Bohumil Seifert

The expanding role of primary care in cancer control

The nature of cancer control is changing, with an increasing emphasis, fuelled by public and political demand, on prevention, early diagnosis, and patient experience during and after treatment. At the same time, primary care is increasingly promoted, by governments and health funders worldwide, as the preferred setting for most health care for reasons of increasing need, to stabilise health-care costs, and to accommodate patient preference for care close to home. It is timely, then, to consider how this expanding role for primary care can work for cancer control, which has long been dominated by highly technical interventions centred on treatment, and in which the contribution of primary care has been largely perceived as marginal. In this Commission, expert opinion from primary care and public health professionals with academic and clinical cancer expertise—from epidemiologists, psychologists, policy makers, and cancer specialists—has contributed to a detailed consideration of the evidence for cancer control provided in primary care and community care settings. Ranging from primary prevention to end-of-life care, the scope for new models of care is explored, and the actions needed to effect change are outlined. The strengths of primary care—its continuous, coordinated, and comprehensive care for individuals and families—are particularly evident in prevention and diagnosis, in shared follow-up and survivorship care, and in end-of-life care. A strong theme of integration of care runs throughout, and its elements (clinical, vertical, and functional) and the tools needed for integrated working are described in detail. All of this change, as it evolves, will need to be underpinned by new research and by continuing and shared multiprofessional development.

Epidemiology of Helicobacter pylori Infection in the Czech Republic

Background:  Prevalence of Helicobacter pylori infection has been estimated to range from 60 to 95% in the former communist countries of Central and Eastern Europe. The aim of this study was to evaluate H. pylori infection prevalence in a representative sample of the Czech population. The second objective was to describe difference of H. pylori prevalence between different social groups of children and adults.

Perspectives of family medicine in Central and Eastern Europe.

INTRODUCTION In the last decade of the 20th century, the countries of Central and Eastern Europe (CEE) have experienced rapid changes in health policies. This process was largely supported by international grants. After this support has ended, it is important to keep up with the development, developing its own strategies and priorities. Aims and methods. The aim of the paper is to make a proposal for the future development of the discipline in CEE countries. The proposal is based on reports on an invitational conference that was organized for the key representatives of family medicine from CEE countries. For the purpose of this paper, additional information about the situation was gathered from literature reviews, country visits and personal interviews. RESULTS Information shows that although family medicine has been formally recognized and introduced in university curricula, there is a very big difference in its academic position. Postgraduate training has been established in all CEE countries, according to the European Directive. Quality measures such as the development and implementation of guidelines and the re-certification procedure have also been formally introduced, but its quality varies. The key areas of concern are atomization of practices, unsatisfactory payment systems, lack of academic infrastructure and unsatisfactory continuous professional development. On the other hand, examples of good practice exist and need to be promoted. CONCLUSION There is a need for continuous exchange of expertise within the countries. The paper will serve as a discussion paper for the next meeting of experts from CEE countries.

Family medicine in post-communist Europe needs a boost. Exploring the position of family medicine in healthcare systems of Central and Eastern Europe and Russia

BackgroundThe countries of Central and Eastern Europe have experienced a lot of changes at the end of the 20th century, including changes in the health care systems and especially in primary care. The aim of this paper is to systematically assess the position of family medicine in these countries, using the same methodology within all the countries.MethodsA key informants survey in 11 Central and Eastern European countries and Russia using a questionnaire developed on the basis of systematic literature review.ResultsFormally, family medicine is accepted as a specialty in all the countries, although the levels of its implementation vary across the countries and the differences are important. In most countries, solo practice is the most predominant organisational form of family medicine. Family medicine is just one of many medical specialties (e.g. paediatrics and gynaecology) in primary health care. Full introduction of family medicine was successful only in Estonia.ConclusionsSome of the unification of the systems may have been the result of the EU request for adequate training that has pushed the policies towards higher standards of training for family medicine. The initial enthusiasm of implementing family medicine has decreased because there was no initiative that would support this movement. Internal and external stimuli might be needed to continue transition process.

