). Those with higher education were more compliant with health-enhancing and muscle-strengthening physical activity guidelines (58.55% vs 45.69%, P = .002; and 60.24% vs 48.28%, P = .003, respectively). Moreover, 67.98% of physiotherapists performed health-enhancing physical activity and 67.54% muscle-strengthening physical activity regularly, and significant differences in all outcomes were observed compared to the rest of health care professionals (P < .05). Technicians showed lower work-related and total physical activity than nurses and nursing assistants (74.55% vs 90.37%, P = .002; and 83.64% vs 95.72%, P < .001, respectively). Additionally, nursing assistants showed higher work-related physical activity compared to nurses (97.18% vs 90.37%, P = .008).Most health care professionals showed an appropriate level of physical activity. Men performed more transport-related and health-enhancing physical activity than women. Younger professionals and those with higher education were more compliant with health-enhancing and muscle-strengthening physical activity guidelines. Physiotherapists were more physically active when compared to the rest of health care professionals.     

Brief report: Patient cognitive status and the identification and management of depression by primary care physicians

OBJECTIVES: No known study has examined the role of patients' cognitive impairment in the identification and management of depression by primary care physicians. DESIGN: A cross-sectional survey conducted between 2001 and 2003. PARTICIPANTS: A sample of 330 adults aged 65 and older from Maryland primary care practices with complete information on cognitive and psychological status, and physician assessments. MEASUREMENTS: Primary care physicians were asked to rate cognition and depression on a Likert scale, as well as report management of depression within 6 months of the index visit. Patient interviews included standardized measures of psychological and cognitive status. RESULTS: Older adults identified as depressed by their physician were more likely to be identified as cognitively impaired (unadjusted odds ratio [OR] = 3.71, [95% confidence interval] [CI] [1.93, 7.16]). Older adults identified as cognitively impaired had a tendency to be managed for depression (unadjusted OR = 2.62, 95% CI [0.96, 7.19]). In adjusted multivariate models, these associations remained unchanged. CONCLUSIONS: When physicians identified a patient as cognitively impaired, they were more likely to identify the patient as depressed and to report treatment of the depression. An understanding of how physicians think about depression in the context of cognitive impairment is important for designing depression interventions for older adults.     

A survey of the primary care management of osteoarthritis in Malaysia: a view from a rheumatologist's perspective

Objective: Primary care management of knee osteoarthritis (OA) has received little attention in the scientific literature and the main reason for this survey is to study and explore the variations and patterns of primary care management and assess both conventional and complementary therapy usage in knee OA in the primary care setting. Methods: A cross‐sectional survey of 200 randomly selected general practitioners (GPs) in the peninsular states of Malaysia was undertaken using a questionnaire. The GPs involved were asked about basic knowledge of OA in terms of diagnosis, investigation, and treatment. They were also asked about their usage of conventional and complementary medication. Results: One hundred and eighty (90%) GPs responded to the questionnaires sent: 77% were in solo practice and 33% in group practice. Most of the GPs surveyed (60%) had been in practice for more than 10 years, 30% for 5–10 years and 10% were in practice for less than 5 years. Of GPs surveyed, 55% saw an average of more than 20 patients per week, 35% about 10–20 patients and 10% less than 10 patients per week. Of GPs surveyed, 65% would arrange an X‐ray, 55% would arrange a blood test, mostly serum uric acid, rheumatoid factor and erythrocyte sedimentation rate. Pharmacological management consists of first‐line treatment with non‐steroidal anti‐inflammatory drugs (NSAIDs) (61%), analgesics (35%) or a combination of the two (4%). Non‐pharmacological management consisted of advice on exercise (27%), weight reduction (33%) and referral to physiotherapy (10%). Of GPs surveyed, 85% prescribed some form of complementary medications, 60% prescribed glucosamine sulphate, 21% chondroitin sulphate, 11% cod liver oil and 9% evening primrose oil. Only 10% of GPs surveyed perform intra‐articular injections. Conclusion: The data suggest that in the primary care setting, the majority of GPs over‐investigate the diagnosis of OA. Pharmacological interventions largely concentrate on analgesics and NSAIDs. The use of physiotheraphy and non‐drug approaches were significantly under‐utilized. There is a need to further educate GPs in the management of OA.     

