International Journal of Family Medicine The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. Early COPD Diagnosis in Family Medicine Practice: How to Implement Spirometry? Thu, 03 Apr 2014 00:00:00 +0000 Introduction. COPD is often diagnosed at an advanced stage because symptoms go unrecognized. Furthermore, spirometry is often not done. Methods. Study was conducted in diverse family medicine practice settings. Patients were targeted if respiratory symptoms were present. Patients had a spirometry to confirm the presence of airflow obstruction and COPD diagnosis. An evaluation of the process was done to better understand facilitating/limiting factors to the implementation of a primary care based spirometry program. Results. 12 of 19 primary care offices participated. 196 of 246 (80%) patients targeted based on the presence of smoking and respiratory symptoms did not have COPD; 18 (7%) and 32 (13%) had COPD, respectively, GOLD I and ≥II. There was no difference in the type and number of respiratory symptoms between non-COPD and COPD patients. Most of the clinics did not have access to a trained healthcare professional to accomplish spirometry. They agreed that giving access to a trained healthcare professional was the easiest and most reliable way of doing spirometry. Conclusion. Spirometry, a simple test, is recommended in guidelines to make the diagnosis of COPD. The lack of allocated time and training of healthcare professionals makes its implementation challenging in family medicine practices. Nathalie Saad, Maria Sedeno, Katrina Metz, and Jean Bourbeau Copyright © 2014 Nathalie Saad et al. All rights reserved. Long-Term Effect of Interactive Online Dietician Weight Loss Advice in General Practice (LIVA) Protocol for a Randomized Controlled Trial Sun, 30 Mar 2014 00:00:00 +0000 Background. Internet-based complex interventions aiming to promote weight loss and optimize healthy behaviors have attracted much attention. However, evidence for effect is lacking. Obesity is a growing problem, resulting in an increasing demand for cost efficient weight loss programs suitable for use on a large scale, for example, as part of standard primary care. In a previous pilot project by Brandt et al. (2011) without a control group, we examined the effects of online dietician counseling and found an average weight loss of 7.0 kg (95% CI: 4.6 to 9.3 kg) after 20 months. Aims and Methods. To analyze the effects of a complex intervention using trained dieticians in a general practice setting combined with internet-based interactive and personalized weight management support compared with conventional advice with a noninteractive internet support as placebo treatment in 340 overweight patients during a 2-year period. Primary endpoints are weight loss and lowering of cholesterol (LDL). We will also explore patients’ sociodemographics and use of the intervention as well as the health professionals’ views and perceptions of the intervention (their role and the advice and support that they provide). Perspective. The project will generate knowledge on the cost-effectiveness of a complex internet-based intervention in a general practice setting and on barriers and acceptability among professionals and patients. Carl J. Brandt, Vibeke Brandt, Mathilde Pedersen, Dorte Glintborg, Søren Toubro, Jesper Bo Nielsen, Gunther Eysenbach, Kirsten Brandt, and Jens Søndergaard Copyright © 2014 Carl J. Brandt et al. All rights reserved. Clinical Utility of Cognistat in Multiprofessional Team Evaluations of Patients with Cognitive Impairment in Swedish Primary Care Sun, 23 Mar 2014 09:55:40 +0000 Background. Diagnostic evaluations of dementia are often performed in primary health care (PHC). Cognitive evaluation requires validated instruments. Objective. To investigate the diagnostic accuracy and clinical utility of Cognistat in a primary care population. Methods. Participants were recruited from 4 PHC centres; 52 had cognitive symptoms and 29 were presumed cognitively healthy. Participants were tested using the Mini-Mental State Examination (MMSE), the Clock Drawing Test (CDT), and Cognistat. Clinical diagnoses, based on independent neuropsychological examination and a medical consensus discussion in secondary care, were used as criteria for diagnostic accuracy analyses. Results. The sensitivity, specificity, positive predictive value, and negative predictive value were 0.85, 0.79, 0.85, and 0.79, respectively, for Cognistat; 0.59, 0.91, 0.90, and 0.61 for MMSE; 0.26, 0.88, 0.75, and 0.46 for CDT; 0.70, 0.79, 0.82, and 0.65 for MMSE and CDT combined. The area under the receiver operating characteristic curve was 0.82 for Cognistat, 0.75 for MMSE, 0.57 for CDT, and 0.74 for MMSE and CDT combined. Conclusions. The diagnostic accuracy and clinical utility of Cognistat was better than the other tests alone or combined. Cognistat is well adapted for cognitive evaluations in PHC and can help the general practitioner to decide which patients should be referred to secondary care. Maria M. Johansson, Anna S. Kvitting, Ewa Wressle, and Jan Marcusson Copyright © 2014 Maria M. Johansson et al. All rights reserved. Prescription Practice for Diabetes Management among a Female Population in Primary Health Care Thu, 20 Mar 2014 07:06:19 +0000 Introduction. Prescription for diabetes care is an important practice in primary care. Methods. This is a descriptive study carried out on at primary care clinics over a five-month period at Al Imam Medical Complex, Riyadh, Saudi Arabia. It was cross-sectional study of 160 female diabetic patients, who visited the services between January and May, 2012. Data were collected from the medical records on the clinical characteristics and drugs prescribed for their diabetic management. Results. The majority of the sample population (82%) was older than 40 years old. Half of them had concomitant hypertension, hyperlipidemia, and obesity. There