[Health system is being rearranged. What do you expect from the New Year?]

MMW Fortschr Med. 2004 Jan 15;146(1-2):44-5, 47

Authors: Weigeldt U, Blank W, Koch HH, Fölsch UR, Ahrens HJ, Strüngmann T, Köbele W

PMID: 18441575 [PubMed - indexed for MEDLINE]

[Revised guidelines for antihypertensive treatment. What is relevant for the general practitioner?]

MMW Fortschr Med. 2004 Jan 15;146(1-2):37-8

Authors: Zidek W

PMID: 18437867 [PubMed - indexed for MEDLINE]

Improving care of patients with diabetes and CKD: a pilot study for a cluster-randomized trial.

Am J Kidney Dis. 2008 May;51(5):777-88

Authors: Cortés-Sanabria L, Cabrera-Pivaral CE, Cueto-Manzano AM, Rojas-Campos E, Barragán G, Hernández-Anaya M, Martínez-Ramírez HR

BACKGROUND: Family physicians may have the main role in managing patients with type 2 diabetes mellitus with early nephropathy. It is therefore important to determine the clinical competence of family physicians in preserving renal function of patients. The aim of this study is to evaluate the effect of an educational intervention on family physicians' clinical competence and subsequently determine the impact on kidney function of their patients with type 2 diabetes mellitus. STUDY DESIGN: Pilot study for a cluster-randomized trial. SETTING & PARTICIPANTS: Primary health care units of the Mexican Institute of Social Security, Guadalajara, Mexico. The study group was composed of 21 family physicians from 1 unit and a control group of 19 family physicians from another unit. 46 patients treated by study physicians and 48 treated by control physicians also were evaluated. INTERVENTION: An educative strategy based on a participative model used during 6 months in the study group. Allocation of units to receive or not receive the educative intervention was randomly established. OUTCOMES: Clinical competence of family physicians and kidney function of patients. MEASUREMENTS: To evaluate clinical competence, a validated questionnaire measuring family physicians' capability to identify risk factors, integrate diagnosis, and correctly use laboratory tests and therapeutic resources was applied to all physicians at the beginning and end of educative intervention (0 and 6 months). In patients, serum creatinine level, estimated glomerular filtration rate, and albuminuria were evaluated at 0, 6, and 12 months. RESULTS: At the end of the intervention, more family physicians from the study group improved clinical competence (91%) compared with controls (37%; P = 0.001). Family physicians in the study group who increased their competence improved renal function significantly better than physicians in the same group who did not increase competence and physicians in the control group (with or without increase in competence): change in estimated glomerular filtration rate, 0.9 versus -33, -21, and -16 mL/min/1.73 m(2) (P < 0.05); and change in urinary albumin excretion of -18 versus 226, 142, and 288 mg/d, respectively (P < 0.05). Compared with other groups, study family physicians with clinical competence also controlled systolic blood pressure significantly better and were more likely to increase the use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and statins and to discontinue nonsteroidal anti-inflammatory drugs. LIMITATIONS: Our analysis did not adjust for clustering. Physicians in only 2 units were randomly assigned; thus, it is not possible to distinguish the effect of the intervention from the effect of the unit. CONCLUSIONS: Educative intervention to primary physicians is feasible. Our data may be the basis for additional prospective studies with a cluster-randomized trial design and larger numbers of centers, physicians, and patients.

PMID: 18436088 [PubMed - indexed for MEDLINE]

Awareness of diabetic eye disease among general practitioners and diabetic patients in Yangon, Myanmar.

Clin Experiment Ophthalmol. 2008 Apr;36(3):265-73

Authors: Muecke JS, Newland HS, Ryan P, Ramsay E, Aung M, Myint S, Esmail-Zadeh R, Zborowska B, Selva D

BACKGROUND: Diabetes is an increasing problem in Myanmar with more than three million people affected. There are no data on awareness of diabetic retinopathy among the general practitioners (GPs) or diabetic population of Myanmar. This study aims to evaluate the awareness of diabetes-related eye disease among GPs and diabetic patients in Yangon, Myanmar. DESIGN: A cross-sectional survey. METHODS: From the Myanmar Medical Association Registry of 978 practicing GPs in Yangon, 200 were randomly selected and a structured questionnaire was sent to each. Each GP was asked to give a separate questionnaire to the first five diabetic patients who attended their practice. RESULTS: One hundred GPs and 480 patients returned the questionnaires. Although 99% of GPs were aware that diabetes could result in loss of vision, 49% never examined the fundi of their diabetic patients. Of the diabetic patients, 86% were aware that diabetes could damage their eyesight. Although 92% realized they should visit an ophthalmologist regularly, only 57% had seen an ophthalmologist. Patients who never attended school were less likely to visit an ophthalmologist than those with tertiary education (odds ratio 0.24; 95% confidence interval 0.09, 0.66). Patients with diabetes for less than 2 years were less likely to visit an ophthalmologist than those with diabetes for more than 10 years (odds ratio 0.21; 95% confidence interval 0.9, 0.44). There was no association between age, gender or work status and the likelihood of having seen an ophthalmologist. CONCLUSION: Although both GPs and diabetic patients are aware of the need for regular fundal screening, just over half the patients had been screened. There exists a need for programmes in Myanmar to induce a behavioural change in diabetic patients with regards to screening examinations.

PMID: 18412597 [PubMed - indexed for MEDLINE]

Referral pathways and management of contact lens-related microbial keratitis in Australia and New Zealand.