Improving the structure of diabetes care in primary care: A pilot study

AimThe aim of this pilot study was to determine whether glycemic control can be improved in patients with type 2 diabetes by implementing a workshop model to improve the structure of diabetes care at primary health care centers (PHCCs).MethodsThe intervention consisted of 4 workshops at 12 PHCCs with HbA1c >70 mmol/mol (high HbA1c). Each PHCC could choose how many workshops they wished to attend and was to be represented by the manager, a diabetes nurse, and a GP. Participants analyzed the structure of diabetes care at their PHCC and developed an action plan to improve it. The percentage of patients with high HbA1c at baseline, 12, and 24 months was collected. Qualitative content analysis was also conducted.ResultsAll PHCCs reduced the percentage of patients with high HbA1c 12 months after the intervention, but not all maintained the reduction at 24 months. Participants experienced structuring diabetes care as central to reducing the percentage of patients with high HbA1c. Pillars of structured diabetes care included establishing routines, working in teams, and having and implementing an action plan.ConclusionsWorking with the structure of diabetes care improved care structure and had a positive impact on HbA1c. To sustain the positive impact, PHCCs had to set long-term goals and regularly evaluate performance.     

Nocturnal hypertension in primary care patients with high office blood pressure: A regional study of the MAPAGE project

Nocturnal hypertension (NH) is an independent cardiovascular risk factor. We aimed to describe the frequency of NH among primary care hypertensive patients and to analyze NH determinants. This observational, cross‐sectional, multicenter study enrolled the patients of 23 general practitioners in Burgundy region, France. We included the first patient of the day with office blood pressure ≥ 140/90 mm Hg, whatever the reason for consultation. All included patients had 24‐hour ambulatory blood pressure monitoring (ABPM). Nocturnal hypertension was considered nighttime mean blood pressure ≥ 120/70 mm Hg, as per current guidelines. Medical, sociodemographic, and deprivation data were collected. Nocturnal hypertensive and non‐hypertensive patients were compared. The determinants of NH were identified using logistic regression models. From July 2015 to November 2018, 447 patients were analyzed. Mean office blood pressure was 158.6/91.5 mm Hg, and 255 patients (57.0%) were taking at least one antihypertensive drug. Among the 409 (91.5%) valid ABPM, 316 (77.3%) showed NH. In multivariate analyses, male sex (odds ratio [OR] = 2.20, 95% confidence interval [CI] 1.29‐3.75), first office diastolic blood pressure >100 mm Hg (OR = 5.71, 95% CI 1.53‐21.40), and current smoking (OR = 5.91, 95% CI 2.11‐16.56) were independent predictors of NH. Obesity was associated with a reduced risk of NH (OR = 0.43, 95% CI 0.25‐0.75). No association was found between deprivation status or sociodemographic factors and NH. To conclude, NH was identified in more than three out of four patients with high office blood pressure. Male smokers with high diastolic blood pressure were most affected by NH. ABPM may improve hypertension management in these patients.     

A psychosocial taxonomy of patients with diabetes: validation in a primary care setting

Aims The aims of this study were (i) to extend a psychosocial taxonomy of patients with diabetes to a primary care setting, and (ii) to validate the taxonomy using more sophisticated clustering methods across an array of psychological dimensions independent of demographic and medical variables. Methods In a cross‐sectional study, 111 adults with Type 2 diabetes seen in a primary care setting completed the Multidimensional Diabetes Questionnaire and the Brief Symptom Inventory (BSI). They also provided diabetes‐specific self‐report measures along with HbA_1c. Results Four psychosocial patient profiles were identified using model‐based cluster analysis in a US primary care setting. The four profiles represent a replication of two and refinement of a third profile found previously in French‐speaking patients at diabetes education centres. Validation of the profiles using the BSI was replicated for depression and extended to other psychological dimensions. The validity and distinctiveness of the four psychosocial profiles were independent of demographic and diabetes‐specific medical variables. Conclusion Replication and extended validation of the psychosocial taxonomy into primary care may allow healthcare workers to supplement medical treatments with psychosocial interventions that can improve outcomes for patients with diabetes that are practical, individually tailored, and cost‐effective.     

Effects of the Diabetes Manual 1:1 structured education in primary care

Aims To determine the effects of the Diabetes Manual on glycaemic control, diabetes‐related distress and confidence to self‐care of patients with Type 2 diabetes. Methods A cluster randomized, controlled trial of an intervention group vs. a 6‐month delayed‐intervention control group with a nested qualitative study. Participants were 48 urban general practices in the West Midlands, UK, with high population deprivation levels and 245 adults with Type 2 diabetes with a mean age of 62 years recruited pre‐randomization. The Diabetes Manual is 1:1 structured education designed for delivery by practice nurses. Measured outcomes were HbA_1c, cardiovascular risk factors, diabetes‐related distress measured by the Problem Areas in Diabetes Scale and confidence to self‐care measured by the Diabetes Management Self‐Efficacy Scale. Outcomes were assessed at baseline and 26 weeks. Results There was no significant difference in HbA_1c between the intervention group and the control group [difference ?0.08%, 95% confidence interval (CI) ?0.28, 0.11]. Diabetes‐related distress scores were lower in the intervention group compared with the control group (difference ?4.5, 95% CI ?8.1, ?1.0). Confidence to self‐care Scores were 11.2 points higher (95% CI 4.4, 18.0) in the intervention group compared with the control group. The patient response rate was 18.5%. Conclusions In this population, the Diabetes Manual achieved a small improvement in patient diabetes‐related distress and confidence to self‐care over 26 weeks, without a change in glycaemic control. Further study is needed to optimize the intervention and characterize those for whom it is more clinically and psychologically effective to support its use in primary care.     