were 500 prescriptions for diabetes management. More than 57% of participants were on two or more drugs for hyperglycemia. Metformin was the most common drug prescribed. Metformin and sulphonylurea were the most common combined medications. Most of cases ( 70%) were on a combination of antihypertensive drugs. ACE or ARBs and diuretic was the most common combined prescriptions. Statins and aspirin were used by 41% and 23.8% of the research population, respectively. Conclusion. Polypharmacy is a feature in diabetes care. Most of the prescription practice for diabetic care follows the recommended guidelines for hyperglycemia and hypertension. Management of dyslipidemia among diabetic patients, however, is an area that needs to be developed. Fouzia A. ALHreashy and Abdulelah F. Mobierek Copyright © 2014 Fouzia A. ALHreashy and Abdulelah F. Mobierek. All rights reserved. Measuring Staff Empowerment Regarding Health Care for Clients with Intellectual Disabilities Tue, 25 Feb 2014 12:08:12 +0000 Background. Women with intellectual disabilities (ID) contract breast cancer at the same rate as the general population but have higher breast cancer mortality and lower rates of breast cancer screening. Many women with ID live in group homes or supported residences where they are cared for by direct support workers. While direct support workers are thought to influence client health, this effect is underresearched, and we lack tools for measuring staff empowerment and perceptions regarding client health. Methods. We developed and validated an instrument, the staff empowerment tool (SET), to measure staff empowerment as related to supporting clients in preventive health. Results. The SET was found to be a reliable instrument for measuring staff activation and empowerment in helping clients access mammography screening. Discussion. Quantifying staff empowerment and perspectives is important in studying and reducing disparities among adults with ID, a vulnerable population. Further research to determine the impact of staff empowerment levels on their clients’ health and health care access is suggested. The SET is a valuable tool for measuring the construct of staff empowerment, evaluating interventions, and collecting data regarding variation in staff empowerment. Joanne Wilkinson, Nechama W. Greenwood, Claire Tienwey Wang, Laura F. White, and Larry Culpepper Copyright © 2014 Joanne Wilkinson et al. All rights reserved. Tablet-Based Screening of Depressive Symptoms in Quito, Ecuador: Efficiency in Primary Care Mon, 17 Feb 2014 13:04:14 +0000 Depression is a frequent yet overlooked occurrence in primary health care clinics worldwide. Depression and related health screening instruments are available but are rarely used consistently. The availability of technologically based instruments in the assessments offers novel approaches for gathering, storing, and assessing data that includes self-reported symptom severity from the patients themselves as well as clinician recorded information. In a suburban primary health care clinic in Quito, Ecuador, we tested the feasibility and utility of computer tablet-based assessments to evaluate clinic attendees for depression symptoms with the goal of developing effective screening and monitoring tools in the primary care clinics. We assessed individuals using the 9-item Patient Health Questionnaire, the Quick Inventory of Depressive Symptoms-Self-Report, the 12-item General Health Questionnaire, the Clinical Global Impression Severity, and a DSM-IV checklist of symptoms. We found that 20% of individuals had a PHQ9 of 8 or greater. There was good correlation between the symptom severity assessments. We conclude that the tablet-based PHQ9 is an excellent and efficient method of screening for depression in attendees at primary health care clinics and that one in five people should be assessed further for depressive illness and possible intervention. Michelle Grunauer, David Schrock, Eric Fabara, Gabriela Jimenez, Aimee Miller, Zongshan Lai, Amy Kilbourne, and Melvin G. McInnis Copyright © 2014 Michelle Grunauer et al. All rights reserved. Adherence to Long-Term Therapies and Beliefs about Medications Thu, 13 Feb 2014 13:07:42 +0000 Objectives. To assess adherence to long-term medications among patients in family medicine clinics and to evaluate relationship between adherence, beliefs about medications, medication information adequacy, and other factors. Methods. Interviewer assisted survey was conducted to assess adherence using the 8-item Morisky Medication Adherence Scale (MMAS-8), beliefs about medications using beliefs about medicine questionnaire (BMQ), and the patients’ perception of medication information adequacy. Results. Of the 408 participants, 56.9% reported low adherence. Pearson’s bivariate correlation showed positive association between MMAS-8 score and BMQ-specific necessity (  ) and the perceived information adequacy (  ), and there was negative association between adherence score and BMQ specific concerns, general overuse, and harm (, 0.466, and 0.663, resp.) (). Multivariable analysis revealed that age, number of medications, number of medical conditions, specific necessity and concerns beliefs, general harm beliefs, and perceived adequacy of medication information were independent predictor of adherence. Furthermore, specific beliefs explain 27.7% of the variance in adherence, while medication information adequacy explains 32.3% of the variance in adherence. Conclusion. The prevalence of low adherence among patients on long-term medications is high and it is related to negative beliefs about medications and to inadequate information given to patients about their medications. Abdullah AlHewiti Copyright © 2014 Abdullah AlHewiti. All rights reserved. The Impact of Insurance and a Usual Source of Care on Emergency Department Use in the United States Sun, 09 Feb 2014 11:26:52 +0000 