A new approach to decision making in primary health care

The village health worker has two basic tasks: (1) to prevent health problems; (2) to identify and provide effective management of illness in the village. The village health worker has limited education and the length of basic health training is usually 12 weeks. This training can only be considered appropriate if it enables the village health worker to practise effectively within the cultural, social, economic and educational constraints of the village. How far does the training help this worker to work with other members of the village community to prevent illness? These others include mothers, children, school teachers, village leaders, religious leaders, traditional birth attendants, and traditional healers; training needs to be problem-oriented. The management decisions that have to be made in situations of shortage of resources are complex to analyse. A W.H.O. research project has been undertaken to determine the feasibility of developing and using flow charts to provide alternative and more appropriate methods to help the village health worker to provide optimal management in suboptimal situations. Some examples of these new methods are presented.     

Alcohol and ischaemic heart disease in middle aged British men.

The relation between alcohol intake and ischaemic heart disease was examined in a large scale prospective study of middle aged men drawn from general practices in 24 British towns. After an average follow up of 6.2 years 335 of the 7729 men had experienced a myocardial infarction (fatal or non-fatal) or sudden cardiac death. No significant relation was found between reported alcohol intake and the incidence of such events. Though the group of light daily drinkers had the lowest incidence of ischaemic heart disease events, it also contained the lowest proportion of current smokers, had the lowest mean blood pressure, had the lowest mean body mass index, and contained the lowest proportion of manual workers. These characteristics are more likely to account for the apparent protective effect of alcohol against ischaemic heart disease than a direct effect of alcohol. Compared with the effects of established risk factors alcohol seems to be quite unimportant in the development of ischaemic heart disease.     

ABO blood group and ischaemic heart disease in British men.

OBJECTIVE--To establish whether ABO blood group is related to ischaemic heart disease on an individual and geographic basis in Britain. DESIGN--Prospective study of 7662 men with known ABO blood group selected from age-sex registers in general practices in 24 British towns. MEASUREMENTS--ABO blood group, standard cardiovascular risk factors, social class, and presence or absence of ischaemic heart disease determined at entry to study. END POINTS--Eight year follow up of fatal and nonfatal ischaemic heart disease events achieved for 99% of study population. RESULTS--Towns with a higher prevalence of blood group O had higher incidences of ischaemic heart disease. In individual subjects, however, the incidence of ischaemic heart disease was higher in those with group A than in those with other blood groups (relative risk 1.21, 95% confidence limits 1.01 to 1.46). Total serum cholesterol concentration was slightly higher in subjects of blood group A. No other cardiovascular risk factor (including social class) was related to blood group. CONCLUSIONS--Blood group A is related to the incidence of ischaemic heart disease in individual subjects. Geographic differences in the distribution of ABO blood groups do not explain geographic variation in rates of ischaemic heart disease in Britain. The findings do not support the view that ABO blood group and social class are related.     

Effective continuing professional development for translating shared decision making in primary care: A study protocol

Background

There is growing interest in the use of cognitive, behavioural, and organisational theories in implementation research. However, the extent of use of theory in implementation research is uncertain.

Methods

We conducted a systematic review of use of theory in 235 rigorous evaluations of guideline dissemination and implementation studies published between 1966 and 1998. Use of theory was classified according to type of use (explicitly theory based, some conceptual basis, and theoretical construct used) and stage of use (choice/design of intervention, process/mediators/moderators, and post hoc/explanation).

Results

Fifty-three of 235 studies (22.5%) were judged to have employed theories, including 14 studies that explicitly used theory. The majority of studies (n = 42) used only one theory; the maximum number of theories employed by any study was three. Twenty-five different theories were used. A small number of theories accounted for the majority of theory use including PRECEDE (Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation), diffusion of innovations, information overload and social marketing (academic detailing).

Conclusions

There was poor justification of choice of intervention and use of theory in implementation research in the identified studies until at least 1998. Future research should explicitly identify the justification for the interventions. Greater use of explicit theory to understand barriers, design interventions, and explore mediating pathways and moderators is needed to advance the science of implementation research.     

Sulphinpyrazone and the platelet serotoninergic mechanism in ischaemic heart disease.

A double blind study in 25 patients with ischaemic heart disease and 20 matched healthy controls examined the effect of sulphinpyrazone on the uptake of serotonin by platelets and the basal concentrations of serotonin in platelets. Uptake was measured using tritium labelled serotonin and basal concentrations estimated spectrophotofluorometrically. Serotonin uptake was significantly increased both in the patients with chronic stable angina of effort and in those with a history of myocardial infarction six months or more previously. Sulphinpyrazone reduced serotonin uptake from 94.25 (SE 8.65) to 57.86 (5.37) cpm/10(8) platelets after 24 weeks of treatment in the group with stable angina and from 137.45 (16.26) to 68.08 (8.38) cpm/10(8) platelets in the myocardial infarction group. Raised basal concentrations in the two groups were also reduced by sulphinpyrazone. Placebo had no effect on serotonin uptake or basal concentrations in either group of patients. The ability of sulphinpyrazone to inhibit uptake and reduce basal concentrations of serotonin in patients with ischaemic heart disease may be yet another mechanism through which this drug exerts its beneficial antiplatelet effect.     

Theory and practice of decision making in coronary care in general practice.

Decisions about coronary care made by 39 randomly selected general practitioners in New Zealand over one year were investigated. Demographic variables and variables relating to the patient''s condition, history, and social circumstances were assessed for 113 patients, and practitioners'' belief about the relevance of each variable to the decision was elicited. A comparison was made between the objective criteria found to be related to the decision, the criteria believed by the practitioners to be relevant to the decision, and a theoretical model of what should govern the decision to admit. The theoretical model was found to be built into the beliefs of the practitioners, but the objective model was far simpler. Further research is needed to determine whether the use of the more complex, theoretical models will confer any benefit, in terms of patient wellbeing, over the pragmatic model in use at present.