Physicians report barriers to deliver best practice care for asplenic patients: a cross-sectional survey

Background

Current management of asplenic patients is not in compliance with best practice standards, such as defined by the British Committee for Standards in Haematology. To improve quality of care, factors inhibiting best practice care delivery need to be identified first. With this study, we aimed to identify and quantify physicians'' barriers to adhere to best practice management of asplenic patients in the Netherlands.

Methods and Principal Findings

A cross-sectional survey, preceded by multiple focus group discussions, was performed among Dutch physicians responsible for prevention of infections in asplenic patients, including specialists (of Internal medicine and Surgery) and general practitioners (GPs). Forty seven GPs and seventy three hospital specialists returned the questionnaire, yielding response rates of 47% and 36,5% respectively. Physicians reported several barriers to deliver best practice. For both GPs and specialists, the most frequently listed barriers were: poor patient knowledge (>80% of hospital specialists and GPs) and lack of clarity about which physician is responsible for the management of asplenic patients (50% of Internists, 46% of Surgeons, 55% of GPs). Both GPs and hospital specialists expressed to experience a lack of mutual trust: specialists were uncertain whether the GP would follow their advice given on patient discharge (33–59%), whereas half of GPs was not convinced that specialists'' discharge letters contained the correct recommendations. Almost all physicians (>90%) indicated that availability of a national guideline would improve adherence to best practice, especially if accessible online.

Conclusion

This study showed that, in accordance with reports on international performance, care delivery for asplenic patients in the Netherlands is suboptimal. We identified and quantified perceived barriers by physicians that prevent adherence to post-splenectomy guidelines for the first time. Better transmural collaboration and better informed patients are likely to improve the quality of care of the asplenic patient population. A national, online-available guideline is urgently required.     

Comparative Quality Indicators for Hospital Choice: Do General Practitioners Care?

Context

The strategy of publicly reporting quality indicators is being widely promoted through public policies as a way to make health care delivery more efficient.

Objective

To assess general practitioners’ (GPs) use of the comparative hospital quality indicators made available by public services and the media, as well as GPs’ perceptions of their qualities and usefulness.

Method

A telephone survey of a random sample representing all self-employed GPs in private practice in France.

Results

A large majority (84.1%–88.5%) of respondents (n = 503; response rate of 56%) reported that they never used public comparative indicators, available in the mass media or on government and non-government Internet sites, to influence their patients’ hospital choices. The vast majority of GPs rely mostly on traditional sources of information when choosing a hospital. At the same time, this study highlights favourable opinions shared by a large proportion of GPs regarding several aspects of hospital quality indicators, such as their good qualities and usefulness for other purposes. In sum, the results show that GPs make very limited use of hospital quality indicators based on a consumer choice paradigm but, at the same time, see them as useful in ways corresponding more to the usual professional paradigms, including as a means to improve quality of care.     

General Practitioners Can Evaluate the Material,Social and Health Dimensions of Patient Social Status

Objective

To identify which physician and patient characteristics are associated with physicians'' estimation of their patient social status.

Design

Cross-sectional multicentric survey.

Setting

Fourty-seven primary care private offices in Western Switzerland.

Participants

Random sample of 2030 patients ≥16, who encountered a general practitioner (GP) between September 2010 and February 2011.

Main measures

Primary outcome: patient social status perceived by GPs, using the MacArthur Scale of Subjective Social Status, ranging from the bottom (0) to the top (10) of the social scale.Secondary outcome: Difference between GP''s evaluation and patient''s own evaluation of their social status. Potential patient correlates: material and social deprivation using the DiPCare-Q, health status using the EQ-5D, sources of income, and level of education. GP characteristics: opinion regarding patients'' deprivation and its influence on health and care.

Results

To evaluate patient social status, GPs considered the material, social, and health aspects of deprivation, along with education level, and amount and type of income. GPs declaring a frequent reflexive consideration of their own prejudice towards deprived patients, gave a higher estimation of patients'' social status (+1.0, p = 0.002). Choosing a less costly treatment for deprived patients was associated with a lower estimation (−0.7, p = 0.002). GP''s evaluation of patient social status was 0.5 point higher than the patient''s own estimate (p<0.0001).

