Gout not induced by diuretics in a case-control study in general practice

OBJECTIVE: To determine the relation between diuretics and the development of gout, taking into account the possible confounding by hypertension and cardiovascular diseases. DESIGN: Case-control study. METHOD: With the aid of the data on morbidity and medication from the electronic medical files ofa dispensing general practitioner, all patients with a first gout registration during the period from October 1994 to September 2002 were identified as cases; in the same practice, for each patient, 3 controls of the same age and sex who were known not to have gout were selected at random. Conditional logistic regression analyses were carried out to estimate the odds ratio (OR) for gout in patients who had used diuretics for at least 3 months and in patients suffering from hypertension, heart failure, or myocardial infarction. The statistical interaction between variables was investigated after stratification for diuretic use. RESULTS: Via the medical files, 70 gout patients (59 men), with a mean age of 55.1 years (SD: 13.5) were identified, plus 210 matched controls. When assessed without correction, the use ofdiuretics seemed to be associated with a definite risk of gout: OR: 2.8 (95% CI: 1.2-6.6). But after adjustment for the cardiovascular variables hypertension, heart failure and myocardial infarction, the risk of gout associated with diuretic use disappeared: OR: 0.6 (95% CI: 0.2-2.0). An independent risk of gout was demonstrated for hypertension (OR: 3.9; 95% CI: 1.6-10.0), and to a lesser degree for myocardial infarction (OR: 1.5; 95% CI: 0-5-4.1). The risk of gout associated with heart failure was also calculated (OR: 40.1; 95% CI: 3.8-437.2), but diuretic independency could not be proven as all patients with heart failure were on diuretics and there was no heart failure among those not using diuretics. CONCLUSION: In this case-control study, the use of diuretics did not increase the risk of gout. The cardiovascular indications for prescribing diuretics were significant confounders.     

The prevalence and history of knee osteoarthritis in general practice: a case-control study

BACKGROUND: There is no clear published estimate of the prevalence of diagnosed knee osteoarthritis based on consultation in primary care. Further, little is known about the clinical history of patients who are subsequently diagnosed with knee osteoarthritis. OBJECTIVES: Our aims were (i) to determine the prevalence of knee osteoarthritis diagnosed in primary care; (ii) to compare the medical history of patients currently diagnosed with knee osteoarthritis with that of controls; and (iii) to determine factors associated with X-ray at the time of first diagnosis. METHODS: A case-control study was carried out in one general practice in North Staffordshire. Cases aged > or =45 years were identified from computer searches for knee osteoarthritis between 1 January 1998 and 31 January 2000. Matched controls had no diagnosis of knee osteoarthritis during that same period. The medical records for both groups were examined to identify recorded knee-related symptoms, X-rays and secondary care referrals. RESULTS: A total of 146 cases and controls were reviewed; 49% of cases and 15% of controls had a previous (pre-1998) diagnosis of knee osteoarthritis. This gives an estimated prevalence of diagnosed knee osteoarthritis in the general population aged > or =45 years of 12.5%. Cases were more likely to have had a prior history of knee-related disorders, X-rays and referral to secondary care than controls. There was no association between an X-ray at first diagnosis and previous knee symptoms (odds ratio 0.98; 95% confidence interval 0.49-1.97) and only weak associations of X-ray with gender (male), age (under 60) of patient and time of diagnosis (pre-1998). CONCLUSIONS: Diagnosed knee osteoarthritis is common in general practice and diagnosed patients often have a long history of knee symptoms prior to diagnosis. Further research might usefully consider what influences GPs' diagnosis of knee osteoarthritis and how diagnosis relates to management and outcome.     

The care management interface with general practice: a case study

This paper reports on a care management initiative at the interface of social work, general practice and district nursing. The aims were to describe the organizational factors, operational criteria and the views of key managers, professionals and users of the care management pilot based in general practice. A multi-method case study design was used. This comprised: retrospective analysis of general practitioner (GP) referrals to social services, reviews of case records of clients in the care management system, and in-depth interviews with stakeholders, professionals, users and carers. This paper focuses on the analysis of the referral information to social services and district nursing from general practice and the themes arising from the interview data such as communication, referral pathways and professional role boundaries. The views of users and carers are presented in terms of satisfaction with continuity, responsiveness and appropriateness of the assessment and delivery of care. Although this care management pilot was discontinued when the funding ceased, the evaluation showed that there were benefits in terms of improved understanding between general practitioners, social workers, and district nurses of working systems, procedures and the organizational constraints of joint working.     

