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...on Primary Care
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www.ProjectCork.org
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Winter 2006
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Use of laboratory markers and the AUDIT questionnaire by primary care physicians to detect alcohol abuse by patients.
Aalto M; Seppa K. Alcohol and Alcoholism 40(6): 520-523, 2005. (14 refs.)
Aims: To evaluate how often laboratory markers [Mean corpuscular volume (MCV), Gamma-glut-amyl transferase, Aspartate aminotransferase, Alanine aminotransferase, or Carbohydrate-deficient transferrin (CDT)] and the Alcohol Use Disorders Identification Test (AUDIT) are used to detect alcohol abuse in primary health care. Methods: Cross-sectional self-administered questionnaire survey to all 3193 primary health care physicians in Finland. Response rate was (65.7%). Results: CDT was used at least occasion-ally by 43.4% of the physicians. Corresponding figures were 53.4% for conventional alcohol laboratory markers (MCV, transaminases) and 67.0% for AUDIT. Almost all the respondents used some laboratory marker to detect alcohol abuse. The use of brief alcohol intervention was associated with the greater likelihood that a physician uses different methods to detect alcohol abuse. The data also indicates that gender, age, and having a specialist licence influence activity in using different methods. Conclusions: Considering the ambivalences in relation to alcohol issues in health care, the use of CDT and AUDIT are reasonably frequent. This may indicate that tools to facilitate the work may also help in adapting new activities. Copyright 2005, Medical Council on Alcoholism.
Experiences of occupational violence in Australian urban general practice: A cross-sectional study of GPs.
Magin PJ; Adams J; Sibbritt DW; Joy E; Ireland MC. Medical Journal of Australia 183(7): 352-356, 2005. (19 refs.)
Objective: To establish the prevalence and char-acteristics of occupational violence in Australian urban general practice, and examine practitioner correlates of violence. Design, setting and participants: Cross-sectional questionnaire survey mailed to all members (n = 1085) of three urban divisions of general practice in New South Wales in August and September 2004. The three divisions were chosen to provide a range of socioeconomic status (SES) demographics. Main outcome measures: Occupational violence towards general practitioners during the previous 12 months. Results: 528 GPs returned question-naires (49% response rate). Of these, 63.7% had experienced violence in the previous year. The most common forms of violence were "low level" violence - verbal abuse (42.1%), property damage/theft (28.6%) and threats (23.1 %). A smaller proportion of GPs had experienced "high level" violence, such as sexual harassment (9.3%) and physical abuse (2.7%). On univariate analysis, violence was significantly more likely towards female GPs (P< 0.001), less experienced GPs (P= 0.003) and GPs working in a lower SES status area (P< 0.001), and among practice populations encompassing greater social disadvantage (P= 0.006), mental health problems (P< 0.001), and drug- and alcohol-related problems (P< 0.001). Experience of violence was greater for younger GPs (P= 0.005) and those providing after-hours care (P= 0.033 for after-hours home visits). On multivariate analysis, a significant association persisted between high level violence and lower SES area (odds ratio [OR], 2.86), being female (OR, 5.87), having practice populations with more drug-related problems (OR, 5.77), and providing home visits during business hours (OR, 4.76). More experienced GPs encountered less violence (OR, 0.77) for every additional 5 years of practice. Conclusion: Occupational violence is a considerable problem in Australian urban general practice. Formal education programs in prevent-ing and managing violence would be appropriate for GPs and doctors-in-training. Copyright 2005, Australasian Medical Publishing Co. Ltd.
Risk factors for adverse perinatal outcomes in imprisoned pregnant women: A systematic review.
Knight M; Plugge E. BMC Public Health 5: ar 111, 2005. (24 refs.)
