The prevalence of dementia is placing an increased burden on specialists.
Canadian neurologists responded to a structured questionnaire to assess reasons for referral and services provided as well as to compare the neurologists' perceptions of their practice characteristics against cases seen over a 3-month period.
The audit confirmed the participants' perception that family practitioners are the main referral source (358/453, 79%). Sixty-two percent of patients had undergone clinical investigation for dementia prior to being seen by the neurologist; 39% (177/453) were on pharmacotherapy at the time of referral, 68% were initiated on pharmacotherapy by the neurologist. A fifth of the referrals did not meet clinical criteria for dementia, which may be directly related to the prevalence of prior workup that did not include mental status testing.
Neurologists currently treat patients referred for dementia who may already have been adequately evaluated and treated by primary care providers.
Comment In: Am J Alzheimers Dis Other Demen. 2008 Dec-2009 Jan;23(6):513-519222144
This paper attempts to go deeper into the topic of social competency of physicians who provide primary care to populations living in poverty in Montreal. Adaptability as well as the ability to tailor practices according to patient expectations, needs and capabilities were found to be important in the development of the concept of social competency. The case of paternalism is used to demonstrate how a historically and socially contested medical approach is readapted by players in certain contexts in order to better meet patient expectations. This paper presents data collected in a qualitative study comprising 25 semi-supervised interviews with physicians recognized by their peers as having developed exemplary practices in Montreal's impoverished neighbourhoods.
Problem drinking is common, and a 15-minute intervention can help some patients reduce drinking to safe levels. Little is known, however, about the frequency and duration of alcohol-related discussions in primary care.
Nineteen clinicians in the Ambulatory Sentinel Practice Network (ASPN) collected data about alcohol-related discussions for 1 week following their usual office routine (Phase 1) and for 1 week with the addition of routine screening for problem drinking (Phase 2). Of those, 15 clinicians collected data for a third week after receiving training in brief interventions with problem drinkers (Phase 3). Clinicians collected data on standard ASPN reporting cards.
In Phase 1 the clinicians discussed alcohol during 9.6% of all visits. Seventy-three percent of those discussions were shorter than 2 minutes long, and only 10% lasted longer than 4 minutes. When routine screening was added (Phase 2), clinicians were more likely to discuss alcohol at acute-illness visits, but the frequency, duration, and intensity of such discussions did not change. Only 32% of Phase 2 discussions prompted by a positive screening result lasted longer than 2 minutes. After training, the duration increased (P
Studies of antibiotic prescribing related to diagnosis comparing prescribers trained abroad with those trained in Sweden are lacking.
To determine whether general practices (GPs) and GP residents trained abroad had different prescribing patterns for antibiotics for common infections than those trained in Sweden using retrospective data from electronic patient records from primary health care in Kalmar County, Sweden.
Consultations with an infection diagnosis, both with and without the prescription of antibiotics to 67 GPs and residents trained in Western Europe outside Sweden and other countries, were compared with a matched control group trained in Sweden.
For 1 year, 44101 consultations of patients with an infection diagnosis and 16276 prescriptions of antibiotics were registered. Foreign-trained physicians had 20% more visits compared with physicians trained in Sweden. The prescription of antibiotics per visit and physician in the respective groups, and independent of diagnosis, did not significantly differ between groups, when scaled down from number of consultations to number of prescribing physicians.
There were minor and non-significant differences in antibiotic prescribing comparing GPs and residents trained abroad and in Sweden, most likely the result of an adaptation to Swedish conditions. Nevertheless, no group prescribed antibiotics in accordance to national guidelines. The results suggest that interventions are needed to reduce irrational antibiotic prescribing patterns, targeting all physicians working in Swedish primary health care.