The management of common gastrointestinal disorders in general practice A survey by the European Society for Primary Care Gastroenterology (ESPCG) in six European countries.

BACKGROUND Gastrointestinal (GI) disorders account for 10% of all consultations in primary care. Little is known about the management of GI disorders by general practitioners (GP) across different European countries. AIM AND METHODS We undertook a postal survey of randomly selected samples of GPs in six European countries (UK, Holland, Spain, Greece, Poland, Czech Republic) to determine patterns of diagnosis, management and service use in GI disorders. RESULTS We received 939 responses, response rate 32%. Over 80% of GPs were aware of at least three national guidelines for gastrointestinal disease. The availability of open access endoscopy ranged from 28% (Poland) to over 80% (Holland, Czech and UK). For uninvestigated dyspepsia the preferred first line management was proton pump inhibitor therapy (33-82%), Helicobacter pylori test and treat (19-47%), early endoscopy (5-32%), specialist referral (2-21%). Regarding irritable bowel syndrome, 23% of respondents were familiar with one or more diagnostic criteria, but between 7% (Netherlands) and 32% (Poland) would ask for a specialist opinion before making the diagnosis. CONCLUSION The wide variation between GPs both between and within countries partly reflects variations in health care systems but also differing levels of knowledge and awareness, factors which are relevant to educational and research policy.

Significant decrease in prevalence of Helicobacter pylori in the Czech Republic

AIM To study possible decrease in prevalence of Helicobacter pylori (H. pylori) infection in the Czech Republic within a 10-year period. METHODS A total of 22 centres entered the study. The catchment areas of these centres covered cities and towns with more than 20,000 inhabitants, smaller towns (≤ 20,000 inhabitants) with surrounding villages and rural areas, and were spread over the whole country, corresponding well to the geographical distribution of the Czech population. A total of 1,837 subjects (aged 5-98 years) took part in the study, randomly selected out of 38,147 people from the general population. H. pylori infection was investigated by means of a (13)C-urea breath test. Breath samples in duplicates were analysed using isotope ratio mass spectrometry. The cut-off point was 3.5. Social and demographic characteristics were based on data from self-completed questionnaires. RESULTS The overall prevalence of H. pylori infection was 23.5% (430/1826), and 4.8% (20/420) in children aged 15 or less. There was no statistically significant difference in prevalence between males (24.3%; 208/857) and females (22.9%, 222/969, P = 0.494). H. pylori infection was strongly associated with higher age, among subjects aged 55+ years, prevalence of H. pylori infection was 39.8% (252/633, P < 0.001). The highest prevalence of H. pylori infection was found among persons aged 55-64 years (43.9%, 97/221) and 75+ years (37.9%, 58/153). Among study subjects aged 15+ years, prevalence of H. pylori infection was significantly increased in those with lowest education (odds risk 3.19, 95% CI 1.87-5.47). Compared to never married (14.1%), the prevalence of H. pylori infection was statistically significantly higher among married (35.4%, 246/694, P < 0.001), divorced (36.8%, 49/133, P < 0.001) and widowed study subjects (40.2%, 45/112, P < 0.001), both in minimally and fully adjusted analysis. There was no significant difference in the prevalence of H. pylori infection between married and widowed subjects (35.4%, 246/694 vs 40.2%, 45/112, P = 0.389). There was little variation in smoking prevalence across categories of smoking and there was no evidence of an increased risk of H. pylori infection among current or past smokers in our data (odds risk 1.04 with 95% CI 0.78-1.40 for current smokers; odds ratio 0.83 with 95% CI 0.60-1.16 for former smokers). The current prevalence of H. pylori in 2011 was significantly lower compared to the prevalence reported from identical geographical areas in 2001 (23.5% vs 41.7%, P < 0.001). CONCLUSION The overall prevalence of H. pylori infection in the general population has fallen substantially in the Czech Republic over the past 10 years.

