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Item does not contain fulltext BACKGROUND: Primary health care requires new approaches to assist patients with overweight and obesity. This is a particular concern for patients with limited access to specialist or allied health services due to financial cost or location. The Change Program is a toolkit that provides a structured approach for GPs working with patients on weight management. OBJECTIVE: To assess the acceptability and feasibility of a GP-delivered weight management programme. METHODS: A feasibility trial in five Australian general practices with 12 GPs and 23 patients. Mixed methods were used to assess the objective through participant interviews, online surveys and the NOrmalization MeAsure Development (NoMAD) tool based on Normalization Process Theory. Content analysis of interviews is presented alongside Likert scales, free text and the NoMAD tool. RESULTS: The Change Program was acceptable to most GPs and patients. It was best suited to patient-GP dyads where the patient felt a strong preference for GP involvement. Patients' main concerns were the time and possible cost associated with the programme if run outside a research setting. For sustainable implementation, it would have been preferable to recruit a whole practice rather than single GPs to enable activation of systems to support the programme. CONCLUSION: A GP-delivered weight management programme is feasible and acceptable for patients with obesity in Australian primary health care. The addition of this structured toolkit to support GPs is particularly important for patients with a strong preference for GP involvement or who are unable to access other resources due to cost or location.

Contains fulltext : 173045.pdf (Publisher’s version ) (Closed access) BACKGROUND: Empathy is an essential skill in doctor-patient communication with positive effects on compliance, patient satisfaction and symptom duration. There are no validated patient-rated empathy measures available in Dutch. OBJECTIVE: To investigate the validity and reliability of a Dutch version of the Consultation and Relational Empathy (CARE) Measure, a widely used 10-item patient-rated questionnaire of physician empathy. METHODS: After translation and back translation, the Dutch CARE Measure was distributed among patients from 19 general practitioners in 5 primary care centers. Tests of internal reliability and validity included Cronbach's alpha, item total correlations and factor analysis. Seven items of the QUality Of care Through the patient's Eyes (QUOTE) questionnaire assessing 'affective performance' of the physician were included in factor analysis and used to investigate convergent validity. RESULTS: Of the 800 distributed questionnaires, 655 (82%) were returned. Acceptability and face validity were supported by a low number of 'does not apply' responses (range 0.2%-11.9%). Internal reliability was high (Cronbach's alpha 0.974). Corrected item total correlations were at a minimum of 0.837. Factor analysis on the 10 items of the CARE Measure and 7 QUOTE items resulted in two factors (Eigenvalue > 1), the first containing the CARE Measure items and the second containing the QUOTE items. Convergent construct validity between the CARE Measure and QUOTE was confirmed with a modest positive correlation (r = 0.34, n = 654, P < 0.001). CONCLUSION: The findings support the preliminary validity and reliability of the Dutch CARE Measure. Future research is required to investigate divergent validity and discriminant ability between doctors.

Contains fulltext : 80862.pdf (Publisher’s version ) (Open Access) BACKGROUND: In family practice, chronic obstructive pulmonary disease (COPD) is usually not diagnosed until clinically apparent and of moderately advanced severity. OBJECTIVE: To analyse the diagnostic process from early development onwards and to assess the current state of underpresentation and underdiagnosis of COPD and asthma in primary care in the Netherlands. METHODS: The population-based study sample consisted of formerly undiagnosed subjects (n = 532) from family practice. Family physicians' (FPs) chronic respiratory disease diagnoses (as recorded over 10 years in their patient records) were compared to a cross-sectional but extensive diagnostic assessment by a chest physician. Logistic regression modelling was used for a retrospective analysis on the relation between respiratory symptoms, practice visit rate and FPs' diagnosis of COPD. RESULTS: After 10 years, the chest physician diagnosed 26% of subjects as COPD and 16% as (late-onset) asthma. Underpresentation of these patients in family practice was 46%, whereas underdiagnosis occurred in 37% of patients. A chest physician diagnosis of COPD was associated with the presence of chronic cough [odds ratio (OR) = 2.3, 95% confidence interval (CI) 1.1-4.6], a FP diagnosis of COPD with chronic phlegm (OR = 10.6, 95% CI 1.3-83.6). Repeated practice visits (OR = 1.8) and presence of wheeze and breathlessness (OR = 5.5) appeared to trigger the diagnostic process in family practice. CONCLUSIONS: There is still considerable underpresentation and underdiagnosis of COPD in family practice. As FPs focus on presented symptoms and as detection increases with the frequency of practice visits, diagnostic guidelines should stress the importance of persistent cough and phlegm to support timely diagnosis of COPD in family practice.

