Oral vitamin B12 versus intramuscular vitamin B12 for vitamin B12 deficiency: a systematic review of randomized controlled trials

BACKGROUND: Vitamin B(12) deficiency is common, increasing with age. Most people are treated in primary care with intramuscular vitamin B(12). Several studies have reported equal efficacy of oral administration of vitamin B(12). OBJECTIVES: We set out to identify randomized controlled trial (RCT) evidence for the effectiveness of oral versus intramuscular vitamin B(12) to treat vitamin B(12) deficiency. METHODS: We conducted a systematic review searching databases for relevant RCTs. Outcomes included levels of serum vitamin B(12), total serum homocysteine and methylmalonic acid, haemoglobin and signs and symptoms of vitamin B(12) deficiency. RESULTS: Two RCTs comparing oral with intramuscular administration of vitamin B(12) met our inclusion criteria. The trials recruited a total of 108 participants and followed up 93 of these from 90 days to 4 months. In one of the studies, mean serum vitamin B(12) levels were significantly higher in the oral (643 +/- 328 pg/ml; n = 18) compared with the intramuscular group (306 +/- 118 pg/ml; n = 15) at 2 months (P < 0.001) and 4 months (1005 +/- 595 versus 325 +/- 165 pg/ml; P < 0.0005) and both groups had neurological responses. In the other study, serum vitamin B(12) levels increased significantly in those receiving oral vitamin B(12) and intramuscular vitamin B(12) (P < 0.001). CONCLUSIONS: The evidence derived from these limited studies suggests that 2000 microg doses of oral vitamin B(12) daily and 1000 microg doses initially daily and thereafter weekly and then monthly may be as effective as intramuscular administration in obtaining short-term haematological and neurological responses in vitamin B(12)-deficient patients.     

Obesity counseling and guidelines in primary care: a qualitative study

BACKGROUND: The problem of obesity is now epidemic in the United States. Despite the existence of clinical guidelines for prevention and treatment of obesity and documented clinician concern about this problem, counseling for obesity reduction in primary care is infrequent. The principal aim of this study was to examine the views of clinicians on obesity counseling and to compare these views to the recommendations of leading obesity guidelines. METHODS: Twenty individual, in-depth interviews and two focus groups of clinicians serving predominantly low-income minority populations were conducted in a practice-based research network. Data were analyzed using immersion/crystallization and template approaches. RESULTS: Clinicians believe obesity is an important problem and report using mostly brief, targeted, low-intensity counseling in the face of limited patient motivation and lack of resources to support weight loss. They view family, cultural, social, and community factors as central to the problem of obesity, and their own efforts as generally ineffective. These clinicians similarly were unconvinced of the long-term effectiveness of any weight-loss strategies. CONCLUSIONS: Low levels of obesity counseling in primary care may reflect clinicians' self-assessment of their ineffectiveness in this area rather than lack of interest or knowledge. These clinicians perceive that obesity control efforts aimed at local community factors and environmental modifications are key strategies in augmenting and linking their efforts to successful outcomes.     

Patient perspectives on quality of care for depression and anxiety in primary health care teams: A qualitative study

BackgroundWidespread policy reforms in Canada, the United States and elsewhere over the last two decades strengthened team models of primary care by bringing together family physicians and nurse practitioners with a range of mental health and other interdisciplinary providers. Understanding how patients with depression and anxiety experience newer team‐based models of care delivery is essential to explore whether the intended impact of these reforms is achieved, identify gaps that remain and provide direction on strengthening the quality of mental health care.ObjectiveThe main study objective was to understand patients’ perspectives on the quality of care that they received for anxiety and depression in primary care teams.MethodsThis was a qualitative study, informed by constructivist grounded theory. We conducted focus groups and individual interviews with primary care patients about their experiences with mental health care. Focus groups and individual interviews were recorded and transcribed verbatim. Grounded theory guided an inductive analysis of the data.ResultsForty patients participated in the study: 31 participated in one of four focus groups, and nine completed an individual interview. Participants in our study described their experiences with mental health care across four themes: accessibility, technical care, trusting relationships and meeting diverse needs.ConclusionGreater attention by policymakers is needed to strengthen integrated collaborative practices in primary care so that patients have similar access to mental health services across different primary care practices, and smoother continuity of care across sectors. The research team is comprised of individuals with lived experience of mental health who have participated in all aspects of the research process.     

Stories from frequent attenders: a qualitative study in primary care

PURPOSE Patients who make frequent office visits (frequent attenders) in primary care are often considered a major burden on resources, yet we know little about their perceptions and expectations. We wanted to explore how these patients viewed their rates of consultation, what they expected from the consultation, and how they perceived their relationship with the primary health care team.     

