Efficacy of an educational intervention on family physicians' risk assessment and management of colorectal cancer

We developed a point-of-care tool indicating risk categories for colorectal cancer (CRC) based on family history (FH) and management recommendations tailored to risk. The study objective was to determine if this CRC Risk Triage/Management Too would enable family physicians (FPs) to appropriately triage and make screening and genetics referral recommendations for patients with CRC FH. Baseline questionnaires were mailed to a random sample of FPs in Ontario and Newfoundland, Canada. Participants were asked to use the tool for 3 months and then complete a follow-up questionnaire. The primary outcomes were correct responses to questions regarding CRC risk category, screening method, starting age, frequency, and decision to refer to genetics, for eight clinical vignettes. The study was completed by 75/121 (62 %) participating FPs. Most (77 %) agreed they routinely recommended fecal occult blood testing for average risk patients age ≥50. This did not change significantly following the intervention. There was a significant increase in confidence in CRC risk assessment (52 % pre; 88 % post; p < 0.001), correct management recommendations for patients with CRC FH (51 % pre; 84 % post; p < 0.001), and improvement in total mean scores on outcome measures for all vignettes. Most (90 %) agreed the tool would improve practice. Receipt of the CRC Risk Triage/Management Tool was associated with improvement in FPs' CRC risk assessment, screening, and genetics referral recommendations for clinical vignettes. This demonstrates the value of point-of-care tools and illustrates a process for development, evaluation, and dissemination of tools needed by FPs if potential impacts of genomic advances are to be achieved.

Continuity of care is good for elderly people with diabetes: retrospective cohort study of mortality and hospitalization

OBJECTIVE

To examine the relationship between continuity of family physician care and all-cause mortality and acute hospitalizations in older people with diabetes.

DESIGN

Retrospective cohort study of administrative health databases. Continuity of family physician care for elderly patients newly diagnosed with diabetes was estimated by 3 continuity indexes using physician claims data. The relationship of continuity of family physician care to mortality and acute hospitalizations was investigated.

SETTING

The province of Newfoundland and Labrador.

PARTICIPANTS

A total of 305 family practice patients 65 years of age or older with diabetes.

MAIN OUTCOME MEASURES

Death rate and hospitalization rate during a 3-year period.

RESULTS

Overall, continuity of family physician care was high. In the 3 years examined, the higher-continuity group had lower rates of hospitalization (53.5% vs 68.2%) and death (8.6% vs 18.5%) than the lower-continuity group.

CONCLUSION

The findings suggest an association between higher continuity of family physician care and reductions in likelihood of death and hospitalizations in older people with diabetes.

Postdated versus usual delayed antibiotic prescriptions in primary care: Reduction in antibiotic use for acute respiratory infections?

OBJECTIVE

To determine whether postdating delayed antibiotic prescriptions results in a further decrease (over usual delayed prescriptions) in antibiotic use.

DESIGN

Randomized controlled trial.

SETTING

A small rural town in Newfoundland and Labrador.

PARTICIPANTS

A total of 149 consecutive adult primary care patients who presented with acute upper respiratory tract infections.

INTERVENTION

Delayed prescriptions for patients who might require antibiotics were randomly dated either the day of the office visit (ie, the usual group) or 2 days later (ie, the postdated group).

MAIN OUTCOME MEASURES

Whether or not the prescriptions were filled and the time it took for the patients to fill the prescriptions were noted by the 4 local pharmacies and relayed to the investigators.

RESULTS

In total, 149 delayed antibiotic prescriptions were written, 1 per patient. Of the 74 usual delayed prescriptions given out, 32 (43.2%) were filled; of the 75 postdated delayed prescriptions given out, 33 (44.0%) were filled. Sixteen patients from each group filled their delayed prescriptions earlier than the recommended 48 hours. Statistical analyses-χ² tests to compare the rates of antibiotic use between the 2 groups and t tests to compare the mean time to fill the prescription between the 2 groups-indicated that these results were not significant (P > .05).

CONCLUSION

Although delayed prescriptions reduce the rate of antibiotic use, postdating the delayed prescription does not seem to lead to further reduction in use.

Can They Keep Going on Their Own? A Four-Year Randomized Trial of Functional Assessments of Community Residents

Objectives:Are people 75 or over enabled to stay at home longer through annual assessments and referrals to health/social services than through assessments only or without assessments?