Contains fulltext : 69179.pdf (Publisher’s version ) (Open Access) OBJECTIVES: The aim of this pilot study was to assess the prevalence of co-morbidity in obese children. Particular emphasis was on cardiovascular risk. METHOD: In this retrospective, cross-sectional, observational study the data of 155 obese children, who visited a paediatric obesity outdoor clinic, have been studied. RESULTS: In all, 92% of the population had at least one cardiovascular risk factor. In all, 48% showed a high systolic and 9% a high diastolic blood pressure, while 18% had an increased fasting glucose. In 60%, we diagnosed insulin resistance: the homeostasis model assessment was elevated. DISCUSSIONS: The prevalence of high blood pressure, dyslipidaemia, abnormal fasting glucose and insulin resistance are high in this retrospective study. Outcomes of foreign studies on this object are difficult to compare because various populations and cut-off points are used. A new, prospective, study will be conducted to asses the prevalence of co-morbidity in obese children in general practice.

Contains fulltext : 71551.pdf (Publisher’s version ) (Closed access) Life style related risk factors have negative consequences for many health outcomes. Although preventive actions undertaken on a population level are effective, these actions do not reach the individuals who could benefit most. Family doctors could reach many of these individuals when they consult them for other reasons. Unfortunately time constraints and competing demands as well as the fact that many practising physicians have not been trained in patient-centred communication and life-style interventions interferes with optimal prevention in primary care. Patient centred approaches can be helpful in prevention. Placing the subject on the agenda of a consultation, followed by a discussion of risks and symptoms that is adjusted to the patients' context are a start. Information building on the patients' existing knowledge is more effective than information in general. Patients can be motivated towards change through discussions, and empowered to make necessary changes. Of the available effective patient centred approaches this article discusses the 'Stages of Change (Trans Theoretical) Model, motivational interviewing, problem solving and action planning, and demonstrates a combined approach using a family practice patient with a number of risk factors. Fortunately modern medical education does pay attention to patient centred communication in general. In order to have a positive impact on the health of populations, additional options for training in patient-centred techniques should become available in residency programmes, and in continuous medical education for those practicing physicians who are not yet trained in patient centred approaches.

Contains fulltext : 69192.pdf (Publisher’s version ) (Closed access) BACKGROUND: Medically unexplained symptoms (MUSs) are frequently presented in primary care. Unfortunately, knowledge of these patients and/or symptoms in primary care is still limited. Available research comes mainly from Europe and North America, while the perspectives of cultures such as Africa, Asia and South America are relatively unknown. To bring cultural perspectives together, a symposium and workshop on MUS in primary care was held at the WONCA World Conference 2007 in Singapore. OBJECTIVE: Main goals of this symposium and workshop-apart from presenting ongoing research and bringing together experts in MUS-were to detect knowledge gaps in MUS and to establish priorities in MUS research. This publication focuses on the proposed research agenda. METHODS: Using a nominal group technique, we generated research topics and set priorities. Research topics were grouped into research themes. RESULTS: Participants' (66 researchers and GPs from 29 nationalities) most important research topics were 'formulating a broadly accepted definition of MUS', 'finding a strategy to recognize MUS better and at an earlier stage', 'studying the value of self-management and empowerment in patients with MUS' and 'finding predictors to decide which strategy will best help the individual patient with MUS'. Priorities in research themes of MUS are as follows: (i) therapeutic options for patients with MUS and (ii) problems in consultations with these patients. CONCLUSIONS: More research on MUS in primary care is needed to improve the consultations with and management of these patients. Internationally primary care conferences are excellent for exchanging ideas and formulating central issues of research.

Contains fulltext : 49909.pdf (Publisher’s version ) (Closed access) BACKGROUND: A substantial number of adult patients with asthma are inadequately controlled despite the availability of effective asthma treatment. Patients and physicians seem to overestimate the level of asthma control. OBJECTIVE: The current study explores whether valid differentiation is possible between asthma patients with controlled and uncontrolled asthma symptoms, on the basis of the Asthma Control Questionnaire (ACQ). METHODS: In this multi-centre, cross-sectional study, patients were classified according to Global Initiative for Asthma criteria into levels of asthma symptom control based on a diary card registration. We defined Step 1 ('well controlled' asthma symptoms), Step 2 ('moderately controlled'), Step 3 ('poorly controlled') and Step 4 ('very poorly controlled'). These control steps were related with the sum score of the ACQ. RESULTS: From 108 asthma patients complete data were obtained. The Step 1 subgroup comprised 17 patients; Step 2, 12 patients; Step 3, 22 patients; and Step 4, 57 patients. Receiver Operating Characteristic curve analysis showed that the optimal ACQ sum score cut-off value to differentiate between Step 1 and Steps 2, 3 and 4 was three points (sensitivity: 84%, specificity: 76%). For Steps 1 and 2 versus Steps 3 and 4, this was four points (sensitivity: 77%, specificity: 59%). For Steps 1, 2 and 3 versus Step 4, this was six points (sensitivity: 70%, specificity: 74%). CONCLUSION: Our results show that discrimination between asthma patients with controlled and uncontrolled asthma symptoms, based on the ACQ, is possible with a reasonable margin of test inaccuracy. Thus, the ACQ may be an important tool for health care professionals who aim to optimize the level of asthma control in their patient population.