Improving the quality of diabetes care in general practice

Objective: The evidence treatment gap for patients with type 2 diabetes. Design: A summary of convenience sample of seven general practices. Setting: Metropolitan and rural Victoria, Australia. Participants: 561 patients of general practices (75% from rural general practices). Main outcome measures: Demographic data, duration of diabetes, diabetes complications, HbA1c and lipid levels, blood pressure and score on PHQ‐9. Results: Patients with depression show more severe, progressive and intensively treated diabetes. The prevalence of depression in diabetes is about twice that of the general population. Conclusion: Australian guidelines for diabetes should recommend screening for depression.     

Participation in a quality of care study and consequences for generalizability of general practice research

BACKGROUND: Non-participation of General Practitioners (GPs) hampers primary care research. Using existing network structures can improve participation, but may introduce sampling effects. OBJECTIVES: To examine the role of network-based recruitment and other determinants of participation, and to estimate effects of sampling and non-participation on generalizability. METHODS: For a study of quality of care assessment, we recruited GPs from a regionally defined population and a GP network. Effects of sampling and non-participation were analysed by comparing characteristics between participants, target samples, and reference data for all German GPs. Factors influencing study participation were assessed in multiple logistic regression. RESULTS: Compared to the regional sample, network GPs were more likely to complete survey questionnaires (92% versus 69%) and to participate in the study (66% versus 23%). Compared to national reference data, study participants from both populations were younger, had a higher level of professional training, and included more men. These differences were already present in the network target sample, but were largely attributable to selective participation in the regional sample. Network membership remained the strongest determinant of participation in multiple logistic regression (odds ratio 5.01; 95% confidence interval 2.53-9.91). A younger age, higher professional training, and membership in the German Society of General Practice were also predictive of participation. CONCLUSIONS: Although network-based recruitment of GPs increases participation rates, sample effects are similar in size and direction as effects of non-participation in the regionally defined population. Careful analysis of participants based on publicly available data is therefore crucial for the assessment of generalizability.     

Evaluating health care quality: the moderating role of outcomes

An integrative model of health care quality is presented. "Health care quality" is defined as provider conformance to patient requirements at three benefit levels: core, intangible, and tangible. The model is operationalized and tested in a clinical setting, a large center for fertility studies with more than 5000 patients. Health care "process variables" such as physician and patient interactions were not as important in patients' evaluations of health care quality when successful outcomes occurred (pregnancy). However, when patients experienced unsuccessful outcomes (no pregnancy), health care "process variables" were important and had a significant influence on patient perceptions of health care quality. Hence, service outcomes can significantly affect the measurement and interpretation of health care quality. Implications for health care management and research are discussed.     

The role of generic and disease-specific measures of physical and role functioning in assessing patient outcomes: a longitudinal study

Using longitudinal data from the Veterans Health Study (VHS), we extended our earlier published cross-sectional analysis in comparing the generic SF-36 physical functioning (PF) and role limitations (role-physical [RP]) scales with the disease-specific PF and RP scales using disease attributions. The present study included 569 patients with chronic lung disease (CLD) and 352 patients with chronic low back pain (LBP) who received Veterans Affairs (VA) ambulatory care between June 1993 and March 1996. Consistent with our earlier study, we found that changes in the generic PF and RP scales had higher correlations with the other generic SF-36 scales than those in the disease-specific PF and RP scales over 12 months. On the other hand, disease-specific measures of PF and RP had larger R and t statistic values in discriminating the impacts of symptom-based illness severity as well as clinical services on physical and role functioning. These results suggest that the generic and disease-specific measures of PF and RP behave distinctly different from each other over time. The generic measures of PF and RP tend to assess a broad array of health-related quality of life, whereas disease-specific attributions of PF and RP scales tend to evaluate disease progression and clinical management associated with specific disease conditions. Disease-specific attribution is an important alternative to the development of new disease-specific instruments for assessing illness severity and the impact of clinical services.     