Clin Experiment Ophthalmol. 2008 Apr;36(3):209-16

Authors: Keay L, Edwards K, Stapleton F

BACKGROUND: We examine the referral pathways and treatment for contact lens-related microbial keratitis in Australia and New Zealand. METHODS: Cases were reported in May 2003-September 2004; data on presentation, referral and treatment collected from practitioners and via patient interview. Severity was graded, 1-week cure rate estimated, delays in treatment and medications documented. Hospital and private clinic managements were compared. RESULTS: A total of 297 eligible cases were reported; detailed information on treatment and referral pathways was available on a subset of these cases. Presentation was to optometrists (81/200, 41%), general practitioners (GPs) (69/200, 34%) or emergency departments (46/200, 23%). Optometrists referred to private ophthalmologists (47/79, 60%) more often than hospitals (27/79, 34%). GPs initiated treatment (39/68, 57%) but also referred to hospitals (22/68, 32%) and to private ophthalmologists (7/68, 10%). Of all cases, 67% (195/297) were managed in hospitals (29% admitted, 87/297). Hospitalized cases were predominantly managed with fortified aminoglycoside/cephalosporin (66/81, 82%) and others fluoroquinolones (168/195, 86%). Steroids were used in 36% (98/276) commencing on day 5 (median, interquartile range = 3-7). One-week cure rate was 60% (49/82) in private clinics, 72% (62/86) for hospital outpatient cases and 37% (25/67, P < 0.001) for inpatient cases, which were more severe diseases (47%, 52% and 0% mild, respectively). Delays (>/=12 h) receiving therapy were experienced by 33% (55/168) because of initial inappropriate treatment (48/55), time delays (7/55) but not remoteness (P = 0.6). CONCLUSIONS: The majority of treatment is via hospital clinics, but milder disease is managed in private clinics. The referral process via optometrists, GPs and emergency departments is generally efficient; however, one-third of cases experienced some delays before receiving appropriate therapy highlighting the need for timely diagnosis.

PMID: 18412588 [PubMed - indexed for MEDLINE]

Who should manage contact lens related microbial keratitis in Australia and New Zealand?

Clin Experiment Ophthalmol. 2008 Apr;36(3):204-5

Authors: Sutton G

PMID: 18412586 [PubMed - indexed for MEDLINE]

[The opinion of practitioners and internists on the impact of health technologies introduced in the last 25 years]

Gac Sanit. 2008 Jan-Feb;22(1):20-8

Authors: Espallargues M, de Sol&#xE0;-Morales O, Moharra M, Tebé C, Pons JM

OBJECTIVES: To identify the most important health technologies (HT) introduced in the last 25 years and their impact on patients' health according to hospital internists and generalist physicians. METHODS: We performed a cross-sectional descriptive study. The 30 HT receiving the highest number of bibliometric citations in the previous 25 years (1977-2002) in generalist and primary care journals were selected. To assess the health impact of HT, a postal survey of the medical heads of 46 hospitals with 100-400 beds and an equal random sample of the directors of primary care centers was carried out in Catalonia, Spain. The professionals surveyed were asked to consider how adverse the effect on their patients' health would be if each of the HT on the list were unavailable. The personal and professional characteristics of the participating physicians were also collected. RESULTS: A total of 49 physicians answered the survey (53%). Instrumental and diagnostic technologies were considered to have the greatest impact on health, diagnostic imaging being the most highly scored. The lowest impact would be caused if some drugs were not available, hypoglycemic agents receiving the lowest scores. Although assessments were similar regardless of professional/practice characteristics (r > or = 0.7), some differences in diagnostic HT were observed, as well as variability in the participants' responses. CONCLUSIONS: Assessment of the impact of HT from the physicians' point of view varied. However, diagnostic and instrumental-visual technologies seem to be more highly rated than pharmacological innovations. Variability in responses was more closely related to the physicians' personal characteristics than to practice setting.

PMID: 18261438 [PubMed - indexed for MEDLINE]

Do practices comply with key recommendations of the British Asthma Guideline? If not, why not?

Prim Care Respir J. 2007 Dec;16(6):369-77

Authors: Wiener-Ogilvie S, Pinnock H, Huby G, Sheikh A, Partridge MR, Gillies J

AIMS: Amongst general practices in the NHS Borders region of Scotland, we aimed to determine compliance with the three key recommendations of the British Guideline for the Management of Asthma and to understand the nature of barriers and facilitators to their implementation. METHODS: Using piloted audit tools, a researcher extracted data from computerised and/or paper patient medical records to assess compliance with recommendations for objective diagnosis and stepwise management. Provision of asthma action plans was assessed by patient survey. Clinicians' attitude to guidelines was assessed by postal survey. RESULTS: Fifteen of the 24 practices in the NHS Borders region participated. Audited compliance with the three key recommendations varied markedly amongst and within practices. Whilst 367/547 (67%) of patients were treated appropriately with add-on therapy, only 58/254 (23%) of patients reported having been given an asthma action plan. Barriers to implementation identified by the clinicians' survey (response rate 64/84 - 76%) were theoretical (doubt about the evidence base and relevance to primary care, lack of knowledge and skills, misconceptions) as well as practical (lack of time and resources) and were exacerbated by poor teamwork. Facilitators were good teamwork and appropriate organisation of work within the practice. CONCLUSIONS: Implementation of key recommendations was variable, particularly in the more complex intervention of issuing asthma action plans. An intervention to enhance compliance with these guideline recommendations will need to address both theoretical and practical barriers within the context of improved teamwork.

PMID: 18026674 [PubMed - indexed for MEDLINE]