Recording blood pressure readings in elderly patients’ charts: What patient and physician characteristics make it more likely?

OBJECTIVE

To identify patient and physician characteristics associated with family physicians recording blood pressure (BP) measurements in the medical charts of their elderly patients.

DESIGN

Retrospective review of patients’ charts during a 12-month period and baseline questionnaire on the sociodemographic and practice characteristics of family physicians participating in the Community Hypertension Assessment Trial. The chart review collected data on patients’ demographics, cardiovascular risk factors, antihypertensive medications, number of visits to family physicians, and number of BP readings recorded.

SETTING

Non-academic family practices in Hamilton and Ottawa, Ont.

PARTICIPANTS

Data were abstracted from the charts of 55 randomly selected regular elderly patients (65 years old and older) from each of 28 participating family practices (N = 1540 charts).

MAIN OUTCOME MEASURE

Number of recordings of BP measurements in medical charts during a 12-month period.

RESULTS

About 16% (241/1540) of elderly patients had not had their BP recorded in their charts during the 12-month review period. Among this 16%, almost half (47%, 114/241) had not had a BP measurement recorded during the previous 24 months. Multivariate analysis indicated that the likelihood of BP recording increased with the number of visits made to family physicians and was greater among patients taking antihypertensive medications or diagnosed with hypertension. Physicians who had more recently graduated from medical school (≤ 24 years) were more likely to record BP measurements.

CONCLUSION

Hypertension guidelines recommend that, for patients at risk, BP be measured and recorded at each office visit. Although more than 84% of older patients had at least 1 BP reading documented in their charts, patients who were already diagnosed with hypertension or who made frequent visits to the office were more likely to have their BP measured and recorded. A more systematic approach to monitoring elderly patients who visit their family physicians less frequently or who are not currently diagnosed with hypertension is needed.     

Family practice patients' adherence to statin medications

OBJECTIVE

To measure family practice patients’ adherence to statin medications and to identify factors associated with adherence to these medications.

DESIGN

Cross-sectional study using a mailed self-report survey sent to 400 patients.

SETTING

Two academic family practice clinics in Halifax, NS.

PARTICIPANTS

A total of 284 patients aged 40 or older who were prescribed statin medications by their family physicians, either for the first time or as a renewal during a 20-month period.

MAIN OUTCOME MEASURES

Level of adherence to statin medications as measured by patients’ self-report on the Morisky scale; association between high adherence on the Morisky scale and 38 patient-reported factors.

RESULTS

Response rate was 82.5%. Average age of patients was 65 years, 57% were men, 62% had been on statin medications for more than 2 years, and 97% reported that their family physicians managed their cholesterol levels. More than 63% of patients reported high adherence as measured by the Morisky scale. On multiple logistic regression, being older than 65, taking 4 to 6 other prescribed medications, and having a lifestyle that included regular exercise or a healthy diet were significant independent predictors of high adherence scores on the Morisky scale.

CONCLUSION

Almost two-thirds (63%) of patients who were prescribed statins by their family physicians reported high adherence to the medications. Strategies to improve adherence would best be directed at patients who are younger or taking fewer than 4 or more than 6 other prescribed medications. Patients should be encouraged to maintain a lifestyle of regular exercise and a healthy diet, as this was associated with better adherence to statin medications.     

Awareness of do-not-resuscitate orders: What do patients know and want?

Objective

To assess outpatient understanding of and previous experiences with do-not-resuscitate (DNR) orders and to gauge patient preferences with respect to DNR discussions.

Design

Cross-sectional, self-administered survey.

Setting

Four urban primary care physician offices in Vancouver, BC.

Participants

A total of 429 consecutive patients 40 years of age and older presenting for routine primary care between March and May 2009.

Main outcome measures

Awareness of, knowledge about, and experiences with DNR decisions; when, where, and with whom patients wished to discuss DNR decisions; and differences in responses by sex, age, and ethnicity, assessed using χ² tests of independence.

Results

The response rate was 90%, with 386 of 429 patients completing the surveys. Most (84%) respondents had heard of the terms do not resuscitate or DNR. Eighty-six percent chose family physicians as among the people they most preferred to discuss DNR decisions with; 56% believed that initial DNR discussions should occur while they were healthy; and 46% thought the discussion should take place in the office setting. Of those who were previously aware of DNR orders, 70% had contemplated DNR for their own care, with those older than 60 years more likely to have done so (P = .02); however, only 8% of respondents who were aware of DNR orders had ever discussed the subject with a health care provider. Few patients (16%) found this topic stressful.