Colorectal cancer screening: 20 years of development and recent progress

Colorectal cancer (CRC) is the second most common cancer in Europe and its incidence is steadily increasing. This trend could be reversed through timely secondary prevention (screening). In the last twenty years, CRC screening programs across Europe have experienced considerable improvements (fecal occult blood testing; transition from opportunistic to population based program settings). The Czech Republic is a typical example of a country with a long history of nationwide CRC screening programs in the face of very high CRC incidence and mortality rates. Each year, approximately 8000 people are diagnosed with CRC and some 4000 die from this malignancy. Twenty years ago, the first pilot studies on CRC screening led to the introduction of the opportunistic Czech National Colorectal Cancer Screening Program in 2000. Originally, this program was based on the guaiac fecal occult blood test (FOBT) offered by general practitioners, followed by colonoscopy in cases of FOBT positivity. The program has continuously evolved, namely with the implementation of immunochemical FOBTs and screening colonoscopy, as well as the involvement of gynecologists. Since the establishment of the Czech CRC Screening Registry in 2006, 2405850 FOBTs have been performed and 104565 preventive colonoscopies recorded within the screening program. The overall program expanded to cover 25.0% of the target population by 2011. However, stagnation in the annual number of performed FOBTs lately has led to switching to the option of a population-based program with personal invitation, which is currently being prepared.

The development of academic family medicine in central and eastern Europe since 1990

BackgroundSince the early 1990s former communist countries have been reforming their health care systems, emphasizing the key role of primary care and recognizing family medicine as a specialty and an academic discipline. This study assesses the level of academic development of the discipline characterised by education and research in central and eastern European (CEE) countries.MethodsA key informants study, using a questionnaire developed on the basis of a systematic literature review and panel discussions, conducted in 11 central and eastern European countries and Russia.ResultsFamily medicine in CEE countries is now formally recognized as a medical specialty and successfully introduced into medical training at undergraduate and postgraduate levels. Almost all universities have FM/GP departments, but only a few of them are led by general practitioners. The specialist training programmes in all countries except Russia fulfil the recommendations of the European Parliament. Structured support for research in FM/GP is not always available. However specific scientific organisations function in almost all countries except Russia. Scientific conferences are regularly organised in all the countries, but peer-reviewed journals are published in only half of them.ConclusionsFamily medicine has a relatively strong position in medical education in central and eastern Europe, but research in family practice is less developed. Although the position of the discipline at the universities is not very strong, most of the CEE countries can serve as an example of successful academic development for countries southern Europe, where family medicine is still not fully recognised.

Systematic review: the perceptions, diagnosis and management of irritable bowel syndrome in primary care – A Rome Foundation Working Team Report

To review studies on the perceptions, diagnosis and management of irritable bowel syndrome (IBS) in primary care.

Prevalence and sociodemographic determinants of uninvestigated dyspepsia in the Czech Republic

Objective There are no data on the epidemiology of dyspepsia in Central Europe. The aim of this study was to evaluate the prevalence of uninvestigated dyspepsia in a representative sample of the Czech population. Methods A total of 2509 persons, aged 5–100 years, randomly selected from 30 012 individuals in the general population, entered this multicentre, prospective, questionnaire-based epidemiological study. Results We found a 17% prevalence of long-lasting (>12 months) dyspeptic symptoms in the general population. Two subgroups were distinguished: (i) persons with dyspepsia as the only one long-lasting symptom and themselves feeling otherwise healthy (9%), mostly among younger patients (subgroup A); and (ii) patients with dyspepsia as part of the complex of previously recognized diseases (8%), mostly in older patients (subgroup B). The prevalence of dyspepsia was significantly higher among women. The excess cases of dyspepsia among the highly educated seemed to be cases of dyspepsia of subgroup A, and the higher prevalence of dyspepsia among the lower social classes was largely dyspepsia of subgroup B. Being a widow/widower had a significant effect on the risk of self-reported dyspepsia among 25–64-year-olds. No association between Helicobacter pylori infection and dyspepsia was found. Conclusion The prevalence of uninvestigated dyspepsia in the Czech Republic is comparable with data from other European countries. Clearly distinct subgroups of dyspeptic patients exist that should be further studied.