Background: Imprisoned pregnant women constitute an important obstetric group about whom relatively little is known. This systematic review was conducted to identify the risk factors associated with adverse pregnancy outcome present in this group of women. Methods: The review was conducted according to a prespecified protocol. Studies of any design were included if they described information on any of the pre-specified risk factors. We calculated the results as summary percentages or odds ratios where data was available on both cases and population controls. Results: The search strategy identified 27 relevant papers of which 13 met the inclusion criteria, involving 1504 imprisoned pregnant women and 4571 population control women. Imprisoned women are more likely to be single, from an ethnic minority, and not to have completed high school. They are more likely to have a medical problem which could affect the pregnancy outcome and yet less likely to receive adequate antenatal care. They are also more likely to smoke, drink alcohol to excess and take illegal drugs. Conclusion: Imprisoned women are clearly a high risk obstetric group. These findings have important implications for the provision of care to this important group of women. Copyright 2005, Biomedical Central Ltd.
Recruitment of physician offices for an office-based adolescent smoking cessation study.
McIntosh S; Ossip-Klein DJ; Hazel-Fernandez L; Spada J; McDonald PW; Klein JD. Nicotine & Tobacco Research 7(3): 405-412, 2005. (15 refs.)
Physician office settings play an important role in tobacco cessation intervention. However, few tobacco cessation trials are conducted at these sites, in part because of the many challenges associated with recruiting community physician offices into research. The present study identified and implemented strategies for recruiting physician offices into a randomized clinical trial of tobacco screening and cessation interventions with adolescent patients. A total of 30 community physicians participated in focus groups to elicit their perceptions of facilitators of and barriers to initial engagement of physician practices and the subsequent enrollment of the practices in long-term research projects. Physicians identified facilitators such as (a) the involvement of office staff in the recruitment process and (b) on-site presentations of the study's background and aims. Some of the barriers identified were time commitment concerns and the lack of incentives in exchange for participation. These focus group findings were then integrated with theory-based and empirically driven recruitment strategies for a 12-month randomized tobacco intervention trial with adolescent patients. Of 185 office practices approached to participate (screened from a pool of 273 practices), 103 agreed to on-site presentations of the study. Subsequently, almost all of the practices (101) that received the presentation agreed to enroll in the study. Conclusions are that (a) recruitment is a multicomponent process, (b) the processes of communication, engagement, and enrollment must be carefully planned and implemented to achieve maximal results, and (c) the development of effective strategies for recruiting health care provider practices presents an important infrastructure for testing adolescent smoking cessation interventions. Copyright 2005, Taylor & Francis, Ltd.
Impact of insurance coverage on the use and effects of smoking cessation medications.
Solberg LI. Disease Management & Health Outcomes 13(3): 151-157, 2005. (49 refs.)
Tobacco use is not only the chief preventable cause of death, but it is also a very important contributor to the cause or complications of most chronic diseases. Therefore, facilitating smoking cessation should be very important to more effective disease management. Well-accepted, evidence-based guidelines describe effective clinical actions in support of smoking cessation; however, they are not followed as well as desired. This article focuses on the question of whether health insurance coverage for cessation med-ications (one of the effective actions) is important for their use and effectiveness. Although there have been accelerating calls from advocates for this coverage and a parallel increase in health plans and government programs providing such coverage, the evidence base is both recent and limited. Three major studies now suggest that coverage or cost sharing may only be effective when combined with extraordinary efforts to ensure that smokers are aware of the benefit and can access it easily. However, it is unclear whether many payors are willing to do that. Chronic disease management programs should definitely be focusing on whatever they can do to encourage smoking cessation. There is good evidence that repeated advice and support (and pharmacotherapy) from a variety of healthcare professionals is effective, especially when it is combined with the other care that patients receive. Since few other patient behaviors contribute as much to the causes and complications of most chronic diseases, great emphasis should be placed on changing this one. Copyright 2005, Adis International Ltd.
Five-year trajectories of health care utilization and cost in a drug and alcohol treatment sample.
Parthasarathy S; Weisner CM. Drug and Alcohol Dependence 80(2): 231-240, 2005. (57 refs.)