Conclusion

Most respondents were well informed about the meaning of DNR, thought DNR discussions should take place when patients were still healthy, preferred to discuss DNR decisions with family physicians, and did not consider the topic stressful. Yet few respondents reported having had a conversation about DNR decisions with any health care provider. Disparity between patient preferences and experiences suggests that family physicians can and should initiate DNR discussions with younger and healthier patients.     

Approach to adolescent suicide prevention

OBJECTIVE

To provide family physicians with an approach to suicide prevention in youth.

SOURCES OF INFORMATION

A literature review was performed using Ovid MEDLINE with the key words suicide, attempted suicide, and evaluation studies or program evaluation, adolescent.

MAIN MESSAGE

Youth suicide might be prevented by earlier recognition and treatment of mental illness. Family physicians can and should screen for mental illness in youth; there are many diagnostic and treatment resources available to assist with this.

CONCLUSION

Earlier detection and treatment of mental illness are the most important ways family physicians can reduce morbidity and mortality for youth who are contemplating suicide.     

Are family physicians using the CHADS2 score?: Is it useful for assessing risk of stroke in patients with atrial fibrillation?

Objective

To assess whether family physicians are using the CHADS₂ (congestive heart failure, hypertension, age ≥ 75, diabetes mellitus, and stroke or transient ischemic attack) score in the decision to initiate warfarin therapy to prevent stroke in patients with atrial fibrillation.

Design

Retrospective analysis of the medical records of patients with atrial fibrillation.

Setting

Data were gathered from records at 3 clinics in a primary care network in Edmonton, Alta.

Participants

The medical records of patients with atrial fibrillation who were currently taking warfarin therapy.

Main outcome measures

Percentage of patients whose CHADS₂ scores indicated warfarin therapy for stroke prophylaxis compared with the actual percentage of patients taking warfarin therapy. Data on patients’ age, number of medications, and number of comorbid conditions were also recorded.

Results

Among these patients, 7% had a CHADS₂ score of 0, for which no warfarin therapy was indicated; 21% had a score of 1, for which either acetylsalicylic acid or warfarin was indicated; and 72% had a score of 2 or greater, for which warfarin therapy was indicated. About 80% of patients were taking medication to control their heart rate.

Conclusion

The CHADS₂ score is not being used in all cases to assess the need for warfarin therapy for preventing stroke in patients with atrial fibrillation. The CHADS₂ score might be of limited use because it is not sensitive enough to stratify patients clearly into high-, intermediate-, and low-risk groups. Although guidelines for stroke prevention should be followed, the CHADS₂ portion of the guidelines might not be the most effective way to assess patients’ risk of stroke.     

Prescription opioid use and misuse: Piloting an educational strategy for rural primary care physicians

Objective

To evaluate the feasibility and effectiveness of a multifaceted educational intervention to improve the opioid prescribing practices of rural family physicians in a remote First Nations community.

Design

Prospective cohort study.

Setting

Sioux Lookout, Ont.

Participants

Family physicians.

Interventions

Eighteen family physicians participated in a 1-year study of a series of educational interventions on safe opioid prescribing. Interventions included a main workshop with a lecture and interactive case discussions, an online chat room, video case conferencing, and consultant support.

Main outcome measures

Responses to questionnaires at baseline and after 1 year on knowledge, attitudes, and practices related to opioid prescribing.

Results

The main workshop was feasible and was well received by primary care physicians in remote communities. At 1 year, physicians were less concerned about getting patients addicted to opioids and more comfortable with opioid dosing.

Conclusion

Multifaceted education and consultant support might play an important role in improving family physician comfort with opioid prescribing, and could improve the treatment of chronic pain while minimizing the risk of addiction.     

Autonomic dysreflexia: Recognizing a common serious condition in patients with spinal cord injury

Objective

To raise family physicians’ awareness of autonomic dysreflexia (AD) in patients with spinal cord injury (SCI) and to provide some suggestions for intervention.

Sources of information

MEDLINE was searched from 1970 to July 2011 using the terms autonomic dysreflexia and spinal cord injury with family medicine or primary care. Other relevant guidelines and resources were reviewed and used.

Main message

Family physicians often lack confidence in treating patients with SCI, see them as complex and time-consuming, and feel undertrained to meet their needs. Family physicians provide a vital component of the health care of such patients, and understanding of the unique medical conditions related to SCI is important. Autonomic dysreflexia is an important, common, and potentially serious condition with which many family physicians are unfamiliar. This article will review the signs and symptoms of AD and offer some acute management options and preventive strategies for family physicians.