Conclusions

GPs can perceive the various dimensions of patient social status, although heterogeneously, according partly to their own characteristics. Compared to patients'' own evaluation, GPs overestimate patient social status.     

A cluster randomized controlled trial aimed at implementation of local quality improvement collaboratives to improve prescribing and test ordering performance of general practitioners: Study Protocol

Background

The use of guidelines in general practice is not optimal. Although evidence-based methods to improve guideline adherence are available, variation in physician adherence to general practice guidelines remains relatively high. The objective for this study is to transfer a quality improvement strategy based on audit, feedback, educational materials, and peer group discussion moderated by local opinion leaders to the field. The research questions are: is the multifaceted strategy implemented on a large scale as planned?; what is the effect on general practitioners' (GPs) test ordering and prescribing behaviour?; and what are the costs of implementing the strategy?

Methods

In order to evaluate the effects, costs and feasibility of this new strategy we plan a multi-centre cluster randomized controlled trial (RCT) with a balanced incomplete block design. Local GP groups in the south of the Netherlands already taking part in pharmacotherapeutic audit meeting groups, will be recruited by regional health officers. Approximately 50 groups of GPs will be randomly allocated to two arms. These GPs will be offered two different balanced sets of clinical topics. Each GP within a group will receive comparative feedback on test ordering and prescribing performance. The feedback will be discussed in the group and working agreements will be created after discussion of the guidelines and barriers to change. The data for the feedback will be collected from existing and newly formed databases, both at baseline and after one year.

Discussion

We are not aware of published studies on successes and failures of attempts to transfer to the stakeholders in the field a multifaceted strategy aimed at GPs' test ordering and prescribing behaviour. This pragmatic study will focus on compatibility with existing infrastructure, while permitting a certain degree of adaptation to local needs and routines.

Trial registration

Nederlands Trial Register ISRCTN40008171     

Do physicians assess lifestyle health risks during general medical examinations? A survey of general practitioners and obstetrician-gynecologists in Quebec

BACKGROUND: In Canada several guidelines have been published for the screening of lifestyle health risks during general medical examinations. The authors sought to examine the extent to which such screening practices have been integrated into medical practice, to measure physicians'' perceived level of difficulty in assessing these risks and to document physicians'' evaluation of their formal medical training in lifestyle risk assessment. METHODS: An anonymous mail survey was conducted in 1995 in Quebec with a stratified random sample of 1086 general practitioners (GPs) and with all 241 obstetrician-gynecologists (Ob-Gyns). The authors evaluated the proportion of physicians who reported routine assessment (with 90% or more of their patients) of substance use, family violence and sexual history during general medical examinations of adult and adolescent patients; the proportion of those who find inquiring about these issues difficult; and the proportion of those who evaluated their medical training in lifestyle risk assessment as adequate or excellent. RESULTS: The overall response rate was 72.6%. Among adult patients, 82.2% of the GPs reported routinely assessing tobacco use, 67.2% alcohol consumption, 34.2% illicit drug use and 3.2% family violence; the corresponding proportions for assessment among adolescent patients were 77.1%, 61.8%, 52.9% and 5.6%. Comparatively fewer Ob-Gyns reported routinely assessing these issues (56.1%, 28.6%, 20.4% and 1.3% respectively among adults and 62.7%, 35.2%, 26.8% and 2.8% respectively among adolescents). In the area of sexual history, condom use was routinely assessed by more Ob-Gyns than GPs (47.0% v. 28.2%); however, the proportion of Ob-Gyns and GPs was equally low for assessing number of partners (24.8% and 23.1%), sexual orientation (18.8% and 16.9%) and STD risk (26.2% and 21.2%). The vast majority of GPs and Ob-Gyns reported finding it difficult to assess family violence (86.5% and 93.0%) and sexual abuse (92.7% and 92.4% respectively). Over 80% of the physicians felt that they had had adequate or excellent medical training in assessing risk behaviours for heart disease and STD risk. The proportion who felt this way about their training in screening for illicit drug use, family violence and sexual abuse ranged between 12.7% and 31.6%. INTERPRETATION: Although morbidity and mortality associated with smoking, alcohol consumption, illicit drug use, unsafe sexual practices, family violence and sexual abuse have been well documented, routine screening for these risk factors during general medical examinations has yet to be integrated into medical practice.     