Contains fulltext : 47622.pdf (Publisher’s version ) (Open Access) BACKGROUND: It has been suggested that severe COPD is associated with depressive symptoms, possibly linked to exacerbations, dyspnea and hospitalisation. However, scarce data are available in primary care where most patients suffer from mild or moderate disease. OBJECTIVE: We aimed to reveal associations of depressive symptoms with demographic and clinical characteristics in mild to moderate COPD. METHODS: Cross-sectional data on lung function measurements, exacerbation frequency, dyspnea, comorbidity, smoking behaviour, body mass index (BMI), age, gender and depressive symptoms (Beck Depression Inventory) of 147 primary care patients were assessed in multiple logistic regression analyses. RESULTS: Patients suffered from mild to moderate obstruction (FEV1 63.6% pred, range 45.1% to 82.1%). Female gender (OR 4.8, 95% CI 2.1 to 10.8), BMI > 25 (OR 0.4, 95% CI 0.2 to 0.8) and current smoking (OR 2.3, 95% CI 1.01 to 5.3) were univariately associated with depressive symptoms, while in a multivariate logistic model only female gender (OR 4.0, 95% CI 1.6 to 9.9), BMI > 25 (OR 0.3, 95% CI 0.1 to 0.7) and dyspnea (OR 1.8, 95% CI 1.1 to 2.9) were independently associated with depressive symptoms. Conclusion. These data suggest that in primary care depressive symptoms in COPD seem to be related with female gender, BMI and dyspnea. In this study, lung function, exacerbation rate, smoking behaviour, age and comorbidity are not independently associated with depressive symptoms in COPD of mild to moderate severity.

Item does not contain fulltext BACKGROUND: The feasibility as well as the suitability of several therapies for medically unexplained symptoms (MUS) in primary care applied by the family physician (FP) appeared to be low. FPs need effective and acceptable strategies to manage these functionally impaired patients. OBJECTIVE: To review important and effective elements in the treatment of patients with MUS in primary care according to experts in MUS research. METHODS: We performed a systematic search of narrative reviews and scientific editorials in Medline and PsycINFO and triangulated our findings by conducting a focus group with MUS experts. RESULTS: We included 7 scientific editorials and 23 narrative reviews. According to MUS experts, the most important elements in the treatment of MUS are creating a safe therapeutic environment, generic interventions (such as motivational interviewing, giving tangible explanations, reassurance and regularly scheduled appointments) and specific interventions (such as cognitive approaches and pharmacotherapy). Furthermore, MUS experts indicate that a multi-component approach in which these three important elements are combined are most helpful for patients with MUS. In contrast to most specific interventions, opinions of MUS experts regarding generic interventions and creating a safe therapeutic relationship seem to be more based on theory and experience than on quantitative research. CONCLUSIONS: MUS experts highlight the importance of generic interventions and doctor-patient communication and relationship. However, studies showing the effectiveness of these elements in the management of MUS in primary care is still scarce. Research as well as medical practice should focus more on these non-specific aspects of the medical consultation.

A long-standing challenge for primary care has been its conflicted relationship with research and science. The evolution of primary care can be marked by the increasing collaboration between community practitioners and biomedical researchers. Since their inception in 1995,(1) The Heelsum International Workshops have represented a dialogue between primary care clinicians and nutrition- oriented researchers. This issue of Family Practice reports the proceedings of the 2010 6th Workshop, which demonstrate this evolving dialogue and better define the role of research in supporting the care of people in communities.

van Weel C and Rosser WW. Unquoted, unchallenged, general practice research will be castingpearls before swine. Family Practice 2005; 22: 471–473.Researchisthemajordrivingfactorinfurtherimprovinghealth care and should be directed at the clinicaldecisions that have the greatest impact on the healthstatus of the population. Most people receive formalmedical care in generalpractice

Item does not contain fulltext BACKGROUND: In type 2 diabetes, educational interventions that target differences between patients' and partners' illness perceptions have been advocated. OBJECTIVE: To investigate how the route to diagnosis of type 2 diabetes (through screening versus clinical symptoms) affects illness perceptions of patients and their partners. METHODS: In a cross-sectional study, we enrolled patients aged 40-75 years from general practices in the Netherlands with a new diagnosis of type 2 diabetes (