Conclusion

Family physicians should be aware of which patients with SCI are susceptible to AD and monitor those affected by it. Outlined is an approach to acute management. Family physicians play a pivotal role in prevention of AD through education (of the patient and other health care providers) and incorporation of strategies such as appropriate bladder, bowel, and skin care practices and warnings and management plans in the medical chart.     

Actionable Nuggets: Knowledge translation tool for the needs of patients with spinal cord injury

Objective

To present the results of a pilot study of an innovative methodology for translating best evidence about spinal cord injury (SCI) for family practice.

Design

Review of Canadian and international peer-reviewed literature to develop SCI Actionable Nuggets, and a mixed qualitative-quantitative evaluation to determine Nuggets’ effect on physician knowledge of and attitudes toward patients with SCI, as well as practice accessibility.

Setting

Ontario, Newfoundland, and Australia.

Participants

Forty-nine primary care physicians.

Methods

Twenty Actionable Nuggets (pertaining to key health issues associated with long-term SCI) were developed. Nugget postcards were mailed weekly for 20 weeks to participating physicians. Prior knowledge of SCI was self-rated by participants; they also completed an online posttest to assess the information they gained from the Nugget postcards. Participants’ opinions about practice accessibility and accommodations for patients with SCI, as well as the acceptability and usefulness of Nuggets, were assessed in interviews.

Main findings

With Actionable Nuggets, participants’ knowledge of the health needs of patients with SCI improved, as knowledge increased from a self-rating of fair (58%) to very good (75%) based on posttest quiz results. The mean overall score for accessibility and accommodations in physicians’ practices was 72%. Participants’ awareness of the need for screening and disease prevention among this population also increased. The usefulness and acceptability of SCI Nugget postcards were rated as excellent.

Conclusion

Actionable Nuggets are a knowledge translation tool designed to provide family physicians with concise, practical information about the most prevalent and pressing primary care needs of patients with SCI. This evidence-based resource has been shown to be an excellent fit with information consumption processes in primary care. They were updated and adapted for distribution by the Canadian Medical Association to approximately 50 000 primary care physicians in Canada, in both English and French.     

Practical use of the Framingham risk score in primary prevention: Canadian perspective

Objective

To review the 2009 Canadian Cardiovascular Society guidelines and provide practical recommendations for physicians.

Sources of information

Initial review of the references provided with the guidelines led to a search of the PubMed, ACP Journal Club, and Cochrane databases using the key words primary prevention and statin for English-language clinical trials, randomized controlled trials, meta-analyses, and reviews conducted with human participants. References from appropriate retrieved articles were also reviewed.

Main message

The guidelines outline low-density lipoprotein cholesterol (LDL-C) thresholds and targets to inform optimal use of statins in the primary prevention of cardiovascular disease (CVD). Family history of CVD and levels of high-sensitivity C-reactive protein (hsCRP) are risk modifiers in calculating the risk score with the new recommendations. An electronic calculator has been developed to facilitate increased uptake of these guidelines. Large numbers of asymptomatic people, particularly the elderly, will become eligible for statin therapy according to these new guidelines. Poor uptake by physicians and patients might result from the need for repeated testing of hsCRP and LDL-C levels in people who do not perceive themselves to be ill. Controversy persists concerning the role of hsCRP in the reclassification of CVD risk, and the concept of treating LDL-C to target has never been tested as an independent variable in a randomized trial. As two-thirds of the LDL-C lowering achieved by a statin occurs at the initial dose, it might be possible to achieve considerable CVD risk reduction for those at risk by treating initially with a mid-dose statin without LDL-C follow-up.

Conclusion

A simplified approach might appeal to patients or physicians who find current guidelines too complex, cumbersome, or costly. Success in getting high-risk patients to take statins is key to achieving improved CVD mortality reduction.     

Debiasing the hidden curriculum: academic equality among medical specialties

Objective

To compare the academic performance of students who entered family medicine residency programs with that of students who entered other disciplines and discern whether or not family physicians are as academically talented as their colleagues in other specialties.

Design

Retrospective quantitative study.

Setting

University of Calgary in Alberta.

Participants

Three graduating classes of students (2004 to 2006) from the University of Calgary medical school.

Main outcome measures

Student performance on various undergraduate certifying examinations in years 1, 2, and 3, along with third-year in-training evaluation reports and total score on the Medical Council of Canada Qualifying Examination Part I.

Results

Complete data were available for 99% of graduates (N = 295). In the analysis, residency program (family medicine [n = 96] versus non–family medicine [n = 199]) served as the independent variable. Using a 1-way multivariate ANOVA (analysis of variance), no significant difference among any of the mean performance scores was observed (F₅₂₈₉ = 1.73, P > .05). Students who entered family medicine were also well represented within the top 10 rankings of the various performance measures.