Background. Finding a usual source of care (USC) is difficult for certain populations. This analysis determines how insurance type and having a USC affect the settings in which patients seek care. Methods. In this cross-sectional study of the 2000–2011 Medical Expenditure Panel Surveys, we assessed the percentage of low-income persons with half or more of their ambulatory visits to the emergency department (ED). Respondents were stratified based on insurance type and presence of a USC. Results. In 2011, among Medicaid enrollees without USCs, 21.6% had half or more of their ambulatory visits to EDs compared to 8.1% for those with USCs. Among the uninsured without USCs, 24.1% went to an ED for half or more of their ambulatory visits compared to 8.8% for those with USCs in 2011. Among the privately insured without USCs, 7.8% went to an ED for half or more of their ambulatory visits compared to 5.0% for those with USCs in 2011. These differences remained in multivariate analyses. Conclusions. Those who lack USCs, particularly the uninsured and Medicaid enrollees, are more likely to rely on EDs. Winston Liaw, Stephen Petterson, David L. Rabin, and Andrew Bazemore Copyright © 2014 Winston Liaw et al. All rights reserved. Primary Healthcare Solo Practices: Homogeneous or Heterogeneous? Sun, 12 Jan 2014 00:00:00 +0000 Introduction. Solo practices have generally been viewed as forming a homogeneous group. However, they may differ on many characteristics. The objective of this paper is to identify different forms of solo practice and to determine the extent to which they are associated with patient experience of care. Methods. Two surveys were carried out in two regions of Quebec in 2010: a telephone survey of 9180 respondents from the general population and a postal survey of 606 primary healthcare (PHC) practices. Data from the two surveys were linked through the respondent’s usual source of care. A taxonomy of solo practices was constructed (), using cluster analysis techniques. Bivariate and multilevel analyses were used to determine the relationship of the taxonomy with patient experience of care. Results. Four models were derived from the taxonomy. Practices in the “resourceful networked” model contrast with those of the “resourceless isolated” model to the extent that the experience of care reported by their patients is more favorable. Conclusion. Solo practice is not a homogeneous group. The four models identified have different organizational features and their patients’ experience of care also differs. Some models seem to offer a better organizational potential in the context of current reforms. Raynald Pineault, Roxane Borgès Da Silva, Sylvie Provost, Marie-Dominique Beaulieu, Antoine Boivin, Audrey Couture, and Alexandre Prud'homme Copyright © 2014 Raynald Pineault et al. All rights reserved. Everyday Living with Diabetes Described by Family Members of Adult People with Type 1 Diabetes Wed, 18 Dec 2013 10:08:27 +0000 The aim of this study was to explore family members’ experiences of everyday life in families with adult people living with type 1 diabetes. The grounded theory method was used to gather and analyse data from the interviews of nineteen family members. Six concepts describing the family members’ views on everyday living with diabetes were generated on the basis of the data. Everyday life with diabetes is described as being intertwined with hypoglycemia. Becoming acquainted with diabetes takes place little by little. Being involved in the management and watching self-management from the sidelines are concepts describing family members’ participation in the daily management of diabetes. The family members are also integrating diabetes into everyday life. Living on an emotional roller-coaster tells about the thoughts and feelings that family members experience. Family members of adult people with diabetes are involved in the management of the diabetes in many ways and experience many concerns. The family members’ point of view is important to take into consideration when developing education for adults with diabetes. Tuula-Maria Rintala, Eija Paavilainen, and Päivi Åstedt-Kurki Copyright © 2013 Tuula-Maria Rintala et al. All rights reserved. Ethical Diversity and the Role of Conscience in Clinical Medicine Thu, 12 Dec 2013 14:12:28 +0000 In a climate of plurality about the concept of what is “good,” one of the most daunting challenges facing contemporary medicine is the provision of medical care within the mosaic of ethical diversity. Juxtaposed with escalating scientific knowledge and clinical prowess has been the concomitant erosion of unity of thought in medical ethics. With innumerable technologies now available in the armamentarium of healthcare, combined with escalating realities of financial constraints, cultural differences, moral divergence, and ideological divides among stakeholders, medical professionals and their patients are increasingly faced with ethical quandaries when making medical decisions. Amidst the plurality of values, ethical collision arises when the values of individual health professionals are dissonant with the expressed requests of patients, the common practice amongst colleagues, or the directives from regulatory and political authorities. In addition, concern is increasing among some medical practitioners due to mounting attempts by certain groups to curtail freedom of independent conscience—by preventing medical professionals from doing what to them is apparently good, or by compelling practitioners to do what they, in conscience, deem to be evil. This paper and the case study presented will explore issues related to freedom of conscience and consider practical approaches to ethical collision in clinical medicine. Stephen J. Genuis and Chris Lipp Copyright © 2013 Stephen J. Genuis and Chris Lipp. All rights reserved. Sexual and Reproductive Health Care for Women with Intellectual