Preconceptional cystic fibrosis carrier screening: opinions of general practitioners, gynecologists, and pediatricians in the Netherlands

Knowledge of the opinions of physicians with regard to preconceptional cystic fibrosis (CF) carrier screening and the possible factors that are associated with their opinions is important for the implementation of such a screening program. Data were obtained from a study in which genetic knowledge, opinions with regard to genetic testing and related skills were investigated. A questionnaire, developed and used by American researchers, was adapted to the Dutch health care situation, and sent to randomly selected general practitioners (GPs) (n = 200), gynecologists (GYNs) (n = 300), and pediatricians (PEDs) (n = 265). In this part of the study, their opinions with regard to genetic preconceptional CF carrier screening in different situations were assessed. The response rate for the GPs, GYNs, and PEDs was 64%, 69%, and 72%, respectively. In total, 63% of the GPs, 69% of the GYNs and 72% of the PEDs supported preconceptional CF carrier testing if a couple requested a test. Sixteen percent, 19% and 25%, respectively, were in favor of actively offering a test with 95% test sensitivity to all couples who were planning a pregnancy. A positive opinion on preconceptional CF carrier screening was associated with the following variables: "considering the test sensitivity as less important" (GPs, GYNs), "high perceived risk of having a child with CF" (GYNs), "providing genetic counselling in their own practice" (PEDs) and "reassurance when both partners test negative" (PEDs). Physicians are sympathetic toward preconceptional CF carrier screening if the couples themselves request a test. Physicians had reservations about routinely offering a CF carrier test.     

Five-year results of the peer assessment program of the College of Physicians and Surgeons of Ontario.

The office practices of 918 physicians selected through stratified random sampling from the College of Physicians and Surgeons of Ontario (CPSO) registry were assessed by peers and the Peer Assessment Committee of the CPSO from 1981 to 1985. The sample comprised 662 general practitioners (GPs) and family physicians (FPs) and 256 specialists in 11 fields. Of the physicians 749 (82%) had neither deficient records nor an unsatisfactory level of patient care. Of the GPs and FPs 97 (15%) had serious deficiencies in one or both areas, as compared with 4 (2%) of the specialists (p2 less than 0.00001). The proportions of certificants of the Royal College of Physicians and Surgeons of Canada and of the College of Family Physicians of Canada (CFPC) with serious deficiencies were low (2% and 3% respectively). Three statistically significant predictors of physician performance were found among the GPs and FPs: age, CFPC membership status and type of practice. Of the 56 physicians who were reassessed 6 to 12 months later 29 (52%) had made the improvements recommended by the committee. Our findings demonstrate the need, feasibility and acceptance of a peer assessment program of office practices in Ontario.     

Medication Adherence in the General Population

Background

Adherence to medication is low in specific populations who need chronic medication. However, adherence to medication is also of interest in a more general fashion, independent of specific populations or side effects of particular drugs. If clinicians and researchers expect patients to show close to full adherence, it is relevant to know how likely the achievement of this goal is. Population based rates can provide an estimate of efforts needed to achieve near complete adherence in patient populations. The objective of the study was to collect normative data for medication nonadherence in the general population.

Methods and Findings

We assessed 2,512 persons (a representative sample of German population). Adherence was measured by Rief Adherence Index. We also assessed current medication intake and side effects. We found that at least 33% of Germans repeatedly fail to follow their doctor''s recommendations regarding pharmacological treatments and only 25% of Germans describe themselves as fully adherent. Nonadherence to medication occurs more often in younger patients with higher socioeconomic status taking short-term medications than in older patients with chronic conditions. Experience with medication side effects was the most prominent predictor of nonadherence.

Conclusions

The major strengths of our study are a representative sample and a novel approach to assess adherence. Nonadherece seems to be commonplace in the general population. Therefore adherence cannot be expected per se but needs special efforts on behalf of prescribers and public health initiatives. Nonadherence to medication should not only be considered as a drug-specific behaviour problem, but as a behaviour pattern that is independent of the prescribed medication.     