Background: The study examined the effect of individual characteristics on longitudinal patterns of health care utilization and cost among individuals entering chemical dependency (CD) treatment. Method: Structured interviews and computerized administrative databases were linked to obtain severity, utilization and cost data. Total medical costs and their components were examined for the 6 months prior to intake through 5 years post-intake. Statistical analyses were conducted using the hierarchical linear modeling framework. Results: Age was positively cor-related with total medical costs. Women had higher inpatient utilization and higher inpatient, primary care and total cost at baseline (p <.05). However, they had steeper decline in primary care costs. While age was not related to inpatient and ER use at baseline (after controlling for psychiatric and medical severity), older individuals had smaller declines in hospital days and inpatient cost over time. Individuals with high medical and psychiatric severity had higher utilization and costs (p <.01). Those who were abstinent had higher costs. Conclusions: There are important differences in patient characteristics and treatment outcomes that influence utilization and cost trajectories. The relationship between medical severity at intake and primary care cost pre-intake among patients with drug and alcohol problems suggests an opportunity to identify and treat drug and alcohol problems in primary care settings. It also suggests that medical evaluations and treatment should not be overlooked during CD treatment. The positive association between abstinence and trajectories of primary care and total medical costs suggests that maintaining abstinence over a long term requires some kind of continuing care either in primary care settings or via additional contacts with specialty CD departments. Copyright 2005, Elsevier Ireland Ltd.
Brief report: Buprenorphine retention in primary care.
Stein MD; Cioe P; Friedmann PD. Journal of General Internal Medicine 20(11): 1038-1041, 2005. (17 refs.)
BACKGROUND: This study assesses the rate and predictors of treatment retention for primary care patients with opioid dependence-prescribed buprenorphine, a long-acting partial opioid agonist. METHODS: Observational cohort study of patients prescribed buprenorphine/naloxone and followed for 6 months in the period after the adoption of buprenophine/naloxone by a primary care practice in Rhode Island. Practice policy precluded patient discharges due to continuing drug use. RESULTS: Patients (n=41) had a mean duration of opioid use of 15.7 years and most had a history of heroin use (63.4%). Thirty-nine percent of patients transferred from methadone maintenance. At 24 weeks, 59% remained in treatment. Nearly half of dropouts occurred in the first 30 days. Participants with opiate-positive toxicologies at week 1 were more likely to drop out of the program (P <.01) and had a significantly shorter retention time (P <.01) on average. Among other drug use and drug treatment variables, employment and addiction counseling during treatment were significantly associated with treatment retention (P=.03). CONCLUSIONS: Retention rates in a real world, primary care-based buprenorphine maintenance practice reflect those reported in clinical trials. Abstinence during the first week of treatment and receipt of counseling were critical to patient retention. Copyright 2005, Blackwell Science Ltd.
An evaluation of an intervention to assist primary care physicians in screening and educating older patients who use alcohol.
Fink A; Elliott MN; Tsai M; Beck JC. Journal of the American Geriatrics Society 53(11): 1937-1943, 2005. (49 refs.)
To evaluate whether providing physicians and older patients with personalized reports of drinking risks and benefits and patient education reduces alcohol-related risks and problems. Prospective comparison study. Community primary care. Twenty-three physicians and 665 patients aged 65 and older. Combined report, in which six physicians and 212 patients received reports of patients' drinking classifications and patients also received education; patient report, in which 245 patients received reports and education, but their five physicians did not receive reports; and usual care. Assessments at baseline and 12 months later to determine patients' nonhazardous (no known risks), hazardous (risks for problems), or harmful (presence of problems) classifications using the Computerized Alcohol-Related Problems Survey (CARPS). The CARPS contains a scanned screening measure and scoring algorithms and automatically produces patient and physician reports and patient education. At baseline, 21% were harmful drinkers, and 26% were hazardous drinkers. The patient report and combined report interventions were each associated with greater odds of lower-risk drinking at follow-up than usual care (odds ratio=1.59 and 1.23, respectively, P <.05 for each). The patient report intervention significantly reduced harmful drinking at follow-up from an expected 21% in usual care to 16% and increased nonhazardous drinking from 52% expected in usual care to 58%. Patients in the combined report intervention experienced a significantly greater average decrease in quantity and frequency. Older primary care patients can effectively reduce their alcohol consumption and other drinking risks when given personalized information about their drinking and health. Copyright 2005, Blackwell Publishing.