Disabilities: A Primary Care Perspective Thu, 12 Dec 2013 08:49:02 +0000 Adults with intellectual disabilities (ID) face multiple health disparities and challenges to accessing health care. Little is known about sexual health care of this population and about how to optimize women’s reproductive health care for women with intellectual disabilities. Women with ID face important barriers to care, including lack of provider training and experience, hesitancy to broach the topic of sexual health, a lack of sexual knowledge and limited opportunities for sex education, disability-related barriers, higher prevalence of sexual abuse and assault, often underreported, lack of dialogue around this population’s human right to consensual sexual expression, undertreatment of menstrual disorders, and legal and systemic barriers. We conducted a limited literature review related to six aspects of sexual health care of women with ID, including barriers to sexual health care, sex education, sexual abuse and consensual sexuality, contraception, screening for sexually transmitted infections and cervical cancer, and pregnancy and parenting. After providing background information about each topic, we suggest practice recommendations for primary care clinicians, using a rights-based framework. Nechama W. Greenwood and Joanne Wilkinson Copyright © 2013 Nechama W. Greenwood and Joanne Wilkinson. All rights reserved. A Pharmacist-Led Point-of-Care INR Clinic: Optimizing Care in a Family Health Team Setting Thu, 12 Dec 2013 08:27:50 +0000 Purpose. Monitoring patients’ international normalized ratio (INR) within a family medicine setting can be challenging. Novel methods of doing this effectively and in a timely manner are important for patient care. The purpose of this study was to determine the effectiveness of a pharmacist-led point-of-care (POC) INR clinic. Methods. At a community-based academic Family Health Team in Toronto, Canada, charts of patients with atrial fibrillation managed by a pharmacist with usual care (bloodtesting at lab and pharmacist follow up of INR by phone) from February 2008 to April 2008 were compared with charts of patients attending a weekly POC INR clinic from February 2010 to April 2010. Time in therapeutic range (TTR) was measured for both groups. Results. 119 patient charts were reviewed and 114 had TTR calculated. After excluding patients with planned inconsistent Coumadin use (20), such as initiating Coumadin treatment or stopping for a surgical procedure, the mean TTR increased from 64.41% to 77.09% with the implementation of the POC clinic. This was a statistically significant difference of 12.68% (CI: 1.18, 24.18; ). Conclusion. A pharmacist-led POC-INR clinic improves control of anticoagulation therapy in patients receiving warfarin and should be considered for implementation in other family medicine settings. Jennifer Rossiter, Gursharan Soor, Deanna Telner, Babak Aliarzadeh, and Jennifer Lake Copyright © 2013 Jennifer Rossiter et al. All rights reserved. Assessment of Preference and Its Determinant Factors to Ward Modern Contraceptive Methods among Women of Reproductive Age Group in Shire Indaselassie Town, Northern Ethiopia, 2011 Wed, 11 Dec 2013 12:04:03 +0000 Background. Women’s preferences for various contraceptive methods attribute vary according to the type of relations and other aspects of their life. The discrepancy between fertility preferences and contraceptive practice is regarded as an indicator of unmet demand for family planning. Objective. To assess modern contraceptive methods preference and its determinant factors among women of reproductive age group in Shire Indaselassie town, Tigray Region, Northern Ethiopia. Method. A community based cross-sectional study design was employed on 367 sampled women. Stratified sampling technique was used to select the study subjects. Then, data was collected using structured questionnaire. Result. In this study, the most commonly preferred modern contraceptive method was injectable contraceptive 202 (55%), the second 61 (16.6%) was oral contraceptives, and the third 47 (12.8%) was Norplant. Condom 31 (8.4%), IUD 14 (3.8%), female sterilization 7 (1.9%), and others were less commonly preferred methods. Some of the reasons for preference were effectiveness of the method, reversibility, fewer side effects, convenience, long duration of use, and no need to remember daily. Conclusion. This study clearly described that women preferences of modern contraceptive methods increased after they had higher number of children and less desire to limit family size. Weyzer T. Tsehaye, Daniel Mengistu, Emebet Birhanu, and Kalayou K. Berhe Copyright © 2013 Weyzer T. Tsehaye et al. All rights reserved. Risk of Burnout in Danish GPs and Exploration of Factors Associated with Development of Burnout: A Two-Wave Panel Study Sat, 07 Dec 2013 14:20:07 +0000 Background. We assessed risk of burnout in GPs during a 7-year followup and examined whether (1) thoughts about changing medical specialty increased the risk of burnout and (2) burned out GPs had higher job turnover rates than burnout-free GPs. Methods. In 2004 and 2012, all GPs in the county of Aarhus, Denmark, were invited to participate in a survey. Retirement status of physicians who participated in 2004 was obtained through the Registry of Health Providers in 2012. Results. 