Design:randomized controlled trial

Participants:520 people 75 or over living in their own homes

Intervention:Four annual RAI-HC computerized functional assessments. Intervention group 1: elders and primary caregivers received the results and were invited to take appropriate actions. Intervention group 2: elders and primary caregivers were offered referrals to health/social services.

Measurements/Outcomes:death, institutionalization, home care services, RAI-HC scores, self-rated health, perceived self-efficacy, caregiver burden

Results:By the end of the study, annual functional assessment and offers of referrals to health/social services led to a greater use of home care (6.3%) than did assessment alone (1.8%), but there were no significant differences in death rates, institutionalization, perceived self-efficacy, self-rated health status, or caregiver burden scores between groups.

Conclusion:We discovered that this was a group of healthy seniors. Multi-dimensional functional assessment is time- and labour-intensive and should be targeted at the minority of least self-reliant seniors.

Herpes labialis

INTRODUCTION

Herpes simplex virus type 1 infection usually causes a mild, self-limiting painful blistering around the mouth, with 20% to 40% of adults affected at some time. Primary infection usually occurs in childhood, after which the virus is thought to remain latent in the trigeminal ganglion. Recurrence may be triggered by factors such as exposure to bright light, stress, and fatigue.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of antiviral treatments for the first attack of herpes labialis? What are the effects of interventions aimed at preventing recurrent attacks of herpes labialis? What are the effects of treatments for recurrent attacks of herpes labialis? We searched: Medline, Embase, The Cochrane Library, and other important databases up to February 2009 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 27 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: oral antiviral agents, sunscreen, topical anaesthetic agents, topical antiviral agents, and zinc oxide cream.

Diagnosing streptococcal sore throat in adults: randomized controlled trial of in-office aids

OBJECTIVE

To determine whether use of clinical decision rules or rapid streptococcal antigen detection tests (alone or in combination) can lower the number of unnecessary prescriptions for antibiotics for adults with acute sore throats.

DESIGN

Four-arm randomized controlled trial.

SETTING

Family practice offices in eastern Newfoundland.

PARTICIPANTS

Forty urban and suburban family practitioners.

INTERVENTIONS

Participants were randomly assigned to one of 4 arms (usual practice, decision rules only, rapid antigen test only, decision rules and antigen test combined), and each recruited successive adult patients presenting with acute sore throat as their main symptom. Following usual care or use of decision rules or rapid antigen tests or both (where applicable), physicians were to record what they prescribed for each patient.

MAIN OUTCOME MEASURES

Prescribing rates and types of antibiotics prescribed.

RESULTS

The prescribing rate using decision rules (55%) did not differ significantly from the rate using usual clinical practice (58%). Physicians using rapid antigen tests, both alone and with decision rules, had significantly lower prescribing rates (27% and 38%, respectively, both P < .001).

CONCLUSION

Evidence-based clinical decision rules alone do not change family doctors' prescribing behaviour. Use of rapid antigen tests might allow physicians to persuade patients that negative results (and hence, viral infection) mean antibiotic therapy is not required.

Herpes labialis

INTRODUCTION

Herpes simplex virus type 1 infection usually causes a mild, self-limiting painful blistering around the mouth, with 20-40% of adults affected at some time. Primary infection usually occurs in childhood, after which the virus is thought to remain latent in the trigeminal ganglion. Recurrence may be triggered by factors such as exposure to bright light, stress, and fatigue.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of antiviral treatments for the first attack of herpes labialis? What are the effects of interventions aimed at preventing recurrent attacks of herpes labialis? What are the effects of treatments for recurrent attacks of herpes labialis? We searched: Medline, Embase, The Cochrane Library and other important databases up to April 2006 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 25 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: oral antiviral agents (acyclovir, and valaciclovir), sunscreen, topical anaesthetic agents, topical antiviral agents (acyclovir, and penciclovir), and zinc oxide cream.

Continuity of care for older patients in family practice: how important is it?

OBJECTIVE

To examine the evidence that continuity of primary care is important for older people with chronic diseases.

DATA SOURCES

MEDLINE, EMBASE and CINAHL were searched from January 1970 to June 2005 for original articles in English that examined the relationship between interpersonal continuity of patient care and health outcomes of people 50 years old and older. Articles found were reviewed and analyzed by both authors to assess the strength of study design and the quality of the evidence provided.

STUDY SELECTION

We used the search terms "continuity of patient care," "elderly," "primary care," and "outcomes." Criteria from the Canadian Task Force on Preventive Health Care were used to assess the quality of studies; only studies providing levels I to III evidence were included in this review.

