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Phillips RS, Benneyan J, Bargal B, Schiff GD. Closing the Loop: Re-engineering the Assessment and Tracking of Symptoms in Primary Care. J Gen Intern Med 2023; 38:1054-1058. [PMID: 36414802 PMCID: PMC10039145 DOI: 10.1007/s11606-022-07886-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 10/26/2022] [Indexed: 11/24/2022]
Abstract
Reliable systems that track the continuation, progression, or resolution of a patient's symptoms over time are essential for reliable diagnosis and ensuring that patients harboring more worrisome diagnoses are safely followed up. Given their first-contact role and increasing stresses on busy primary care clinicians and practices, new processes that make these tasks easier rather than creating more work for busy clinicians are especially needed.Some symptoms are sufficiently worrisome that they demand an urgent diagnosis and treatment while others result in a differential that can be more safely explored over time, or less differentiated and worrisome that they are best managed with the "test of time" to see if they resolve, worsen, or evolve into symptoms that are more worrisome. Regardless, it is essential that clinicians are able to reliably track symptoms over time, yet this capacity is rarely available or explicit. Working with systems engineers, we are developing prototypes for such systems and are working on their implementation and evaluation. In this commentary, we describe approaches to this essential, but underappreciated, problem in primary care.
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Affiliation(s)
- Russell S Phillips
- Harvard Medical School Center for Primary Care, 635 Huntington Ave, Boston, MA, 02115, USA.
| | - James Benneyan
- Healthcare Systems Engineering Institute, Northeastern University, Boston, USA
| | - Basma Bargal
- Healthcare Systems Engineering Institute, Northeastern University, Boston, USA
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Adibi P, Ani A, Vaez A, Hadizadeh F, Snieder H, Roohafza H. Multidisciplinary approach to functional somatic syndromes: study protocol for a population-based prospective cohort study. BMJ Open 2022; 12:e048941. [PMID: 35777883 PMCID: PMC9252204 DOI: 10.1136/bmjopen-2021-048941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION Isfahan functional disorders (ISFUN) cohort study aims to describe the interplay of genetic and environmental factors in shaping the characteristics of functional somatic syndromes (FSS). This study is primarily intended to investigate the epidemiology, risk factors, course and prognosis of FSSs in a sample of adult Iranian population. The other aim is to develop a new delimitation of FSSs based on an integrated multidisciplinary approach comprising of phenotypic and multiomics data. METHODS AND ANALYSIS ISFUN is a population-based prospective cohort study designed to follow a population of randomly selected seemingly healthy adults (18-65 years) through annual visits during a 4-year observation period. Structured questionnaires are used for data collection and clinical assessment of the participants. Questionnaire-based diagnosis of FSSs are validated in a medical interview. Human DNA genotyping, microbial amplicon sequencing and urine analysis is under progress for genomics, microbiota and metabolomics profiling, respectively. Enrolment began in September 2017, and study completion is expected in 2022. A total number of 1943 participants were initially recruited. ETHICS AND DISSEMINATION Ethical approval for data collection was granted by the National Research Ethics Committee of the Iranian Ministry of Health and Medical Education and the Research Ethics Committee of Isfahan University of Medical Sciences (IR.MUI.REC.1395.1.149). Following the description of the study procedure, we obtained written informed consent from all study participants. Study findings will be disseminated through peer-reviewed publications and presentations at scientific meetings.
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Affiliation(s)
- Peyman Adibi
- Isfahan Gastroenterology and Hepatology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Alireza Ani
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Bioinformatics, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ahmad Vaez
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Bioinformatics, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fatemeh Hadizadeh
- Department of Bioinformatics, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Harold Snieder
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Hamidreza Roohafza
- Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
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Houwen J, de Bont OA, Lucassen PL, Rosmalen JGM, Stappers HW, Olde Hartman TC, van Dulmen S. Development of a blended communication training program for managing medically unexplained symptoms in primary care using the intervention mapping approach. PATIENT EDUCATION AND COUNSELING 2022; 105:1305-1316. [PMID: 34561144 DOI: 10.1016/j.pec.2021.09.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 07/29/2021] [Accepted: 09/08/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND General practice (GP) training in how to communicate with patients with medically unexplained symptoms (MUS) is limited. OBJECTIVE Development, implementation and evaluation of an evidence-based communication training program for GP residents focused on patients with MUS in primary care. METHODS We used the intervention mapping (IM) framework to systematically develop the MUS training program. We conducted a needs assessment to formulate change objectives and identified teaching methods for a MUS communication training program. Next, we developed, implemented and evaluated the training program with 46 residents by assessing their self-efficacy and by exploring their experiences with the training. RESULTS The resulting program is a blended training with an online course and two training days. After attending the training program, GP residents reported significantly higher self-efficacy for communication with patients with MUS at four weeks follow up compared to baseline. Furthermore, GP residents experienced the training program as useful and valued the combination of the online course and training days. CONCLUSION AND PRACTICE IMPLICATIONS We developed an evidence-based communication training program for the management of patients with MUS in primary care. Future research should examine the effect of the training on GP residents' communication skills in MUS consultations in daily practice.