Pandemic Influenza (A/H1N1) Vaccine Uptake among French Private General Practitioners: A Cross Sectional Study in 2010

Background

In July, 2009, French health authorities, like those in many other countries, decided to embark on a mass vaccination campaign against the pandemic A(H1N1) influenza. Private general practitioners (GPs) were not involved in this campaign. We studied GPs’ pandemic vaccine (pvaccine) uptake, quantified the relative contribution of its potential explanatory factors and studied whether their own vaccination choice was correlated with their recommendations to patients about pvaccination.

Methodology/Principal Findings

In this cross-sectional telephone survey, professional investigators interviewed an existing panel of randomly selected private GPs (N = 1431; response rate at inclusion in the panel: 36.8%; participation rate in the survey: 100%). The main outcome variable was GPs’ own pvaccine uptake. We used an averaging multi-model approach to quantify the relative contribution of factors associated with their vaccination. The pvaccine uptake rate was 61% (95%CI = 58.3–63.3). Four independent factors contributed the most to this rate (partial Nagelkerke’s R²): history of previous vaccination against seasonal influenza (14.5%), perception of risks and efficacy of the pvaccine (10.8%), opinions regarding the organization of the vaccination campaign (7.1%), and perception of the pandemic''s severity (5.2%). Overall, 71.3% (95%CI = 69.0–73.6) of the participants recommended pvaccination to young adults at risk and 40.1% (95%CI = 37.6–42.7) to other young adults. GPs’ own pvaccination was strongly predictive of their recommendation to both young adults at risk (OR = 9.6; 95%CI = 7.2–12.6) and those not at risk (OR = 8.5; 95%CI = 6.4–11.4).

Conclusions/Significance

These results suggest that around 60% of French private GPs followed French authorities’ recommendations about vaccination of health care professionals against the A(H1N1) influenza. They pinpoint priority levers for improving preparedness for future influenza pandemics. Besides encouraging GPs'' own uptake of regular vaccination against seasonal influenza, providing GPs with clear information about the risks and efficacy of any new pvaccine and involving them in the organization of any future vaccine campaign may improve their pvaccine uptake.     

Benefits of an open access echocardiography service: a Dutch prospective cohort study

Background

Open access echocardiography has been evaluated in the United Kingdom, but hardly in the Netherlands. The echocardiography service of the SHL-Groep in Etten-Leur was set up independently from the regional hospitals. Cardiologists not involved in the direct care of the participating patients evaluated the echocardiograms taken by ultrasound technicians.

Aims

We estimated the reduction in the number of referrals to regional cardiologists, the adherence of the general practitioners (GPs) to the advice of the evaluating cardiologist, GPs’ opinion on the benefit of the echocardiography service and GPs’ adherence to the diagnostic protocol advocated in the Dutch clinical guideline for heart failure.

Methods

A prospective cohort study was performed. Patients were included from April 2011 to April 2012 (N = 155). Data from application forms (N = 155), echocardiography results (N = 155) and telephone interviews with GPs (N = 138) were analysed.

Results

GPs referred less patients to the cardiologist than they would have done without echocardiography available (92 % vs. 34 %, p < 0.001). They treated more patients by themselves (62 % vs. 10 %, p < 0.001). Most GPs (81 %) followed the advice presented on the echocardiogram result. Most GPs (82 %) found the service had clinical benefit for the patient. Sixty two percent of echocardiography requests met the criteria of the Dutch clinical guideline for heart failure.

Conclusion

Open access echocardiography saved referrals to the cardiology department, saved time, and enabled GPs to treat more patients by themselves. Adherence to diagnostic guidelines for heart failure was suboptimal.     

A practical approach for implementation of a basal-prandial insulin therapy regimen in patients with type 2 diabetes

Background

Osteopathic philosophy is consistent with an emphasis on primary care and suggests that osteopathic physicians may have distinctive ways of interacting with their patients.

Methods

The National Ambulatory Medical Care Survey (NAMCS) was used to derive national estimates of utilization of osteopathic general and family medicine physicians during 2003 and 2004 and to examine the patient characteristics and physician-patient interactions of these osteopathic physicians. All analyses were performed using complex samples software to appropriately weigh outcomes according to the multistage probability sample design used in NAMCS and multivariate modeling was used to control for potential confounders.