SYNTHESIS

Of 7563 articles found, we chose 99 studies (and 27 other studies cited in them) by studying their abstracts. Assessment of these 126 studies indicated that only 5 were of good quality and relevant to the inquiry. Two of these 5 were randomized controlled trials, and 3 were observational studies.

CONCLUSION

Although the literature on continuity of care generally suggests that continuity of interpersonal primary care is important and beneficial, specific evidence that it is beneficial for elderly people is scanty. There is a need for well designed studies to investigate this issue.

Inappropriate use of antibiotics for acute respiratory tract infections in a rural emergency department

INTRODUCTION

Evidence-based reviews and guidelines recommend lowering antibiotic prescription rates for acute respiratory tract infections (ARIs).

OBJECTIVE

To determine the number of patients presenting with uncomplicated ARIs at the walk-in emergency department (ED) of a rural community health centre and to determine the antibiotic prescription rate for each type of ARI.

METHODS

A one-year retrospective data collection of a rural ED was carried out using MEDITECH and chart review to determine numbers of patients presenting with an ARI; antibiotic prescriptions were recorded according to ARI diagnosis.

RESULTS

ARIs accounted for 22% of all patients seen by the ED doctor. In 57% of the ARIs diagnosed, patients were prescribed an antibiotic. Individual rates ranged from 2% for influenza to 100% for pneumonia. A breakdown of rates for each type of ARI is provided.

CONCLUSIONS

Antibiotic prescription rates for ARIs remain high, with some ARIs being more inappropriately managed than others. The rate of patients presenting with ARIs to the study ED was higher than in some other EDs, possibly reflecting the problems of recruiting and retaining family doctors in many rural areas, including ours.

Inhaler therapy. What it means for children with asthma

OBJECTIVE

To investigate what inhaler therapy means for children with asthma and to identify problems and concerns children experience with inhalers.

DESIGN

Qualitative research design.

SETTING

A community-based family practice in rural Newfoundland.

PARTICIPANTS

Seventeen children, aged 5 to 16, who had been diagnosed with mild or moderate asthma and were being prescribed inhaled steroids or bronchodilators.

METHOD

Two in-depth interviews with each of a purposive sample of participants were analyzed by the selective or highlighting approach.

MAIN FINDINGS

Common positive themes were identified: inhalers were easy to use, and medication was necessary for good quality of life. Common negative themes were simply forgetting, inconvenient and annoying, only-as-needed approach, medication does not work well anyway, and side effects.

CONCLUSION

Inhaler therapy had both positive and negative meaning for children. Although inhaled medications were seen as very important for good quality of life when taken regularly, most children wanted to use them only as needed for symptom control. Children knew the importance of inhaler therapy but still complied poorly.

One hundred earaches. Family practice case series

OBJECTIVE

To examine whether watchful waiting was an appropriate strategy for patients with earache, when there was no clear indication to prescribe antibiotics at the first visit.

DESIGN

Case series of consecutive patients with unilateral earache.

SETTING

Rural family practice clinic and walk-in centre.

PARTICIPANTS

One hundred patients with unilateral earache.

INTERVENTIONS

Patients who clearly needed antibiotic treatment were given it; others were advised about symptom relief and were followed up as necessary.

MAIN OUTCOME MEASURES

Whether patients returned to the clinic, and whether antibiotics were subsequently prescribed.

RESULTS

Two patients were prescribed antibiotics at the first visit. Of the remaining 98 people, only four returned to the clinic because of earache, and two of these were prescribed antibiotics. Thus, of 100 people with earache, four received antibiotic prescriptions.

CONCLUSIONS

Most people who present to primary care physicians with earache do not need antibiotics for what appears to be a mostly self-limiting condition. Both physicians and patients should be educated about this.

No psychiatry? Assessment of family medicine residents' training in mental health issues

OBJECTIVE

To assess whether the mental health component of the family medicine residency program at Memorial University of Newfoundland, which contains no formal mental health training with psychiatrists, adequately prepares residents for practice, and to assess which aspects of their training enhanced their mental health skills most.

DESIGN

Cross-sectional mailed survey.

SETTING

A 2-year family practice residency program with a focus on training for rural practice offering integrated and eclectic multidisciplinary mental health training rather than formal psychiatry experience.

PARTICIPANTS

Graduates of the family practice residency program, 1990 to 1995. Completed questionnaires were returned by 62 of 116 physicians.