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Affiliation(s)
- Juul Houwen
- Radboud university medical center, Radboud Institute for Health Sciences, Department of Primary and Community Care, Nijmegen, The Netherlands.
| | - Olga A de Bont
- Radboud university medical center, Radboud Institute for Health Sciences, Department of Primary and Community Care, Nijmegen, The Netherlands
| | - Peter Lbj Lucassen
- Radboud university medical center, Radboud Institute for Health Sciences, Department of Primary and Community Care, Nijmegen, The Netherlands
| | - Judith G M Rosmalen
- University Medical Center Groningen, Interdisciplinary Center for Psychopathology and Emotion Regulation, Groningen, the Netherlands
| | - Hugo W Stappers
- Radboud university medical center, Radboud Institute for Health Sciences, Department of Primary and Community Care, Nijmegen, The Netherlands
| | - Tim C Olde Hartman
- Radboud university medical center, Radboud Institute for Health Sciences, Department of Primary and Community Care, Nijmegen, The Netherlands
| | - Sandra van Dulmen
- Radboud university medical center, Radboud Institute for Health Sciences, Department of Primary and Community Care, Nijmegen, The Netherlands; Nivel (Netherlands institute for health services research), Utrecht, The Netherlands
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Nishiyama J, Abe T, Imaizumi S, Yamane A, Fukunaga M. Characteristics of outpatients with functional somatic syndromes at a university hospital's general medicine clinic. J Gen Fam Med 2022; 23:268-274. [PMID: 35800641 PMCID: PMC9249930 DOI: 10.1002/jgf2.543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 02/03/2022] [Accepted: 03/22/2022] [Indexed: 11/16/2022] Open
Abstract
Background The term medically unexplained symptoms (MUS) is unhelpful for both patients and physicians, and more acceptable illness categories are needed as substitutes for MUS. While some potential substitutes are characterized by excessive psychological burden related to somatic symptoms, “functional somatic syndromes” (FSS) is a category that focuses on physical dysfunction and emphasizes similarities among individual syndromes. Examples of FSS include irritable bowel syndrome, functional dyspepsia, and fibromyalgia syndrome. This study aimed to distinguish FSS from MUS and compare the somatic and psychobehavioral characteristics of FSS with those of other diseases. Methods This study included 1975 first‐visit outpatients at a Japanese university hospital's general medicine clinic. According to their first‐listed diagnosis, they were classified as having FSS, acute infection, organic disease (OD), psychiatric disorder, and unknown condition (UC). The somatic symptom burden and health‐related quality of life (HRQoL) were assessed using the Somatic Symptom Scale‐8 and EuroQol‐5 Dimension, respectively; the involvement of psychobehavioral factors affecting somatic symptoms was also evaluated. Results Overall, 33% of patients were included in the FSS category, and 93% of the supposed MUS (FSS and UC) were diagnosed with FSS. Compared with OD, FSS showed more severe somatic symptom burden, similar reduced HRQoL, and higher involvement of psychobehavioral factors. Conclusion It can be useful to improve FSS diagnostic skills for the reduction of MUS misdiagnosis. Psychobehavioral factors might be less associated with MUS (in the narrow sense of the term) than FSS. We classified 1975 first‐visit outpatients at a Japanese university hospital's general medicine clinic as having functional somatic syndrome (FSS), acute infection, organic disease, psychiatric disorder, and unknown condition (UC). FSS comprised one‐third of our study population, and almost all of the supposed medically unexplained symptoms (FSS and UC) were diagnosed with FSS. Compared with other organic diseases, FSS showed more severe somatic symptom burden, similar health‐related quality of life, and higher involvement of psychobehavioral factors.