Results and discussion

When weighted according to the multistage probability sample design used, the 6939 patient visits studied represented an estimated 341.4 million patient visits to general and family medicine specialists in the United States, including 64.9 million (19%) visits to osteopathic physicians and 276.5 million (81%) visits to allopathic physicians. Osteopathic physicians were a major source of care in the Northeast (odds ratio [OR], 2.94; 95% confidence interval [CI], 1.42–6.08), providing more than one-third of general and family medicine patient visits in this geographic region. Pediatric and young adult patients (OR, 0.64; 95% CI, 0.45–0.91), Hispanics (OR, 0.63; 95% CI, 0.40–1.00), and non-Black racial minority groups (OR, 0.39; 95% CI, 0.18–0.82) were less likely to visit osteopathic physicians. There were no significant differences between osteopathic and allopathic physicians with regard to the time spent with patients, provision of five common preventive medicine counseling services, or a focus on preventive care during office visits.

Conclusion

Osteopathic physicians are a major source of general and family medicine care in the United States, particularly in the Northeast. However, pediatric and young adult patients, Hispanics, and non-Black racial minorities underutilize osteopathic physicians. There is little evidence to support a distinctive approach to physician-patient interactions among osteopathic physicians in general and family medicine, particularly with regard to time spent with patients and preventive medicine services.     

Effects of residency training in family medicine v. internship training on professional attitudes and practice patterns.

OBJECTIVES: To determine whether the professional attitudes and practice patterns of physicians with residency training in family medicine differ from those of generalists with internship training. DESIGN: Mail survey conducted in 1985-86. SETTING: Province of Quebec. PARTICIPANTS: A stratified random sample of French-speaking family and general practitioners who graduated after 1972 (325 physicians with residency training and 304 with internship training) (response rate 82%). MAIN RESULTS: Physicians with residency training were 3 years younger on average than those with internship training, were more likely to be female (38% v. 18%, p less than 0.001) and were more likely to work on a salaried basis in CLSCs (public community health centres) (36% v. 14%, p less than 0.001). Even after these confounding factors were controlled for, physicians with residency training seemed to be more sensitive to the psychosocial aspects of patient care and tended to attach more importance to informing patients about useful materials and resources concerning their health problems. They were not, however, more likely to value health counselling or integrate it in medical practice. CONCLUSION: Our findings provide some evidence that the new requirement that physicians complete a residency in family medicine to obtain medical licensure in general practice in Quebec may foster a more patient-centred approach to health care.     

Mobilizing physicians to conduct clinical intervention in tobacco use through a medical-association program: 5 years' experience in British Columbia.

During the last 5 years, a program run by the medical association in British Columbia has recruited 23% of the province''s general practitioners (GPs) to take an active, systematic approach to clinical intervention in tobacco use. Another 9% of GPs (considered "semi-active") regularly use the program''s educational materials for patients, and another 25% have been trained in intervention or have been given intervention materials or both. If the cessation rate (rate of patients who quit smoking who would not otherwise have done so) was 4% among physicians actively involved in intervention and 2% among physicians considered semi-active, in 1995 an estimated 4700 smokers quit and were followed by their GPs as a result of the program. Another 135,000 smokers received brief counselling from their GPs and were also followed. This article reviews the strategies and methods used in this program to mobilize physicians.     

The Knowledge of the Role of Papillomavirus—Related Head and Neck Pathologies among General Practitioners,Otolaryngologists and Trainees. A Survey-Based Study

Objectives

The aim of the survey was to introduce knowledge of HPV''s role in head and neck pathologies to general physicians (GPs), otorhinolaryngologists (ENTs) and newly graduated doctors, as well as to promote HPV-related diseases prevention.

Study Design

Cross-sectional study.

Methods

Self-designed questionnaire was sent to 2100 doctors. A total of 404 doctors, including 144 ENTs, 192 GPs and 68 trainees, responded.