Low-income women's priorities for primary care: a qualitative study

BACKGROUND: Because of their challenging social and economic environments, low-income women may find particular features of primary care uniquely important. For this qualitative study we explored which features are priorities to women fiumi low-income settings and whether those priorities fit into an established primary care framework. METHODS: We performed a qualitative analysis of 4 focus groups of women aged 40 to 65 years from 4 community health clinics in Washington, DC. Prompted by semistructured open-ended questions, the focus groups discussed their experiences with ambulatory care and the attributes of primary care that they found important. The focus groups were audiotaped, and the tapes were transcribed verbatim and coded independently by 3 readers. RESULTS: The comments were independently organized into 5 content areas of primary care service delivery plus the construct of patient-provider relationship in the following order of frequency: accessibility (37.4%), the physician-patient relationship (37.4%), comprehensive scope of services (11.5%), coordination between providers (6.8%), continuity with a single clinician (3.7%), and accountability (3.2%). Commonly reported specific priorities included a sense of concern and respect from the clinicians and staff toward the patient, a physician who was willing to talk and spend time with them (attributes of the physician-patient relationship), weekend or evening hours, waiting times (attributes of organizational accessibility), location in the inner city and on public transport routes (an attribute of geographic accessibility), availability of coordinated social and clinical services on-site; and, availability of mental health services on-site (attributes of comprehensiveness and of coordination). CONCLUSIONS: All attributes of care that were priorities for low-income women fit into 1 of 6 content areas. Specific features within the content areas of accessibility, physician-patient relationship, and comprehensiveness were particularly important for these women.     

Comparing costs of intramuscular and oral vitamin B12 administration in primary care: A cost-minimization analysis

Objective: To establish whether savings could be made by changing patients from intramuscular to high doses of oral vitamin B₁₂ in primary care without compromising their wellbeing. Methods: Cost-minimization analysis from a UK perspective, using secondary data obtained from the literature available and expert opinion. Results: The cost of the resources used to treat patients with vitamin B₁₂ deficiency with intramuscular vitamin B₁₂ was calculated as between £55.99 (€83.1) and £99.99 (€148.5) per year. The cost of treating patients with high doses of oral vitamin B₁₂ during the first year was between £125.55 (€186.5) and £248.55 (€369.1). However, once patients receiving intramuscular treatment had been converted to oral treatment, or in new patients treated orally from the outset, the cost was £35.55 per year (€52.8). One variable, home visits, had a high impact on the calculations.

Conclusion: Switching patients with vitamin B₁₂ deficiency from intramuscular to high-dose oral therapy and treating patients newly diagnosed with vitamin B₁₂ deficiency with oral vitamin B₁₂ from the outset could save resources in the medium and long term, and in newly diagnosed patients. Savings would come particularly in the form of nursing time.     

The impact of welfare advice in primary care: a qualitative study

This qualitative study documents the perceived impact of welfare advice on the health and circumstances of people living on low incomes; assesses the acceptability of a primary care based welfare advice service provided by the Citizen's Advice Bureaux; identifies a range of relevant and appropriate health and social outcome measures for evaluating primary care welfare advice services; and builds theory concerning socio-economic position and health. Findings are based on semi-structured interviews with eleven recipients of welfare advice whose resources increased following consultation with a welfare advice worker. Respondents reported positive effects on financial, material and social circumstances and health, in particular reduced stress and anxiety, better sleeping patterns; reversal of weight loss; changes in medication; reduced contact with the primary care team; reduction or cessation of smoking, improved diet and physical activity. Participants characterised the effects of welfare advice in terms of releasing them from a burden or pressure and giving greater choice and control over circumstances. We hypothesise that improvements in health-related quality of life may be mediated by reduced stress, the adoption of more advantageous social arrangements and healthier behaviours. These changes seem to enable greater choice and control over circumstances. The study has enabled the development of an empirically testable theoretical model; adds to evidence suggesting that welfare advice has an important impact on health; and confirms that primary health care provides an important route for potential claimants. The study has formed the basis for a formal outcome evaluation using an appropriate trail design in order to establish the evidence base for welfare advice as a health intervention in primary care.     

Coding for asthma patient education in the primary care setting

Counseling and education for chronic diseases is a common service provided by primary care physicians. By not using and understanding the basic concepts in documentation and coding, primary care providers deny themselves proper reimbursement for the quality care they provide. Although we have used asthma as an example, concepts discussed here can be applied to other chronic diseases that require patient self-management. We review coding strategies that should be used when counseling and education are the main focus of the patient visit. We review additional procedures and techniques to make office flow, documentation, and coding proceed more smoothly.     

Meeting and treating cultural difference in primary care: a qualitative interview study

BACKGROUND: Primary care doctors see patients from diverse cultural backgrounds and communication plays an important role in diagnosis and treatment. Communication problems can arise when patient and doctor do not share the same cultural background. OBJECTIVE: The aim of this study was to examine how consultations with immigrant patients are understood by GPs and how GPs manage these consultations. METHODS: Semi-structured interviews with GPs about their experiences with immigrant patients were recorded on audio-tape, transcribed and analysed using a qualitative thematic analysis methodology. A constructivist approach was taken to analysis and interpretation. RESULTS: Culture is not in focus when GPs meet immigrant patients. The consultation is seen as a meeting between individuals, where cultural difference is just one of many individual factors that influence how well doctor and patient understand each other. However, when mutual understanding is poor and the consultation not successful, cultural differences are central. The GPs try to conduct their consultations with immigrant patients in the same way that they conduct all their consultations. There is no specific focus on culture, instead, GPs tend to avoid addressing even pronounced cultural differences. CONCLUSION: This study indicates that cultural difference is not treated in GPs consultation with immigrant patients. Learning about cultural difference's effect on mutual understanding between doctor and patient could improve GPs cross-cultural communication. Increased awareness of the culture the doctor brings to the consultation could facilitate management of cross-cultural consultations.