216 GPs completed both surveys. The risk of developing burnout during the 7-year followup was 13.2% (8.2–19.6%). GPs who in 2004 were burnout-free and reported that they would not select general practice as medical specialty again had a statistically significant increased risk of burnout in 2012 (OR = 4.5; 95% CI = 1.2–16.5; ). Among GPs with burnout in 2004, 25.0% had withdrawn from general practice during followup compared to 28.8% of burnout-free GPs in 2004 (adj. OR = 0.99; 95% CI = 0.48–2.02; ). Conclusion. The 7-year incidence of burnout was 13%. Thoughts about changing medical specialty were an important predictor of burnout. Burned out GPs had not higher job turnover rates than burnout-free GPs. Anette Fischer Pedersen, Christina Maar Andersen, Frede Olesen, and Peter Vedsted Copyright © 2013 Anette Fischer Pedersen et al. All rights reserved. Psychological Distress in Women with Chronic Bronchitis in a Fishing Community in the Niger Delta Region of Nigeria Thu, 05 Dec 2013 14:57:20 +0000 Background. Biomass smoke exposure is a known risk factor for chronic bronchitis. Psychiatric comorbidities may have significant impact on the quality of life of patients with chronic bronchitis. Methods. Women who engage in fish preservation by drying over burning firewood in a fishing community were recruited for this survey. The British medical research questionnaire was used to determine chronic bronchitis, and psychological distress was determined using the hospital anxiety and depression scale. Results. A total of 342 women were recruited for this study and 63 of them had chronic bronchitis. 96 women had features suggestive of psychological distress: 57 (16.6%) women with anxiety, 51 (14.9%) women with depression and 12 women (3.5%) had combined features. Psychological distress was more common among women with chronic bronchitis. Anxiety was significantly associated with chronic bronchitis and the level of biomass exposure while depression was significantly associated with chronic bronchitis, level of exposure, and a history of sleeping in the fish smoking room. Conclusion. Anxiety and depression show significant association with chronic bronchitis among women with biomass smoke exposure with the level of exposure having an aggravating effect on the relationship. Victor Aniedi Umoh, Andrew Ibok, Bassey Edet, Ekpe Essien, and Festus Abasiubong Copyright © 2013 Victor Aniedi Umoh et al. All rights reserved. Danish General Practitioners' Use of Prostate-Specific Antigen in Opportunistic Screening for Prostate Cancer: A Survey Comprising 174 GPs Tue, 19 Nov 2013 10:53:54 +0000 Background. The use of prostate-specific antigen test has markedly increased in Danish general practice in the last decade. Despite the national guidelines advice against PSA screening, opportunistic screening is supposed to be the primary reason for this increased number of PSA tests performed. Aims. Based on the increase in the amount of PSA conducted, we aimed to analyse how GPs in Denmark use the PSA test. Methods. A self-administrated questionnaire concerning symptomatic and asymptomatic patient cases was developed based on the national and international guidelines and the extensive literature review, and an in-depth interview conducted with a GP was performed. Results. None of the GPs would do a PSA measurement for an asymptomatic 76-year-old man. For asymptomatic 55- and 42-year-old men, respectively, 21.9% and 18.6% of GPs would measure PSA. Patient request and concern could be potential reasons for measuring PSA for asymptomatic patients. Almost all GPs stated that a PSA measurement is indicated for symptomatic 49- and 78-year-old men, respectively, 98.9% and 93.8%. Conclusion. Opportunistic PC screening is being performed in general practice to a high degree. Hence, current guidelines are not followed, and intense focus should be on more effective implementation strategies in order to avoid overuse of PSA. Kasper Jessen, Jens Søndergaard, Pia Veldt Larsen, and Janus Laust Thomsen Copyright © 2013 Kasper Jessen et al. All rights reserved. From Doctor to Nurse Triage in the Danish Out-of-Hours Primary Care Service: Simulated Effects on Costs Mon, 30 Sep 2013 13:47:03 +0000 Introduction. General practitioners (GP) answer calls to the Danish out-of-hours primary care service (OOH) in Denmark, and this is a subject of discussions about quality and cost-effectiveness. The aim of this study was to estimate changes in fee costs if nurses substituted the GPs. Methods. We applied experiences from The Netherlands on nurse performance in the OOH triage concerning the number of calls per hour. Using the 2011 number of calls in one region, we examined three hypothetical scenarios with nurse triage and calculated the differences in fee costs. Results. A new organisation with 97 employed nurses would be needed. Fewer telephone consultations may result in an increase of face-to-face contacts, resulting in an increase of 23.6% in costs fees. Under optimal circumstances (e.g., a lower demand for OOH services, a high telephone termination rate, and unchanged GP fees) the costs could be reduced by 26.2% though excluding administrative costs of a new organisation. Conclusion. Substituting GPs with nurses in OOH primary care may increase the cost in fees compared to a model with only GPs. Further research is needed involving more influencing factors, such as costs due to nurse training and running the organisation. Grete Moth, Linda Huibers, and Peter Vedsted Copyright © 2013 Grete Moth et al. All rights reserved. Relevance of Hypersexual Disorder to Family Medicine and Primary Care as a Complex Multidimensional Chronic Disease Construct Tue, 27 Aug 2013 08:56:45 +0000 Hypersexual disorder (HD) is not defined in a uniform way in the psychiatric literature. In the absence of solid evidence on prevalence, causes, empirically validated diagnostic criteria, instruments for diagnosis, consistent guidelines on treatment options, medical and psychosocial consequences, and type of caregivers that need to be involved, HD remains a controversial and relatively poorly understood chronic disease construct. The role of family medicine in the detection, treatment, and followup of HD is not well studied. The purpose of this paper is to describe the complexity of HD as a multidimensional chronic disease construct and its relevance to family medicine and primary care. Liesbeth Borgermans, Bert Vrijhoef, Jan Vandevoorde, Jan De