Results

The majority of ENTs (86.8%) had contact with recurrent respiratory papillomatosis (RRP) and oropharyngeal cancers (OPCs) patients; in contrast, the majority of GPs (55.7%) did not (p = 0.00). The knowledge of HPV aetiology of cervical cancer versus OPCs and RRP was statistically higher. 7% of ENTs, 20% of GPs and 10% of trainees had not heard about HPV in oropharyngeal diseases. Women had greater knowledge than men. Both in the group of GPs and ENTs, 100% of respondents had heard about the impact of vaccination on the reduction of cervical cancer incidence. Only 39.11% of respondents had heard about the possibility of using vaccination against HPV in RRP—ENT doctors significantly more often than GPs and trainees (p = 0.00). Only 28.96% of physicians had heard about the potential value of HPV vaccination in preventing OPCs, including 44.44% of ENT doctors, 23.44% of GPs and 11.76% of trainees (p = 0.00). The doctors from district hospitals showed lower level of knowledge compared with clinicians (p = 0.04).

Conclusions

The different levels of knowledge and awareness of HPV issues highlight the need for targeted awareness strategies in Poland with implementation of HPV testing and vaccination. The information should be accessible especially to those with lower education levels: ENTs from small, provincial wards, GPs from cities of < 200 000 inhabitants and older physicians. The incorporation of HPV issues into the studies curriculum would be fruitful in terms of improving the knowledge of trainees.     

Prevalence and antimicrobial susceptibilities of bacteria isolated from blood cultures of hospitalized patients in the United States in 2002

Background

Upper respiratory tract infections (URTIs) are among the most frequent reasons for physician office visits in paediatrics. Despite their predominant viral aetiology, URTIs continue to be treated with antimicrobials. We explored general practitioners' (GPs) prescribing behaviour for antimicrobials in children (≤ 16 years) with URTIs in Trinidad, using the guidelines from the Centers for Disease Control and Prevention (CDC) as a reference.

Methods

A cross-sectional study was conducted on 92 consenting GPs from the 109 contacted in Central and East Trinidad, between January to June 2003. Using a pilot-tested questionnaire, GPs identified the 5 most frequent URTIs they see in office and reported on their antimicrobial prescribing practices for these URTIs to trained research students.

Results

The 5 most frequent URTIs presenting in children in general practice, are the common cold, pharyngitis, tonsillitis, sinusitis and acute otitis media (AOM) in rank order. GPs prescribe at least 25 different antibiotics for these URTIs with significant associations for amoxicillin, co-amoxiclav, cefaclor, cefuroxime, erythromycin, clarithromycin and azithromycin (p < 0.001). Amoxicillin alone or with clavulanate was the most frequently prescribed antibiotic for all URTIs. Prescribing variations from the CDC recommendations were observed for all URTIs except for AOM (50%), the most common condition for antibiotics. Doctors practicing for >30 years were more likely to prescribe antibiotics for the common cold (p = 0.014). Severity (95.7%) and duration of illness (82.5%) influenced doctors' prescribing and over prescribing in general practice was attributed to parent demands (75%) and concern for secondary bacterial infections (70%). Physicians do not request laboratory investigations primarily because they are unnecessary (86%) and the waiting time for results is too long (51%).

Conclusions

Antibiotics are over prescribed for paediatric URTIs in Trinidad and amoxicillin with co-amoxiclav were preferentially prescribed. Except for AOM, GPs' prescribing varied from the CDC guidelines for drug and duration. Physicians recognise antibiotics are overused and consider parents expecting antibiotics and a concern for secondary bacterial infections are prescribing pressures. Guidelines to manage URTIs, ongoing surveillance programs for antibiotic resistance, public health education on non-antibiotic strategies, and postgraduate education for rational pharmacotherapy in general practice would decrease inappropriate antibiotic use in URTIs.     