Conclusion

The academic performance of students who pursued careers in family medicine did not differ from that of students who chose other specialties. Unfounded negativity toward family medicine has important societal implications, especially at a time when the gap between the number of family physicians and patients seeking primary care services appears to be widening.     

Monitoring of international normalized ratios: Comparison of community nurses with family physicians

Objective

To determine whether community-based, nurse-led monitoring of the international normalized ratio (INR) in patients requiring long-term warfarin therapy was comparable to traditional physician monitoring.

Design

A retrospective cohort analysis of patients taking long-term warfarin therapy.

Setting

The study used data gathered from 3 family medicine clinics in a primary care network in Edmonton, Alta.

Participants

Medical records of patients currently taking warfarin were examined.

Intervention

Implementation of nurse-led monitoring in a primary care network in place of standard family physician INR monitoring.

Main outcome measures

The degree of INR control before and after the implementation of nurse-run INR monitoring was assessed. The average proportion of time spent outside of therapeutic INR ranges, as well as the average number of days between successive INR readings, was calculated and compared. The degree of control placed patients into either a good-control group (out of range ≤ 25% of the time) or a moderate-control group (out of range > 25% of the time) and these groups were compared.

Results

Before nurse monitoring, INR values were out of range 20.4% of the time; after nurse monitoring they were out of range 19.2% of the time (P = .115); the time between sequential INR readings also did not differ before and after implementation of nurse monitoring (23.9 vs 21.6 days, P = .789).

Conclusion

Nurse-led monitoring of INR is as effective as traditional physician monitoring. Advantages of nurse-led monitoring might include freeing family physicians to see more patients or to spend less time at work. It might also represent potential cost savings.     

Quebec breast cancer screening program: A study of the perceptions of physicians in Laval, Que

OBJECTIVE

To identify physicians’ perceptions of breast cancer prevention in order to generate strategies to increase women’s participation in the Quebec breast cancer screening program (QBCSP).

DESIGN

Qualitative study using archival data and in-depth interviews.

SETTING

Laval, Que, a suburban city north of Montreal.

PARTICIPANTS

Twenty family physicians and 1 gynecologist practising in Laval who had received at least 1 screening mammography report in 2004 or 2005.

METHODS

Archival data were obtained in order to refine our understanding of the QBCSP. In-depth individual interviews were conducted with participating physicians until data saturation was reached in order to determine physicians’ knowledge of, beliefs and attitudes about, and behaviour toward preventive breast cancer practices, as well as their suggestions for enhancing patient compliance. The interviews were recorded, transcribed, and coded, and the content was analyzed.

MAIN FINDINGS

Respondents indicated that the screening age groups, the age for beginning clinical breast examination, and the instructions to patients about breast self-examination should be harmonized. Letters to patients should be shortened, simplified, and endorsed by physicians. Screening mammography reports should include more details and be clearer about patient follow-up. The need for patients to sign authorization forms for transmission of information related to their participation in the QBCSP should be reinforced by their physicians. Following abnormal mammogram results, services and procedures should be simplified and delays in appointments decreased. Referral for “orphan patients” (ie, patients without family physicians) should be supervised by nurse practitioners, with physician consultations when needed.

CONCLUSION

This study provides a qualitative understanding of improvements or modifications needed in order to reach a screening mammography participation rate sufficient to reduce breast cancer mortality in women.     

Family physicians providing regular care to residents in Ontario long-term care homes: Characteristics and practice patterns

Objective

To describe the characteristics and practice patterns of family physicians who regularly treat long-term care (LTC) residents in order to inform quality improvement strategies.

Design

Cross-sectional study involving a 2005 province-wide census of LTC residents’ charts linked to additional health care administrative databases.

Setting

All LTC homes in Ontario.

Participants

Residents aged 66 years and older (n = 50375) and the family physicians (n = 1190) most responsible for their care.

Main outcome measures

Distribution of LTC residents across family physicians, and physician demographic characteristics and practice patterns.

Results

The distribution of residents across physicians was highly skewed (median 27 residents, mean 42.5 residents). The care of 90.4% of residents was accounted for by 628 (52.8%) identified physicians. Family physicians practising in LTC facilities were more likely to be older (mean age 52.4 years vs 48.2 years, P < .001) and male (82.4% vs 61.5%, P < .001) than other family physicians. Urban physicians who provided care to LTC residents had bigger LTC practices than rural LTC physicians did (median 50 residents vs median 12 residents).