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Affiliation(s)
- Junji Nishiyama
- Department of Psychosomatic and General Internal Medicine Kansai Medical University Hirakata Japan
- Clinic of General Medicine Kansai Medical University Hospital Hirakata Japan
| | - Tetsuya Abe
- Department of Psychosomatic and General Internal Medicine Kansai Medical University Hirakata Japan
| | - Sumito Imaizumi
- Department of Psychosomatic and General Internal Medicine Kansai Medical University Hirakata Japan
| | - Akira Yamane
- Department of Psychosomatic and General Internal Medicine Kansai Medical University Hirakata Japan
| | - Mikihiko Fukunaga
- Department of Psychosomatic and General Internal Medicine Kansai Medical University Hirakata Japan
- Clinic of General Medicine Kansai Medical University Hospital Hirakata Japan
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Morris L, Moule P, Pearson J, Foster D, Walsh N. Patient acceptability of the physiotherapy first contact practitioner role in primary care: A realist informed qualitative study. Musculoskeletal Care 2020; 19:38-51. [PMID: 32989900 DOI: 10.1002/msc.1505] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 08/17/2020] [Accepted: 08/21/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Leah Morris
- Centre for Health and Clinical Research University of the West of England Bristol UK
| | - Pam Moule
- Department of Nursing University of the West of England Bristol UK
| | - Jennifer Pearson
- Centre for Health and Clinical Research University of the West of England Bristol UK
| | | | - Nicola Walsh
- Centre for Health and Clinical Research University of the West of England Bristol UK
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Selinheimo S, Vuokko A, Hublin C, Järnefelt H, Karvala K, Sainio M, Suojalehto H, Paunio T. Psychosocial treatments for employees with non-specific and persistent physical symptoms associated with indoor air: A randomised controlled trial with a one-year follow-up. J Psychosom Res 2020; 131:109962. [PMID: 32078837 DOI: 10.1016/j.jpsychores.2020.109962] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 02/10/2020] [Accepted: 02/11/2020] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Persistent physical symptoms (PPS) associated with indoor air without an adequate pathophysiological- or environmental-related explanation may lead to work disability and decreased health-related quality of life (HRQoL). We attempted to assess the effect of cognitive behavioural therapy (CBT) for PPS and also psychoeducation (PE) on these symptoms involving disability. METHOD The intention-to-treat (ITT) sample included 52 employees recruited from an occupational healthcare service randomised as either controls undergoing treatment as usual (TAU) or TAU enhanced with CBT or PE. The primary outcome was HRQoL measuring the severity of symptoms and restrictions in everyday life caused by them. Secondary outcomes included depressive, anxiety and insomnia symptoms, and intolerance to environmental factors, assessed at baseline and at 3-, 6- and 12-month follow-ups. RESULTS At the 12-month follow-up assessment point, no statistically significant differences between treatments emerged following adjustment for gender, age, and HRQoL before the waiting period in the ITT analysis [F(2,46)=2.89, p=.07]. The secondary analysis revealed a significant improvement in HRQoL in the combined intervention group as compared with controls [F(1,47)=5.06, p=.03, g=0.41]. In total, 15% of participants dropped out during follow-up. CONCLUSIONS The results suggest that CBT for PPS or PE might not have a robust effect on HRQoL in PPS associated with indoor air, but the study did not achieve the planned power. Despite difficulties during the recruitment process, the final dropout rates remained low, and participants positively evaluated CBT, suggesting that it represents an acceptable treatment to them. Trial status This study was registered at the ClinicalTrials.gov registry (NCT02069002).
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Affiliation(s)
- Sanna Selinheimo
- Finnish Institute of Occupational Health, Helsinki, Finland; Department of Psychology and Logopedics, University of Helsinki, Helsinki, Finland.
| | - Aki Vuokko
- Finnish Institute of Occupational Health, Helsinki, Finland.
| | - Christer Hublin
- Finnish Institute of Occupational Health, Helsinki, Finland.
| | - Heli Järnefelt
- Finnish Institute of Occupational Health, Helsinki, Finland.
| | - Kirsi Karvala
- Finnish Institute of Occupational Health, Helsinki, Finland; Insurance Medicine and Rehabilitation Unit, Keva, Finland.
| | - Markku Sainio
- Finnish Institute of Occupational Health, Helsinki, Finland.