Overweight and Obesity: Knowledge,Attitudes, and Practices of General Practitioners in France

Objective: To describe the current knowledge, attitudes, and practices of French general practitioners (GPs) in the field of adult overweight and obesity management. Research Methods and Procedures: A cross‐sectional telephone survey interviewed a sample of 600 GPs, representative of the private GPs in southeastern France. A four‐part questionnaire assessed personal and professional characteristics, attitudes and opinions about overweight and obesity, relevant knowledge and training, and practices (diagnostic methods, clinical assessments, weight loss objectives, types of counseling). Results: Most GPs knew that weight problems are health‐threatening, and 79% agreed that managing these problems is part of their role. Nevertheless, 58% did not feel they perform this role effectively, and one‐third did not find it professionally gratifying. Approximately 30% had negative attitudes toward overweight and obese patients; 57% were pessimistic about patients’ ability to lose weight; 64% often set weight loss objectives more demanding than guidelines call for; and neither food diaries nor nutritional education were used systematically. GPs’ feelings of effectiveness and attitudes toward obese patients were associated with some professional (training) and personal (BMI, personal diet experience) characteristics. Discussion: GPs’ feelings of ineffectiveness may stem from an underlying conflict between practitioners’ and patients’ representations of weight problems and the relationship problems this causes. Inadequate practices and health care system organization may also play a role.     

Prevalence of Chronic Conditions in Australia

Objectives

To estimate prevalence of chronic conditions among patients seeing a general practitioner (GP), patients attending general practice at least once in a year, and the Australian population.

Design, setting and participants

A sub-study of the BEACH (Bettering the Evaluation and Care of Health) program, a continuous national study of general practice activity conducted between July 2008 and May 2009. Each of 290 GPs provided data for about 30 consecutive patients (total 8,707) indicating diagnosed chronic conditions, using their knowledge of the patient, patient self-report, and patient''s health record.

Main outcome measures

Estimates of prevalence of chronic conditions among patients surveyed, adjusted prevalence in patients who attended general practice at least once that year, and national population prevalence.

Results

Two-thirds (66.3%) of patients surveyed had at least one chronic condition: most prevalent being hypertension (26.6%), hyperlipidaemia (18.5%), osteoarthritis (17.8%), depression (13.7%), gastro-oesophageal reflux disease (11.6%), asthma (9.5%) and Type 2 diabetes (8.3%). For patients who attended general practice at least once, we estimated 58.8% had at least one chronic condition. After further adjustment we estimated 50.8% of the Australian population had at least one chronic condition: hypertension (17.4%), hyperlipidaemia (12.7%), osteoarthritis (11.1%), depression (10.5%) and asthma (8.0%) being most prevalent.

Conclusions

This study used GPs to gather information from their knowledge, the patient, and health records, to provide prevalence estimates that overcome weaknesses of studies using patient self-report or health record audit alone. Our results facilitate examination of primary care resource use in management of chronic conditions and measurement of prevalence of multimorbidity in Australia.     

A South African Public-Private Partnership HIV Treatment Model: Viability and Success Factors

Introduction

The increasing number of people requiring HIV treatment in South Africa calls for efficient use of its human resources for health in order to ensure optimum treatment coverage and outcomes. This paper describes an innovative public-private partnership model which uses private sector doctors to treat public sector patients and ascertains the model’s ability to maintain treatment outcomes over time.

Methods

The study used a retrospective design based on the electronic records of patients who were down-referred from government hospitals to selected private general medical practitioners (GPs) between November 2005 and October 2012. In total, 2535 unique patient records from 40 GPs were reviewed. The survival functions for mortality and attrition were calculated. Cumulative incidence of mortality for different time cohorts (defined by year of treatment initiation) was also established.

Results

The median number of patients per GP was 143 (IQR: 66–246). At the time of down-referral to private GPs, 13.8% of the patients had CD4 count <200 cell/mm³, this proportion reduced to 6.6% at 12 months and 4.1% at 48 months. Similarly, 88.4% of the patients had suppressed viral load (defined as HIV-1 RNA <400 copies/ml) at 48 months. The patients’ probability of survival at 12 and 48 months was 99.0% (95% CI: 98.4%–99.3%) and 89.0% (95% CI: 87.1%–90.0%) respectively. Patient retention at 48 months remained high at 94.3% (95% CI: 93.0%–95.7%).

Conclusions

The study findings demonstrate the ability of the GPs to effectively maintain patient treatment outcomes and potentially contribute to HIV treatment scale-up with the relevant support mechanism. The model demonstrates how an assisted private sector based programme can be effectively and efficiently used to either target specific health concerns, key populations or serve as a stop-gap measure to meet urgent health needs.