General practitioners' and family physicians' negative beliefs and attitudes towards discussing smoking cessation with patients: A systematic review. (review).
Vogt F; Hall S; Marteau TM. Addiction 100(10): 1423-1431, 2005. (57 refs.)
Objective: To estimate the proportion of general practitioners (GPs) and family physicians (FPs) with negative beliefs and attitudes towards discussing smoking cessation with patients. Methods: A systematic review. Study selection: All studies published in English, in peer-reviewed journals, which allowed the extraction of the proportion of GPs and FPs with negative beliefs and attitudes towards discussing smoking cessation. Data synthesis: Negative beliefs and attitudes were extracted and categorised. Proportions were synthesized giving greater weight to those obtained from studies with larger samples. Those assessed in two or more studies are reported. Results: Across 19 studies, eight negative beliefs and attitudes were identified. While the majority of GPs and FPs do not have negative beliefs and attitudes towards discussing smoking with their patients, a sizeable minority do. The most common negative beliefs were that such discussions were too time-consuming (weighted proportion: 42%) and were ineffective (38%). Just over a quarter (22%) of physicians reported lacking confidence in their ability to discuss smoking with their patients, 18% felt such discussions were unpleasant, 16% lacked confidence in their knowledge, relatively few considered discussing smoking outside of their professional duty (5%), or that it intruded upon patients' privacy (5%), or discussion were inappropriate (3%). Conclusion: In addition to providing skills training, interventions to increase the implementation of smoking cessation interventions by primary care physicians may be more effective if they address a range of commonly held negative beliefs and attitudes towards discussing smoking cessation. These include beliefs and values that influence primary care physicians' judgements about whether discussing smoking is an effective use of their time. Copyright 2005, Society for Study of Addiction to Alcohol and Other Drugs
Attitudes of Swedish general practitioners and nurses to working with lifestyle change, with special reference to alcohol consumption.
Geirsson M; Bendtsen P; Spak F. Alcohol and Alcoholism 40(5): 388-393, 2005. (30 refs.)
Aims: To explore the attitudes of Swedish general practitioners (GPs) and nurses to secondary alcohol prevention (early identification of, and intervention for, alcohol-related problems) and compare it to their attitudes to other important lifestyle behaviours such as smoking, stress, exercise, and overweight. Methods: An adjusted version of The WHO Collaborative Study Questionnaire for General Practitioners was posted to all GPs and nurses in the County of Skaraborg, Sweden; 68 GPs and 193 nurses responded. Results: The importance of drinking alcohol moderately, counselling skills on reducing alcohol consumption and perceived current effectiveness in helping patients change lifestyle behaviours ranked lower than working with all the other lifestyle behaviours. The nurses rated their potential effectiveness in helping patients change lifestyle higher than that of GPs for all the lifestyle behaviours. Nurses receiving more alcohol-related education had more positive attitudes than nurses with less education. For alcohol, the GPs assessed their role adequacy, role legitimacy and motivation higher than that of the nurses. The main obstacles for the GPs to carry out alcohol intervention were lack of training in counselling for reducing alcohol consumption, time constraints, and the fact that the doctors did not know how to identify problem drinkers who have no obvious symptoms of excess consumption. Conclusion: GPs and the nurses estimated their alcohol-related competence as lower than working with many other health-related lifestyles. These results can be explained by lack of practical skills, lack of training in suitable intervention techniques, and unsupportive working environments. All these elements must be considered when planning secondary alcohol prevention programs in primary health care. Copyright 2005, Oxford University Press.
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