| | | | - Tiina Paunio
- Finnish Institute of Occupational Health, Helsinki, Finland; Department of Health, National Institute for Health and Welfare, Helsinki, Finland; Department of Psychiatry and the SleepWell Research Program, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
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Bernard L, Ecochard R, Gueyffier F, Letrilliart L. Drug prescription goals in primary care: a cross-sectional study. BMC Health Serv Res 2020; 20:6. [PMID: 31898496 PMCID: PMC6941394 DOI: 10.1186/s12913-019-4870-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 12/24/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Care goals are often implicit, although their identification is a key element of any prescription process. This study aimed to describe the clinical goals of drug prescriptions in general practice, their determinants and the agreement between physicians and patients. METHODS This was a cross-sectional study conducted by 11 resident trainees acting as observers in 23 general practices. The residents recorded the indication and main physician's goal for all drugs prescribed during five consultation days in each practice in December 2015, and the main patient's goal for a sub-sample of consultations. We used an eight-category generic classification of prescription goals, including three specific (mortality, morbidity and cure), three non-specific (symptoms, quality of life, functioning) and two non-specified (other goal, no goal) categories. Analyses were based on a multivariable, multilevel model and on the kappa statistic applied to the sub-sample of consultations. RESULTS The sample encompassed 2141 consultations and 5036 drugs. The main physicians' goal of drug prescriptions was to relieve symptoms (43.3%). The other goals were to decrease the risk of morbidity (22.4%), to cure disease (11.7%), to improve quality of life (10.6%), to decrease the risk of mortality (8.5%) and to improve functioning (1.8%). The choice of a specific goal was more frequent in patients with the following characteristics: over 50 (OR [1.09;1.15]), of male gender (OR [1.09;1.39]), with full financial coverage for a long-term condition (OR [1.47;1.97]), known by the physician (OR [1.19;2.23]), or with a somatic health problem (OR [2.56;4.17]). Cohen's kappa for drug prescription goals between the patients and the physicians was 0.26 (0.23-0.30). CONCLUSIONS Physicians' goals are poorly shared with patients. It remains to be assessed whether it is possible to collect and discuss information on prescription goals on a daily basis.
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Affiliation(s)
- Louis Bernard
- Univ. Lyon, Université Claude Bernard Lyon 1, Collège universitaire de médecine générale, F-69008 Lyon, France
| | - René Ecochard
- Hospices Civils de Lyon, Service de Biostatistique-Bioinformatique, Lyon, France
- Université Lyon 1, Villeurbanne, France
- Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, CNRS, Villeurbanne, France
| | - François Gueyffier
- UMR5558, service de pharmacologie et toxicologie, faculté Laennec, Lyon, France
| | - Laurent Letrilliart
- Univ. Lyon, Université Claude Bernard Lyon 1, Collège universitaire de médecine générale, F-69008 Lyon, France
- Univ. Lyon, Université Claude Bernard Lyon 1, HESPER EA 7425, F-69008 Lyon, France
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Enhancing dysphonia clinic consultations through a focus on patients' expectations: streamlining and validation of a new tool ('ACaPELa-R' questionnaire). The Journal of Laryngology & Otology 2019; 133:236-240. [PMID: 30803456 DOI: 10.1017/s0022215119000276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE The Assessing and Caring for Patients' Expectations in Laryngology ('ACaPELa') questionnaire was developed to guide laryngology clinic consultations. This study aimed to audit its use, revise it depending on outcomes and validate it. METHODS The questionnaire was completed by all new patients attending a laryngology clinic over one year. The questionnaire was refined and validated in a new cohort of patients over a six-month period. RESULTS Thirty-seven of 242 patients (15.3 per cent) incorrectly gave the same ranking to more than one question. Questions with similar content were collapsed to cover broader themes, and an outcome question was added, resulting in the five-item Assessing and Caring for Patients' Expectations in Laryngology - Revised ('ACaPELa-R') questionnaire. Using this revised questionnaire, there was a significant reduction in the number of same-ranked questions (4.4 vs 15.3 per cent; p = 0.003) and high patient satisfaction post-consultation (95.7 per cent). CONCLUSION The Assessing and Caring for Patients' Expectations in Laryngology - Revised questionnaire makes patients' rank ordering of questions easier. It can be used to inform how different topics should be approached during the consultation and utilised for clinician self-audit.