MAIN OUTCOME MEASURE

Confidence of respondents in dealing with 23 mental health problems.

RESULTS

Respondents felt prepared to address most of the mental health needs of their patients. Higher levels of confidence were associated with lower referral rates. There was no significant relationship between time spent in practice and confidence in dealing with mental health problems. Graduates' confidence correlated with areas in the program identified as strong.

CONCLUSIONS

The program appears to train family doctors effectively to meet the mental health needs of their patients.

Effectiveness of an educational strategy to improve family physicians' detection and management of depression: a randomized controlled trial

BACKGROUND

Depression, a common disorder often treated by family physicians, may be both underdiagnosed and undertreated. The objective of this study was to determine whether the diagnosis and treatment of depression by family physicians could be improved through an educational strategy.

METHODS

In this study, conducted between July and December 1997, 42 family physicians in Newfoundland were randomly assigned to an intervention group (3-hour case-based educational session on clinical practice guidelines [CPGs] for depression and access to a psychiatrist for consultation) or to a control group (receipt of CPGs without educational session or access to the psychiatrist). Physicians were asked to keep a log of patients with newly diagnosed depression and to record information on severity of depression, medications and referrals to mental health professionals. Patients were asked to complete the Centre for Epidemiologic Studies Depression (CES-D) scale before treatment and after 6 months of follow-up. The primary outcome measure was the "gain" score (difference between first and last CES-D scores).

RESULTS

During the study period physicians in the intervention group diagnosed 91 new cases of depression (mean 4.1 per physician) and those in the control group diagnosed 56 (mean 2.8 per physician); the difference was not significant. Most patients (91.2% in the intervention group and 89.3% in the control group received a prescription for an antidepressant on their first visit. Similar proportions (46.2% in the intervention group and 37.5% in the control group) took their medication for the full 6 months; however, significantly more patients in the intervention group were taking an antidepressant at the 6-month follow-up (56% v. 39.3%, p = 0.02). The mean number of visits per patient was similar in the 2 groups (7.7 in the intervention group and 7.6 in the control group). Physicians in the intervention group consulted the psychiatrist 9 times. The overall rate of referrals to psychiatrists and other mental health professionals was 10.9%; however, referrals were significantly higher in the intervention group (15.4% v. 3.5%, p = 0.05). After 6 months of follow-up, a significant difference in gain scores was detected between the intervention and control groups for both the patient's self-rated CES-D scores (mean gain score 19.3 v. 15.5 respectively, p = 0.04) and the physicians' ratings of depression severity before treatment and at 6 months (mean gain 1.1 v. 0.7 respectively, p = 0.02).

INTERPRETATION

The educational strategy had a modest beneficial effect on the outcomes of patients with depression, but there are still concerns regarding the low rates of drug treatment and referral to mental health professionals by family physicians.

Clinical practice guidelines: questions family physicians should ask themselves

Family physicians increasingly are being pressured to use clinical practice guidelines. This article reviews the methods of developing, disseminating and implementing guidelines, and suggests a list of questions that family physicians should ask themselves before accepting any clinical practice guidelines.

Are rural general practitioner--obstetricians performing too many prenatal ultrasound examinations? Evidence from western Labrador

OBJECTIVE

To determine the frequency of prenatal ultrasonography (PNU) in western Labrador in 1994, assess the appropriateness of the ultrasound examinations according to current guidelines and determine whether there was any relation between number of PNU examinations and patient management and obstetric outcomes.

DESIGN

Review of all obstetric charts and PNU requisition forms for all deliveries in one hospital in 1994.

SETTING

Labrador City and Wabush, Newfoundland.

RESULTS

During the study period, there were 103 singleton deliveries, and these mothers underwent a total of 225 PNU studies (mean 2.16 studies per delivery). More than half (53.3%) of the examinations were classified as inappropriate. There were no significant differences in the number of studies between low- and high-risk pregnancies or between uncomplicated deliveries and those in which induction or instrumental or operative delivery occurred, nor was there any relation between number of PNU examinations and maternal or neonatal outcome.

CONCLUSION

Compared with PNU use as recommended by the Canadian Task Force on the Periodic Health Examination, this type of examination was overused in Labrador City and Wabush, although the rate of use was comparable to that reported in other Canadian studies. This overuse was not associated with any identifiable effect on maternal or neonatal outcome or on the management of pregnancy and labour. More judicious use of PNU, in accordance with evidence-based guidelines, is recommended.