Maeseneer, Johan Vansintejan, and Dirk Devroey Copyright © 2013 Liesbeth Borgermans et al. All rights reserved. Family Doctors Seen through the Eyes of Specialists: A Qualitative Study Sun, 02 Jun 2013 11:44:28 +0000 Germany is facing a shortage of young family doctors. In search of possible reasons the aim of this study was to explore the perception of specialists on family doctors. Within a qualitative study 16 medical specialists from different fields in hospital and outpatient care setting were interviewed. Interviews were analysed using qualitative content analysis according to Mayring. Most of the interviewed specialists have a positive view on family doctors although a certain depreciative assumption is resonated in a number of statements. According to the specialists, family doctors enjoy a high status in public, even if social processes of change may have a negative influence on their rather old-fashioned image. Specialists find that family medicine is underrepresented in university education suffering from an upgrading of specialized disciplines. Altogether the majority of the interviewed specialists certify family doctors in Germany a positive image. Lecturer in medical education and training should be aware of their key role in the career choices of young trainees and avoid degradation or upgrading of certain medical disciplines. Interlinked measures on different levels focusing on the improvement of working conditions and representation at the universities would be needed to regain attractiveness for the family doctor's profession as a career choice for young doctors. Anna Probst, Iris Natanzon, Joachim Szecsenyi, and Stefanie Joos Copyright © 2013 Anna Probst et al. All rights reserved. Gaps between Adolescent Risk Behaviors and Disclosure during Outpatient Visits Wed, 24 Apr 2013 15:54:49 +0000 Objective. The purpose of this study was to determine the gaps between disclosed high-risk behaviors in low-income, mainly Hispanic youth and the identification of these risks by health care providers. Methods. This cross-sectional study included youth 13–19 years old who participated in a study on latent tuberculosis treatment. Youth were interviewed at baseline by bilingual research assistants; the provider visit was assessed by the chart review. Results. Of 221 youth, the majority (96%) were identified as Hispanic, 45% were foreign-born, and 46% were male. A total of 399 risk behaviors were revealed to research staff by the participants; only 24 risk behaviors were revealed to providers. Conclusions. The majority of risk behaviors based on the chart review were neither queried nor disclosed to the physicians. Physicians providing care to adolescents should consider strategies to improve disclosure as a necessary precursor to interventions. Linda L. Hill, Melbourne Hovell, Elaine Blumberg, Norma Kelley, Sara Baird, Carol Sipan, Katharine Schmitz, and Lawrence Friedman Copyright © 2013 Linda L. Hill et al. All rights reserved. Decision-Making of Older Patients in Context of the Doctor-Patient Relationship: A Typology Ranging from “Self-Determined” to “Doctor-Trusting” Patients Thu, 18 Apr 2013 17:52:26 +0000 Background. This qualitative study aims to gain insight into the perceptions and experiences of older patients with regard to sharing health care decisions with their general practitioners. Patients and Methods. Thirty-four general practice patients (≥70 years) were asked about their preferences and experiences concerning shared decision making with their doctors using qualitative semistructured interviews. All interviews were analysed according to principles of content analysis. The resulting categories were then arranged into a classification grid to develop a typology of preferences for participating in decision-making processes. Results. Older patients generally preferred to make decisions concerning everyday life rather than medical decisions, which they preferred to leave to their doctors. We characterised eight different patient types based on four interdependent positions (self-determination, adherence, information seeking, and trust). Experiences of a good doctor-patient relationship were associated with trust, reliance on the doctor for information and decision making, and adherence. Conclusion. Owing to the varied patient decision-making types, it is not easy for doctors to anticipate the desired level of patient involvement. However, the decision matter and the self-determination of patients provide good starting points in preparing the ground for shared decision making. A good relationship with the doctor facilitates satisfying decision-making experiences. Jennifer Wrede-Sach, Isabel Voigt, Heike Diederichs-Egidi, Eva Hummers-Pradier, Marie-Luise Dierks, and Ulrike Junius-Walker Copyright © 2013 Jennifer Wrede-Sach et al. All rights reserved. Adherence to Medications after Hospital Discharge in the Elderly Tue, 26 Mar 2013 15:14:46 +0000 Objectives. To evaluate the adherence rate to prescribed medications in elderly patients 24–48 hours after being discharged from the hospital. Methods. Family medicine residents visited patients over the age of 65 years at their homes one to two days after being discharged from the hospital and documented all the medications that they were taking since coming home from the hospital. The list of medications was later compared to the medications recorded in hospital discharge instructions. Results. Complete data was available for 46 participants. The average patient age was 76 years; 54.4% were women. Only three patients (6.5%) adhered completely to the discharge medication list found in the medical record. Thirty-six patients (78.2%) reported taking at least one additional prescription medication, twenty patients (43.4%) missed at least one prescription medication, twenty patients (43.4%) reported taking the wrong dose of at least one medication, and nineteen