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Rasmussen EB, Rø KI. How general practitioners understand and handle medically unexplained symptoms: a focus group study. BMC FAMILY PRACTICE 2018; 19:50. [PMID: 29720093 PMCID: PMC5932817 DOI: 10.1186/s12875-018-0745-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 04/23/2018] [Indexed: 11/10/2022]
Abstract
Background Medically unexplained symptoms (MUS) are a common yet challenging encounter in primary care. The aim of this study was to explore how general practitioners (GPs) understand and handle MUS. Methods Three focus group interviews were conducted with a total of 23 GPs. Participants with varied clinical experience were purposively recruited. The data were analysed thematically, using the concept of framing as an analytical lens. Results The GPs alternated between a biomedical frame, centred on disease, and a biopsychosocial frame, centred on the sick person. Each frame shaped the GPs’ understanding and handling of MUS. The biomedical frame emphasised the lack of objective evidence, problematized subjective patient testimony, and manifested feelings of uncertainty, doubt and powerlessness. This in turn complicated patient handling. In contrast, the biopsychosocial frame emphasised clinical experience, turned patient testimony into a valuable source of information, and manifested feelings of confidence and competence. This in turn made them feel empowered. The GPs with the least experience relied more on the biomedical frame, whereas their more seasoned seniors relied mostly on the biopsychosocial frame. Conclusion The biopsychosocial frame helps GPs to understand and handle MUS better than the biomedical frame does. Medical students should spend more time learning biopsychosocial medicine, and to integrate the clinical knowledge of their peers with their own. Electronic supplementary material The online version of this article (10.1186/s12875-018-0745-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Erik Børve Rasmussen
- Centre for the study of professions, OsloMet - Oslo Metropolitan University, P.O. Box. 4, St. Olavs plass, N-0130, Oslo, Norway.
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Minué-Lorenzo S, Fernández-Aguilar C. [Critical view and argumentation on chronic care programs in Primary and Community Care]. Aten Primaria 2017; 50:114-129. [PMID: 29174714 PMCID: PMC6836966 DOI: 10.1016/j.aprim.2017.09.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 09/27/2017] [Indexed: 11/17/2022] Open
Abstract
El análisis detallado de los planes de atención a la cronicidad desarrollados por los servicios regionales de salud pone de manifiesto un sorprendente nivel de uniformidad en su diseño y despliegue, a pesar de las diferencias existentes entre dichos servicios. La revisión de la literatura sobre los modelos teóricos que lo sustentan y los instrumentos que lo desarrollan no aporta evidencias concluyentes que permitan afirmar que los modelos de atención a pacientes crónicos alcanzan mejores resultados que modelos de atención alternativos. A pesar de que todos los planes de atención a la cronicidad incluyen sistemas de evaluación de los mismos, no se han publicado hasta la fecha estudios rigurosos sobre su efecto. Dado que, por el contrario, sí existen pruebas sólidas y reiteradas de que modelos con una Atención Primaria fuerte obtienen mejores resultados, cabe preguntarse sobre la necesidad de buscar modelos alternativos, cuando las metas propuestas probablemente podrían alcanzarse de fortalecer realmente la Atención Primaria.
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Affiliation(s)
- Sergio Minué-Lorenzo
- Integrated Health Services based on Primary Health Care WHO Collaborating Centre, Escuela Andaluza de Salud Pública, Granada, España.
| | - Carmen Fernández-Aguilar
- Integrated Health Services based on Primary Health Care WHO Collaborating Centre, Escuela Andaluza de Salud Pública, Granada, España
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Rosendal M, Olde Hartman TC, Aamland A, van der Horst H, Lucassen P, Budtz-Lilly A, Burton C. "Medically unexplained" symptoms and symptom disorders in primary care: prognosis-based recognition and classification. BMC FAMILY PRACTICE 2017; 18:18. [PMID: 28173764 PMCID: PMC5297117 DOI: 10.1186/s12875-017-0592-6] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 01/25/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Many patients consult their GP because they experience bodily symptoms. In a substantial proportion of cases, the clinical picture does not meet the existing diagnostic criteria for diseases or disorders. This may be because symptoms are recent and evolving or because symptoms are persistent but, either by their character or the negative results of clinical investigation cannot be attributed to disease: so-called "medically unexplained symptoms" (MUS). MUS are inconsistently recognised, diagnosed and managed in primary care. The specialist classification systems for MUS pose several problems in a primary care setting. The systems generally require great certainty about presence or absence of physical disease, they tend to be mind-body dualistic, and they view symptoms from a narrow specialty determined perspective. We need a new classification of MUS in primary care; a classification that better supports clinical decision-making, creates clearer communication and provides scientific underpinning of research to ensure effective interventions. DISCUSSION We propose a classification of symptoms that places greater emphasis on prognostic factors. Prognosis-based classification aims to categorise the patient's risk of ongoing symptoms, complications, increased healthcare use or disability because of the symptoms. Current evidence suggests several factors which may be used: symptom characteristics such as: number, multi-system pattern, frequency, severity. Other factors are: concurrent mental disorders, psychological features and demographic data. We discuss how these characteristics may be used to classify symptoms into three groups: self-limiting symptoms, recurrent and persistent symptoms, and symptom disorders. The middle group is especially relevant in primary care; as these patients generally have reduced quality of life but often go unrecognised and are at risk of iatrogenic harm. The presented characteristics do not contain immediately obvious cut-points, and the assessment of prognosis depends on a combination of several factors. CONCLUSION Three criteria (multiple symptoms, multiple systems, multiple times) may support the classification into good, intermediate and poor prognosis when dealing with symptoms in primary care. The proposed new classification specifically targets the patient population in primary care and may provide a rational framework for decision-making in clinical practice and for epidemiologic and clinical research of symptoms.