The cost-effectiveness of point of care testing in a general practice setting: results from a randomised controlled trial

Background  

While point of care testing (PoCT) for general practitioners is becoming increasingly popular, few studies have investigated whether it represents value for money. This study aims to assess the relative cost-effectiveness of PoCT in general practice (GP) compared to usual testing practice through a pathology laboratory.     

Improving quality of organizing cardiovascular preventive care in general practice by outreach visitors: a randomized controlled trial

BACKGROUND: Adequate care for patients with cardiovascular risks requires an adequate practice organization. Educational outreach visits are a promising approach to modifying professional behavior. We aimed to assess whether the quality of cardiovascular preventive care in general practice can be improved through a comprehensive intervention implemented by an educational outreach visitor. METHODS: After baseline measurements, general practices (n = 124) in the southern half of The Netherlands were randomly allocated to either intervention or control group. The intervention, based on the educational outreach model, comprised 15 practice visits over a period of 21 months and addressed a large number of issues around task delegation, availability of instruments and patient leaflets, record-keeping, and follow-up routines. Twenty-one months after the start of the intervention, postintervention measurements were performed. The difference between ideal and actual practice in each aspect of organizing preventive care was defined as a deficiency score. Primary outcome measure was the difference in deficiency scores before and after the intervention. RESULTS: All practices completed both baseline and postintervention measurements. The difference in change between intervention and control group adjusted for baseline was statistically significant (P < 0.001) for each aspect of organizing preventive care. The largest absolute improvement was found for the number of preventive tasks performed by the practice assistant. CONCLUSIONS: This study showed that a comprehensive intervention implemented by outreach visitors was effective in improving organization of cardiovascular preventive care in general practice.     

Dilemmas in general practice: The care of the cancer patient

Recent investigations of the care provided for cancer patients in the community have revealed substantial shortcomings, both in the identification of problems and in the help offered to patients and their families. While some explanations have been sought for these omissions, it has generally been assumed that they are due to practitioners' ignorance of problems encountered by families. Focusing on general practitioners, this paper argues that these deficiencies in care arise not only from ignorance, but also from the conceptual and structural framework within which practitioners operate. Working within such a framework, general practitioners experience considerable dilemmas in decisions about the management and care of cancer patients. This paper argues that explicit acknowledgement of these dilemmas is a necessary prerequisite to any recommendations for improvements in care.     

The quality of prescribing in general practice

General practitioner prescribing is a subject of legitimate interest to all those concerned with the quality of patient care. The analysis of prescribing and cost data can reveal much about this quality. Suggests that both general practitioners and those who administer and advise on family practitioner services will need to understand the issues involved. Warns that, taken in isolation, prescribing data can be misleading, and it must be compared with other aspects of patient care. Simple calculations can suggest areas of possible under-prescribing and over-prescribing, and in turn lead to consideration of the criteria for diagnosis of common chronic diseases such as asthma and diabetes, as well as their subsequent management. Suggests that the prescribing of both new drugs and those of dubious merit is a subject for particular scrutiny, and those who prescribe these drugs must accept the duty of extra vigilance this imposes on them.     

The effect of an integrated care approach for heart failure on general practice

BACKGROUND: Recent studies have investigated specific strategies for heart failure management. None has involved collaboration between primary and secondary care. Potential gains for patients may result from collaborative strategies. OBJECTIVE: To assess the effect of an integrated management approach for patients with heart failure on general practice. METHODS: The study design was a cluster randomized controlled trial of integrated primary/ secondary care compared with usual care for heart failure patients. The study took place at Auckland Hospital, New Zealand and involved 197 patients admitted with an episode of heart failure. Patients were randomized to management group or control group (who received "usual" care). Management group patients received early clinical review, education sessions, a personal diary for medications and weight, and regular clinical follow-up alternating between GP and hospital clinic. Follow-up was for 12 months. RESULTS: Patients visited GPs frequently (median 14 visits, range 0-40), with no statistical difference between the two groups. Heart failure was the most common reason for consulting the GP. There was no relationship between GP consultations and patients' attendance at the study clinic, or hospital admissions. Management group GPs and patients expressed a high level of satisfaction. CONCLUSION: GP consultation rates were not affected by the programme. Further research will determine if general practice based programmes result in further gains.