patients (41.3%) reported taking medications at an incorrect frequency. Conclusion. The vast majority of elderly patients in our study did not adhere to the medication regimen in the first two days after hospital discharge. Cost-effective improvements to hospital discharge processes are needed to improve adherence and reduce preventable posthospitalization complications. Elie Mulhem, David Lick, Jobin Varughese, Eithne Barton, Trevor Ripley, and Joanna Haveman Copyright © 2013 Elie Mulhem et al. All rights reserved. “Preventing the Pain” When Working with Family and Sexual Violence in Primary Care Tue, 26 Feb 2013 08:10:28 +0000 Primary care professionals (PCPs) are increasingly being expected to identify and respond to family and sexual violence as the chronic nature and severity of the long-term health impacts are increasingly recognized. This discussion paper reports the authors’ expert opinion from their experiences running international workshops to prevent trauma among those who work and research sexual violence. It describes the burnout and secondary traumatic stress literature which provides the evidence supporting their work. Implications for practicing basic training in response to trauma and ongoing education are a key area for responding to family violence and preventing professional stress. A professional culture that supports and values caring well for those who have experienced family violence as well as “caring for the carer” is needed. Working in teams and having more support systems in place are likely to protect PCPs from secondary traumatic stress and burnout. Undergraduate and postgraduate training of PCPs to develop trauma knowledge and the skills to ask about and respond to family violence safely are essential. In addition, the healthcare system, workplace, and the individual practitioner support structures need to be in place to enable PCPs to provide safe and effective long-term care and access to other appropriate services for those who have experienced family violence. Jan Coles, Elizabeth Dartnall, and Jill Astbury Copyright © 2013 Jan Coles et al. All rights reserved. Consultations between Immigrant Patients, Their Interpreters, and Their General Practitioners: Are They Real Meetings or Just Encounters? A Qualitative Study in Primary Health Care Tue, 05 Feb 2013 11:29:30 +0000 Objective. In Sweden, about 19% of residents have a foreign background. Previous studies reported immigrant patients experience communication difficulties despite the presence of interpreters during consultations. The objective of this study was to gain insights into the participants’ perceptions and reflections of the triangular meeting by means of in-depth interviews with immigrant patients, interpreters, and general practitioners (GPs). Method. A total of 29 participants—10 patients, 9 interpreters, and 10 GPs—participated in face-to-face interviews. Content analysis was used to process the interview material. Results. Six themes were generated and arranged under two subject areas: the interpretation process (the means of interpreting and means of informing) and the meeting itself (individual tailored approaches, consultation time, the patient’s feelings, and the role of family members). Conclusion. This paper highlights feelings including frustration and insecurity when interpretation and relationships are suboptimal. Strategies for immigrant patients, interpreters, and GPs for getting a successful consultation may be needed. To transform the triangular meeting from an encounter to a real meeting, our results indicate a need for professional interpreters, for GPs to use a patient-tailored approach, and sufficient consultation time. Practice Implications. Use of professional interpreters is recommended, as is developing cultural competence. Eivor Wiking, Jan Sundquist, and Nouha Saleh-Stattin Copyright © 2013 Eivor Wiking et al. All rights reserved. Mental and Physical Health and Intimate Partner Violence against Women: A Review of the Literature Wed, 23 Jan 2013 09:58:44 +0000 Associations between intimate partner violence (IPV) and poor physical and mental health of women have been demonstrated in the international and national literature across numerous studies. This paper presents a review of the literature on this topic. The 75 papers included in this review cover both original research studies and those which undertook secondary analyses of primary data sources. The reviewed research papers published from 2006 to 2012 include quantitative and qualitative studies from Western and developing countries. The results show that while there is variation in prevalence of IPV across various cultural settings, IPV was associated with a range of mental health issues including depression, PTSD, anxiety, self-harm, and sleep disorders. In most studies, these effects were observed using validated measurement tools. IPV was also found to be associated with poor physical health including poor functional health, somatic disorders, chronic disorders and chronic pain, gynaecological problems, and increased risk of STIs. An increased risk of HIV was reported to be associated with a history of sexual abuse and violence. The implications of the study findings in relation to methodological issues, clinical significance, and future research direction are discussed. Gina Dillon, Rafat Hussain, Deborah Loxton, and Saifur Rahman Copyright © 2013 Gina Dillon et al. All rights reserved. Open Access to General Practice Was Associated with Burnout among General Practitioners Sun, 20 Jan 2013 14:17:43 +0000 Walk-in open access in general practice may influence the general practitioner’s (GP’s) work, but very little research has been done on the consequences. In this study from Danish general practice, we compare the prevalence of burnout between GPs with a walk-in open access and those without. In a questionnaire study (2004), we approached all 