OBJECTIVE: Anticoagulant (AC) treatment in primary health care with regard to change over time, quality of care, and prevalence. DESIGN: Surveys of patients on AC treatment during 3 months in 1992 and 1997. SETTING: A community in the Stockholm metropolitan area. MAIN OUTCOME MEASURES: Main indications, rate of values within recommended treatment interval, prevalence. RESULTS: The number of patients increased in primary health care in the community from 115 in 1992 to 170 in 1997. There were no differences in age and sex distribution, nor in the main indications. Values within the recommended treatment range 10-25% at the community health centre (CHC) were 74% in 1992 versus 86% in 1997 (p
The aim of this study was to evaluate two implementation strategies for the introduction of a lifestyle intervention tool in primary health care (PHC), applying the RE-AIM framework to assess outcome. A computer-based tool for lifestyle intervention was introduced in PHC. A theory-based, explicit, implementation strategy was used at three centers, and an implicit strategy with a minimum of implementation efforts at three others. After 9 months a questionnaire was sent to staff members (n= 159) and data from a test database and county council registers were collected. The RE-AIM framework was applied to evaluate outcome in terms of reach, effectiveness, adoption and implementation. The response rate for the questionnaire was 73%. Significant differences in outcome were found between the strategies regarding reach, effectiveness and adoption, in favor of the explicit implementation strategy. Regarding the dimension implementation, no differences were found according to the implementation strategy. A theory-based implementation strategy including a testing period before using a new tool in daily practice seemed to be more successful than a strategy in which the tool was introduced and immediately used for patients.
To describe an approach to sleep apnea for family physicians based on a review of current practice limitations for Canadian family physicians, validated risk prediction tools, and ambulatory sleep apnea technologies.
Published epidemiologic studies focused on family practice management of sleep apnea, clinical practice guidelines, risk prediction tools for sleep apnea, randomized controlled treatment trials, and the author's community practice audit. Evidence was levels I, II, and III.
Sleep apnea is commonly encountered in family practice, but many family physicians are unfamiliar with sleep medicine. The pretest probability of sleep apnea can be accurately predicted using any one of several simple risk prediction tools. Screening for other common sleep disorders is important, especially when the pretest probability of sleep apnea is low to intermediate; one-third of sleep apnea patients have additional sleep disorders. The use of home-based rather than laboratory-based diagnostic testing and treatment titration is controversial, but the former setting is often used when referral access is limited.
There are several tools that allow family physicians to make accurate sleep apnea risk assessments. There is growing evidence to guide home- versus laboratory-based diagnosis and treatment of sleep apnea.
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Primary health care contacts are a suitable arena to reduce patients' risky drinking. We studied whether the clinical guidelines are followed and thus considered feasible by nurses and physicians. A naturalistic material in Helsinki primary health care was collected in 2006-2008. Most professionals participated giving information on 18000 primary health care patients, of whom 56% had fulfilled the AUDIT-test. Most risky drinkers (AUDIT > or = 8) were given advice, 80% even booklets or other material, as recommended in the guidelines. Thus, brief intervention recommendations, including the use of the AUDIT, seem to be feasible in primary care settings.
Primary care in remote communities in northern Canada is delivered primarily by nurses who receive clinical support from physicians in regional centres and the patient transportation system. To improve continuity, quality and access to care in remote northern communities, it is important to understand the perspectives of front-line providers and the complex challenges they face.
To design and implement a survey of primary care providers to identify issues relating to inter-professional communication, clinical support and patient evacuation.
In collaboration with the territorial government and regional health authority partners, we developed a 21-item self-administered questionnaire survey, which could be completed online. The survey was sent to 218 physicians and nurses who were employed in the Northwest Territories (NWT) at the time of the survey and were involved in sending patients out of the community and/or receiving patients. The survey also contained an open-ended question at the end seeking comments regarding primary health care.
The overall low response rate of 39% among nurses and 19% among physicians threatens the validity of the quantitative results. The majority of providers were satisfied with their ability to communicate with other providers in a timely manner, their freedom to make clinical decisions and their overall experience practicing in the NWT. The patient transfer system appears to work from both the sender and receiver perspectives. However, a common theme reported by nurses was that physicians providing clinical advice, especially short-term locums, were not familiar with the local situation, whilst physicians at the receiving end remarked that the clinical information provided to them often lacked clarity.
Important lessons were learnt from the pilot study, especially in better engagement of providers in planning and dissemination. The questionnaire design and the online method of delivery were acceptable. Although important issues were identified, a larger definitive survey is needed to investigate them in the future.
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