Five‐year cost‐effectiveness of the Patient Empowerment Programme (PEP) for type 2 diabetes mellitus in primary care

This study evaluated the short‐term cost‐effectiveness of the Patient Empowerment Programme (PEP) for diabetes mellitus (DM) in Hong Kong. Propensity score matching was used to select a matched group of PEP and non‐PEP subjects. A societal perspective was adopted to estimate the cost of PEP. Outcome measures were the cumulative incidence of all‐cause mortality and diabetic complication over a 5‐year follow‐up period and the number needed to treat (NNT) to avoid 1 event. The incremental cost‐effectiveness ratio (ICER) of cost per event avoided was calculated using the PEP cost per subject multiplied by the NNT. The PEP cost per subject from the societal perspective was US$247. There was a significantly lower cumulative incidence of all‐cause mortality (2.9% vs 4.6%, P < .001), any DM complication (9.5% vs 10.8%, P = .001) and CVD events (6.8% vs 7.6%, P = .018), in the PEP group. The costs per death from any cause, DM complication or case of CVD avoided were US$14 465, US$19 617 and US$30 796, respectively. The extra amount allocated to managing PEP was small and it appears cost‐effective in the short‐term as an addition to RAMP.     

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.     

Families' acceptance of near death: A qualitative study of the process for introducing end-of-life care

Aim:   Providing effective end-of-life (EOL) care for the elderly with severe brain damage is difficult because patients' families find it hard to accept the condition of their loved ones as near death. In Japan, this has become an urgent social problem. Although health-care teams sometimes expect that the elderly with severe brain damage should be treated as terminal, many find that patients' families cannot accept the condition as near death. As a result, they are not able to appropriately introduce any EOL services. It was the aim of the present study to develop a comprehensive understanding of the process by which families accept the elderly with severe brain damage as near death.
Methods:   Qualitative methodology with focus groups and semi-structured interviews were used. Twenty-three participants in two sets of male and female focus groups were interviewed in a semi-structured format. Ten participants (five men and five women) who made important medical decisions were then interviewed separately.
Results:   Eleven categories emerged: (i) family affection with wishes for continued survival; (ii) vacillation of desire for death with dignity; (iii) family members' hierarchy; (iv) awareness that others may make different decisions; (v) family members' discussion overcoming discordance; (vi) satisfaction with physicians' explanations; (vii) impressions of life-sustaining measures; (viii) entrusting important decisions to hospital physicians; (ix) significance of family members' previous experiences; (x) patient's age; and (xi) duration of medical treatment.
Conclusion:   We developed a conceptual model that is useful for evaluating which stage of the process families are currently experiencing as well as introducing EOL care in a timely manner.     

Feasibility,acceptability, and effectiveness of a multidisciplinary intervention in childhood obesity from primary care: Nutrition,physical activity,emotional regulation,and family

Childhood obesity is a growing problem with a complex aetiology, for which multidisciplinary interventions are required. Our programme describes a novel structured psychosocial family‐based intervention targeting the emotional regulation in childhood obesity, using a train trip metaphor aimed at improving healthy lifestyles for the family. The aims were (a) to describe the feasibility and acceptability of this psychosocial family‐based intervention among children with overweight or obesity in primary care and (b) to examine the effectiveness of the “ENTREN‐F” programme (with family intervention) compared with the “ENTREN” programme (without family intervention) among Spanish children regarding anthropometric variables, physical activity, emotional well‐being, and family functioning. Children were randomly allocated to either ENTREN‐F programme (n = 30) or psychological intervention for children (ENTREN, n = 40), and assessments were carried out over time (T₀ baseline vs. T₁ post/6‐month vs. T₂ 6‐month follow‐up). Both parent groups expressed high levels of satisfaction with the interventions. ENTREN‐F resulted in higher adherence to treatment and was more effective in improving z–body mass index, reducing children's anxiety, and increasing family adaptability than the ENTREN programme. There were no significant changes in parents' emotional well‐being and expressed emotion. Both groups improved in the children's emotional well‐being and light physical activity. In summary, this multidisciplinary psychosocial family‐based intervention was succesful.