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Affiliation(s)
- Marianne Rosendal
- Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Alle 2, DK-8000 Aarhus C, Denmark
- Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, J.B. Winslows Vej 9 A, DK-5000 Odense, Denmark
| | - Tim C Olde Hartman
- Department of Primary and Community Care, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Aase Aamland
- Research Unit for General Practice, Uni Research Health, Bergen, Norway
| | - Henriette van der Horst
- Department of General Practice and Elderly Care Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - Peter Lucassen
- Department of Primary and Community Care, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Anna Budtz-Lilly
- Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Alle 2, DK-8000 Aarhus C, Denmark
| | - Christopher Burton
- Academic Unit of Primary Medical Care, University of Sheffield, Samuel Fox House, Northern General Hospital, Sheffield, S5 7 AU UK
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Smits FT, Brouwer HJ, Schene AH, van Weert HCPM, ter Riet G. Is frequent attendance of longer duration related to less transient episodes of care? A retrospective analysis of transient and chronic episodes of care. BMJ Open 2016; 6:e012563. [PMID: 27965250 PMCID: PMC5168647 DOI: 10.1136/bmjopen-2016-012563] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Frequent attenders (FAs) suffer more and consult general practitioners (GPs) more often for chronic physical and psychiatric illnesses, social difficulties and distress than non-FAs. However, it is unclear to what extent FAs present transient episodes of care (TECs) compared with non-FAs. DESIGN Retrospective analysis of all episodes of care (ECs) in 15 116 consultations in 1 year. Reasons for encounter (RFEs) linked to patients' problem lists were defined as chronic ECs (CECs), other episodes as TECs. SETTING 1 Dutch urban primary healthcare centre served by 5 GPs. PARTICIPANTS All 5712 adult patients were enlisted between 2007 and 2009. FAs were patients whose attendance rate ranked within the top decile of their sex and age group in at least one of the years between 2007 and 2009. OUTCOME MEASURES Number of RFEs linked to TECs/CECs for non-FAs and 1-year (1yFAs), 2-year (2yFAs) and 3-year FAs (3yFAs), and the adjusted effect of frequent attendance of different duration on the number of TECs. RESULTS The average number of RFEs linked to TECs (non-FAs 1.4; 3yFAs 7.3) and to CECs (non-FAs 0.9; 3yFAs 6.2) increased substantially with the duration of frequent attendance. The ratio of TECs to all ECs differed little for FAs (52-54%) and non-FAs (64%). Compared with non-FAs, the adjusted additional number of TECs was 3.4 (95% CI 3.2 to 3.7, 1yFAs), 6.6 (95% CI 6.1 to 7.0, 2yFAs) and 9.4 (95% CI 8.8 to 10.1, 3yFAs). CONCLUSIONS FAs present more TECs and CECs with longer duration of frequent attendance. The constant ratio of TECs might be a sign of a low threshold for FAs to consult their GP. The large numbers of TECs in FAs might be associated with their high level of anxiety and low mastery. The consultation pattern of FAs may best be characterised by describing both TECs and CECs.
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Affiliation(s)
- Frans T Smits
- Department of General Practice, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Henk J Brouwer
- Department of General Practice, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Aart H Schene
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Henk C P M van Weert
- Department of General Practice, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Gerben ter Riet
- Department of General Practice, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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