458 active GPs in the county of Aarhus, Denmark, and 376 (82.8%) GPs returned the questionnaire. Walk-in open access was defined as at least 30 minutes every weekday where patients could attend practice without an appointment. Burnout was measured by the Maslach Burnout Inventory. Analyses using logistic regression were adjusted for gender, age, marital status, job satisfaction, minutes per consultation, practice organisation, working hours, number of listed patients per GP, number of contacts per GP, continuing medical education- (CME-) activities, and clusters of GPs. In all, 8% of GPs had open access and the prevalence of burnout was 24%. GPs with walk-in open access were more likely to suffer from burnout. Having open access was associated with a 3-fold increased likelihood of burnout (OR = 3.1 (95% CI: 1.1–8.8, )). Although the design cannot establish causality, it is recommended to closely monitor possible negative consequences of open access in general practice. Peter Vedsted, Ineta Sokolowski, and Frede Olesen Copyright © 2013 Peter Vedsted et al. All rights reserved. Point-of-Care Troponin T Testing in the Management of Patients with Chest Pain in the Swedish Primary Care Thu, 10 Jan 2013 14:39:51 +0000 Objective. To investigate the diagnostic accuracy and clinical benefit of point-of-care Troponin T testing (POCT-TnT) in the management of patients with chest pain. Design. Observational, prospective, cross-sectional study with followup. Setting. Three primary health care (PHC) centres using POCT-TnT and four PHC centres not using POCT-TnT in the southeast of Sweden. Patients. All patients ≥35 years old, contacting one of the primary health care centres for chest pain, dyspnoea on exertion, unexplained weakness, and/or fatigue with no other probable cause than cardiac, were included. Symptoms should have commenced or worsened during the last seven days. Main Outcome Measures. Emergency referrals, patients with acute myocardial infarctions (AMI), or unstable angina (UA) within 30 days of study enrolment. Results. 25% of the patients from PHC centres with POCT-TnT and 43% from PHC centres without POCT-TnT were emergently referred by the GP ( ). Seven patients (5.5%) from PHC centres with POCT-TnT and six (8.8%) from PHC centres without POCT-TnT were diagnosed as AMI or UA (). Two patients with AMI or UA from PHC centres with POCT-TnT were judged as missed cases in primary health care. Conclusion. The use of POCT-TnT may reduce emergency referrals but probably at the cost of an increased risk to miss patients with AMI or UA. Staffan Nilsson, Per O. Andersson, Lars Borgquist, Ewa Grodzinsky, Magnus Janzon, Magnus Kvick, Eva Landberg, Håkan Nilsson, and Jan-Erik Karlsson Copyright © 2013 Staffan Nilsson et al. All rights reserved. The Missing Evaluation at the End of GP’s Consultation Tue, 08 Jan 2013 10:34:43 +0000 Evaluation at the end of a consultation is an element of a successful encounter. The doctor should inquire if patient’s expectations were fulfilled and sum up the information given, the examinations performed, and the decisions made with the patient. This way the patient would be fully aware of what has been decided and that the problems and expectations of the patient had been taken into account. Twenty consultations of four general practitioners (GPs) in Finland were videotaped. The doctors were men and women, two of them had a long experience and two were trainees in general practice. The data (videotapes, questionnaires, and interviews) were analysed by multiple research methods with investigator and methodological triangulation. MAAS-Global Rating List was used as an assessment tool. The evaluation of the consultation was often missing or having shortages; only one-third was assessed to be better than doubtful. The assessments done by experienced GPs and the medical student were similar. According to the result of this study as well as the information in the current literature, doctors in all periods of their career should repeatedly be reminded about the importance of the evaluation at the end of the consultation. Maisa Kuusela, Paula Vainiomäki, Anni Kiviranta, and Päivi Rautava Copyright © 2013 Maisa Kuusela et al. All rights reserved. Patient Attitudes to Tonsillectomy Mon, 24 Dec 2012 18:49:11 +0000 Introduction. Recent changes to primary care trusts’ Procedures of Limited Clinical Value (PLCV) policy mean that otolaryngologists must now follow policy rather than exercising clinical judgment when listing patients for tonsillectomy. Objectives. To gauge perception within the general public of when tonsillectomy is acceptable and to compare this to the current policy. Method. All patients or their parents attending the adult and paediatric outpatient ENT departments were asked to anonymously complete questionnaires. Results. One hundred and twenty-five completed questionnaires were collected. Thirty-one percent of respondents thought tonsillectomy should be offered solely on patient request, 19% after one to three bouts, and 35% after four to six bouts of tonsillitis. Only 9% thought the current guidelines were reasonable. Patients who had suffered recurrent tonsillitis or had undergone previous tonsillectomy generally thought tonsillectomy advisable after more bouts of tonsillitis than those who had not. Fourteen patients fulfilled the SIGN guidelines for tonsillectomy for recurrent tonsillitis. Of these, 13 (93%) felt that suffering 4–6 bouts of tonsillitis was reasonable before tonsillectomy. Conclusion. All patients we surveyed who meet the current PLCV and SIGN guidelines regarding the appropriateness of tonsillectomy for recurrent tonsillitis perceive that they are excessive, believing that 4–6 bouts of recurrent tonsillitis are adequate to justify tonsillectomy. Kishan Ubayasiri, Ravi Kothari, Lisha McClelland, and Mriganka De Copyright © 2012 Kishan Ubayasiri et al. All rights reserved.