Conclusion

About 600 family physicians are responsible for the regular care of more than 90% of LTC residents in Ontario and quality improvement efforts could be aimed at this relatively small group of physicians. Half of the urban physicians who practise in LTC homes are responsible for 50 or more LTC residents. This might represent a key part of their overall practice.     

Length of stay and hospital costs among patients admitted to hospital by family physicians

Objective

To compare length of stay and total hospital costs among patients admitted to hospital under the care of family physicians who were their usual health care providers in the community (group A) and patients admitted to the same inpatient service under the care of family physicians who were not their usual health care providers (group B).

Design

Retrospective observational study.

Setting

A large urban hospital in Vancouver, BC.

Participants

All adult admissions to the family practice inpatient service between April 1, 2006, and June 30, 2008.

Main outcome measures

Ratio of length of stay to expected length of stay and total hospital costs per resource intensity weight unit. Multivariate linear regression was performed to determine the effect of admitting group (group A vs group B) on the natural logarithm transformations of the outcomes.

Results

The median acute length of stay was 8.0 days (interquartile range [IQR] 4.0 to 13.0 days) for group A admissions and 8.0 days (IQR 4.0 to 15.0 days) for group B admissions. The median (IQR) total hospital costs were $6498 ($4035 to $11 313) for group A admissions and $6798 ($4040 to $12 713) for group B admissions. After adjustment for patient characteristics, patients admitted to hospital under the care of their own family physicians did not significantly differ in terms of acute length of stay to expected length of stay ratio (percent change 0.6%, P = .942) or total hospital costs per resource intensity weight unit (percent change −2.0%, P = .722) compared with patients admitted under the care of other family physicians.

Conclusion

These findings suggest that having networks of family physicians involved in hospital care for patients is not less efficient than having family physicians provide care for their own patients.     

Physicians as parents: Parenting experiences of physicians in Newfoundland and Labrador

OBJECTIVE

To investigate the experiences of physicians as parents and to see if there were any differences in the parenting challenges perceived by male and female physicians.

DESIGN

Mailed survey.

SETTING

Newfoundland and Labrador.

PARTICIPANTS

The survey was mailed to 180 male and 180 female licensed physicians, with a response rate of 60% (N = 216).

MAIN OUTCOME MEASURES

Self-reported experiences of being a parent and a physician.

RESULTS

Female physicians reported spending significantly more time on child care activities and domestic activities than their male counterparts did (P < .001). There was no significant difference in the number of professional hours between the 2 sexes, but income was significantly lower for female physicians (P < .001). More women than men had positive physician-parent role models, although very few physicians of either sex had such role models. Female physicians reported bearing the most responsibility for the day-to-day functioning of the family; male physicians relied on their female partners to carry out the main family responsibilities. Women reported feeling guilty about their performance as mothers and as doctors. Male physicians reported regrets about the lack of time with family.

CONCLUSION

Although women make up an increasing percentage of the physician work force in Canada, they still face challenges as they continue to take primary responsibility for child care and domestic activities. Women are torn between their careers and their families and sometimes feel inadequate in both roles. Male physicians regret having a lack of time with family. Strategies need to be employed in both the workplace and at home to achieve an acceptable balance between being a physician and being a parent.     

Effect of colleague and coworker abuse on family physicians in Canada

Objective

To assess the effects of physician-colleague and coworker abuse on family physicians in Canada.

Design

A mixed-methods, bilingual study that included surveys and telephone interviews.

Setting

Canada.

Participants

Family physicians in active practice who were members of the College of Family Physicians of Canada in 2009.

Methods

Surveys were mailed to a random sample of family physicians (N = 3802), and 37 family physicians who had been abused in the past year participated in telephone interviews.

Main findings

A total of 770 surveys (20%) were completed. A small number of respondents reported having been subjected to abuse by physician colleagues (9%) or coworkers (6%) in the previous month. Many of the respondents reported that the same physician colleagues or coworkers were repeat abusers. More than three-quarters (77%) of the physician-colleague abusers were men, whereas more than three-quarters (77%) of the other coworker abusers were women. Interviewed family physicians described feeling humiliated and unappreciated, and developed symptoms of anxiety or depression. As a result of the abuse, some family physicians terminated their employment or refused to work in certain environments. The most striking effect of this abuse was that respondents reported losing confidence in their professional abilities and skills.

Conclusion

Although only a small number of family physicians experience abuse by physician colleagues and other coworkers, the effects can be considerable. Victims reported a loss of confidence in their clinical abilities and some subsequently were faced with mental health issues.